Insomnia Treatment Guidelines

Introduction to Insomnia Treatment

The American College of Physicians recommends Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment for all forms of chronic insomnia, including maintenance insomnia, due to its improvements in global outcomes, including increased remission and treatment response 1, 2, 3, 4, 5

Low-dose doxepin (3-6mg) is recommended for sleep maintenance insomnia, reducing wake after sleep onset by 22-23 minutes and improving total sleep time by 26-32 minutes 2
Eszopiclone (2-3mg) is recommended for mixed onset/maintenance insomnia, improving total sleep time by 28-57 minutes and reducing wake after sleep onset by 10-14 minutes 2
Suvorexant is recommended for sleep maintenance insomnia, improving total sleep time by 10 minutes and reducing wake after sleep onset by 16-28 minutes 2
Temazepam (15mg) is recommended for severe maintenance insomnia cases only, improving total sleep time by 99 minutes, but with a small improvement in sleep quality 2
Ramelteon (8mg) is recommended for sleep onset insomnia, with no black box warning for suicide risk, and should be administered at the lowest effective dose for the shortest duration 2

Relaxation therapy, including progressive muscle relaxation, guided imagery, diaphragmatic breathing, meditation, and biofeedback, can be effective for reducing physiological and cognitive arousal in individuals with insomnia 6
Recommended sleep hygiene practices include maintaining stable bed and wake times, avoiding daytime napping, avoiding caffeine, nicotine, and alcohol, avoiding heavy exercise within 2 hours of bedtime, using the bedroom only for sleep and sex, and leaving the bedroom if unable to fall asleep within 20 minutes 6

For elderly patients, a starting dose of 5mg is recommended due to altered pharmacokinetics, and medication should be initiated at the lowest possible dose in patients aged ≥85 years, with consideration of screening for frailty using validated clinical tests and testing for orthostatic hypotension before starting medications that may lower blood pressure 2, 7
Implementing a developmentally appropriate bedtime and consistent bedtime routine is recommended for children with sleep onset association, and using visual schedules can support the routine, especially for children with Autism Spectrum Disorder (ASD) 8
Behavioral interventions, such as consistent bedtime routines and extinction techniques, are recommended as the first-line treatment for insomnia related to sleep onset association in children, as suggested by the American Academy of Pediatrics 8

Hypnotic medications may be associated with serious adverse effects, including dementia, serious injury and fractures, daytime impairment, "sleep driving" and behavioral abnormalities, and worsening depression 3
The FDA recommends lower dosages than those used in many studies, especially for older adults, and non-benzodiazepine hypnotics should be limited to short-term use (typically 4 weeks or less) 3, 2
Benzodiazepines should be avoided due to risks of dependency, diversion, falls, cognitive impairment, and hypoventilation, as well as adverse effects outweighing benefits, and should be avoided in older patients and in patients with cognitive impairment 1, 9
Trazodone is not recommended for sleep onset or maintenance insomnia due to the risk of triggering manic episodes and lack of supporting evidence for its efficacy in treating insomnia, as advised by the American Academy of Sleep Medicine 2

The FDA has approved pharmacologic therapy for short-term use only (4-5 weeks), and patients whose insomnia doesn't improve within 7-10 days should be further evaluated 3
Follow-up within 2-4 weeks of any intervention is recommended to assess the frequency and severity of episodes, daytime functioning and behavior, side effects of any medications, and need for adjustment of treatment plan 8, 10, 11
Standardized sleep assessment tools, such as the Insomnia Severity Index or Pittsburgh Sleep Quality Index, should be used to track progress, as recommended by the American Academy of Pediatrics and the American Academy of Sleep Medicine 12, 8

The evidence for long-term use of any medication for insomnia is insufficient, and patients should be discouraged from using these drugs for extended periods, as recommended by the American College of Physicians and the American Academy of Sleep Medicine 3, 13, 14, 5
Sleep disorders management requires careful consideration of underlying conditions, such as bipolar disorder, and should prioritize correction of these conditions before treating insomnia, as recommended by the American Academy of Sleep Medicine and American College of Cardiology 13, 14, 5