Treatment for Insomnia
Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia disorder in adults of any age, including those with comorbidities, and should be offered before any pharmacological intervention 1, 2.
Why CBT-I First
CBT-I demonstrates superior long-term effectiveness with durable treatment gains that persist after therapy ends, unlike medications which lose efficacy upon discontinuation 1, 3. The therapy produces clinically meaningful improvements in sleep quality, sleep efficiency, sleep latency, wake time after sleep onset, and remission rates with only moderate quality evidence showing temporary side effects 4, 1.
CBT-I Components and Structure
The multicomponent approach includes:
- Sleep restriction therapy (limiting time in bed to actual sleep time, then gradually increasing as sleep efficiency improves)
- Stimulus control (strengthening bed-sleep association, establishing consistent sleep-wake patterns)
- Cognitive therapy targeting maladaptive thoughts about sleep
- Relaxation therapy and counterarousal strategies
- Sleep hygiene education (though this alone is insufficient as monotherapy)
Treatment typically spans 4-8 sessions with ongoing sleep diary monitoring 1.
Brief Behavioral Therapy for Insomnia (BBT-I)
If full CBT-I is unavailable, multicomponent brief therapies (1-4 sessions) focusing on behavioral components are conditionally recommended 1. These abbreviated versions emphasize sleep restriction, stimulus control, and education about sleep regulation, making them more accessible when resources are limited.
Delivery Methods
CBT-I can be delivered face-to-face, digitally, or via telehealth platforms 4, 2. While evidence for Internet-based or group delivery compared to face-to-face treatment is insufficient to make definitive recommendations, digital CBT-I receives an "A" level recommendation in European guidelines 2.
When to Consider Pharmacotherapy
Pharmacological intervention should only be offered when CBT-I is not sufficiently effective 2. This is critical: medications are not first-line therapy even though they remain the most commonly prescribed treatment in practice 4.
Pharmacological Options by Duration
Short-term treatment (≤4 weeks):
- Benzodiazepines (A-level evidence)
- Benzodiazepine receptor agonists/Z-drugs (A-level evidence)
- Daridorexant (A-level evidence)
- Low-dose sedating antidepressants (B-level evidence)
Longer-term treatment (up to 3 months or more):
- Orexin receptor antagonists including daridorexant, suvorexant, lemborexant (A-level evidence) 2
- Prolonged-release melatonin 2mg for patients ≥55 years (B-level evidence) 2
For older adults specifically: Low-dose doxepin, melatonin, ramelteon, and dual orexin receptor antagonists are preferred due to better safety profiles 5.
Medications NOT Recommended
The following should NOT be used for insomnia treatment:
- Antihistaminergic drugs
- Antipsychotics
- Fast-release melatonin
- Ramelteon (conflicting evidence)
- Phytotherapeutics
All receive "A" level recommendations against use 2.
Critical Caveats and Pitfalls
Sleep restriction therapy contraindications: When used as part of CBT-I, sleep restriction may be contraindicated in:
- Heavy machinery operators or drivers
- Those predisposed to mania/hypomania
- Patients with poorly controlled seizure disorders 1
Early treatment effects: Patients starting CBT-I may experience temporary daytime fatigue, sleepiness, mood impairment (irritability), and attention problems during early treatment stages. These typically resolve by treatment end 1.
Benzodiazepine/Z-drug discontinuation: If switching from these medications, discontinuation must be gradual with dose reductions of 10-25% per week. Multi-component CBT-I, daridorexant, eszopiclone, and melatonin 2mg PR can facilitate gradual discontinuation within cross-tapered programs 6.
Combined treatment approach: While combining CBT-I with medication may decrease latency to treatment response, it might diminish the durability of CBT-I's positive long-term effects 3. Therefore, sequential rather than simultaneous treatment is generally preferred.
Adjunctive Therapies
Light therapy and exercise interventions may be useful as adjunct therapies to CBT-I (B-level evidence) 2, particularly given the circadian disruption component often present in insomnia 7.