Treatment of Insomnia

First-Line Treatment

The American College of Physicians recommends Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment for adults with chronic insomnia disorder, with pharmacological therapy reserved as second-line treatment only when CBT-I alone is unsuccessful 1, 2
CBT-I has demonstrated superior long-term efficacy compared to pharmacological options and carries minimal risk of adverse effects 1
CBT-I components include cognitive therapy, behavioral interventions, and educational interventions 1, 3

The American Academy of Sleep Medicine suggests that non-benzodiazepine receptor agonists, such as eszopiclone and zolpidem, should be used at the lowest effective dose for the shortest period possible (4-5 weeks) 1, 2, 4
Orexin receptor antagonists, such as suvorexant, have shown moderate-quality evidence for improving treatment response and sleep outcomes in mixed adult populations 1
Melatonin receptor agonists, such as ramelteon, have low-quality evidence showing no statistically significant difference between ramelteon and placebo for sleep outcomes in the general population, but may be suitable for patients with substance use history due to lower abuse potential 1, 5
Sedating antidepressants, such as low-dose doxepin, have shown moderate-quality evidence for improving Insomnia Severity Index scores and sleep outcomes 1

The FDA has approved pharmacologic therapy for short-term use only (4-5 weeks) 4
Hypnotic drugs may be associated with serious adverse effects, including dementia, injury, and fractures 4
The FDA labels warn of daytime impairment, "sleep driving," behavioral abnormalities, and worsening depression 4
Antipsychotics are not recommended as first-line treatment for insomnia due to metabolic side effects 6

Start with CBT-I as first-line treatment, and consider pharmacological therapy only when CBT-I alone is unsuccessful 1, 2, 5
Use medications at the lowest effective dose for the shortest duration (ideally ≤4-5 weeks) 1, 4
Continue to incorporate behavioral techniques even when using medications 5
Monitor regularly for treatment response, adverse effects, and potential misuse 5