Management of Insomnia in Adults
All adult patients with chronic insomnia should receive cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and medications should only be added through shared decision-making if CBT-I alone is unsuccessful. 1, 2
Initial Treatment Approach
Start with multicomponent CBT-I as your primary intervention. This is a strong recommendation supported by the highest quality guidelines from both the American College of Physicians and the American Academy of Sleep Medicine 1, 2. The European guidelines from 2023 reinforce this same approach 3.
CBT-I consists of:
- Cognitive therapy to address maladaptive beliefs about sleep
- Behavioral interventions including stimulus control and sleep restriction
- Sleep hygiene education
CBT-I can be delivered through multiple modalities:
- In-person individual or group sessions
- Digital/web-based platforms
- Telephone-based modules
- Self-help materials
The evidence supporting CBT-I is moderate-to-high quality, and it addresses the underlying mechanisms of insomnia rather than just symptoms 1, 2.
When CBT-I Alone Is Insufficient
Only after CBT-I has been tried and found insufficient should you consider adding pharmacological therapy. This requires a shared decision-making conversation covering benefits, harms, and costs 1.
Pharmacological Options by Duration
For short-term use (≤4 weeks):
- Benzodiazepines (triazolam, estazolam, temazepam, flurazepam, quazepam)
- Z-drugs/benzodiazepine receptor agonists (zaleplon, zolpidem, eszopiclone)
- Low-dose sedating antidepressants (particularly doxepin)
- Daridorexant (dual orexin receptor antagonist)
For longer-term use (up to 3 months or more):
- Orexin receptor antagonists (suvorexant, lemborexant, daridorexant) - can be used for 3+ months 3
- Prolonged-release melatonin 2mg - for patients ≥55 years, up to 3 months 3
Important Caveats About Medications
The guideline evidence is clear about what NOT to use:
- Antihistamines (including diphenhydramine) - not recommended despite being commonly used 3, 4. Note: One 2025 expert consensus 5 supports diphenhydramine for acute insomnia, but this contradicts higher-quality European guidelines 3 that explicitly recommend against antihistamines.
- Antipsychotics - not recommended 3, 4
- Fast-release melatonin - not recommended 3
- Ramelteon - not recommended by European guidelines 3
- Sleep hygiene as monotherapy - explicitly not recommended as single-component therapy 2
Alternative Single-Component Therapies
If multicomponent CBT-I is unavailable, consider these conditional recommendations:
- Stimulus control therapy (conditional recommendation) 2
- Sleep restriction therapy (conditional recommendation) 2
- Relaxation therapy (conditional recommendation) 2
- Brief behavioral therapy for insomnia (conditional recommendation) 2
Special Considerations
Older adults (≥65 years): Exercise particular caution with benzodiazepines and Z-drugs due to increased fall risk, cognitive impairment, and dependence. Preferred options include low-dose doxepin, prolonged-release melatonin, or dual orexin receptor antagonists 6.
When to consider polysomnography: Not routinely needed, but indicated for:
- Suspected comorbid sleep disorders (sleep apnea, periodic limb movements)
- Treatment-resistant insomnia
- Substantial sleep state misperception 1, 3, 4
Common Pitfalls to Avoid
- Starting with medications instead of CBT-I - This violates all major guidelines and misses the opportunity to address underlying mechanisms
- Using antihistamines - Despite over-the-counter availability and patient preference, these are not evidence-based treatments
- Indefinite benzodiazepine/Z-drug use - These should be time-limited (≤4 weeks standard, longer only in select cases with careful monitoring)
- Prescribing sleep hygiene alone - This is insufficient as monotherapy for chronic insomnia 2
The strength of evidence consistently prioritizes CBT-I first, with medications reserved as adjunctive therapy when behavioral interventions prove inadequate.