All patients with insomnia should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia. They should also receive general behavioral suggestions, particularly advice regarding sleep hygiene and stimulus control.
For patients who continue to have insomnia that is severe enough to require an intervention, we suggest cognitive behavioral therapy for insomnia (CBT-I) as the initial therapy rather than medication (Grade 2B). An alternative type of behavioral therapy is reasonable if CBT-I is not available.
For patients whose insomnia continues to be severe enough to require an intervention despite CBT-I, we suggest the addition of a medication to CBT-I rather than changing to a strategy of medication alone (Grade 2B).
For patients who require medication for sleep onset insomnia, we suggest a short-acting medication rather than a longer-acting agent (Grade 2C).
For patients who require medication for sleep maintenance insomnia, we suggest a longer-acting medication rather than a short-acting agent (Grade 2C). Alternatively, a formulation of zolpidem has been approved for use in the middle of the night. Patients should be warned about the risk for daytime drowsiness, impaired driving, dizziness, and lightheadedness.
Patients given behavioral plus pharmacologic therapy should continue behavioral therapy for six to eight weeks. In patients who respond to therapy, the medication can be tapered while continuing the behavioral therapy. Patients whose symptoms recur may require evaluation in a sleep disorders center, prior to the institution of long-term therapy.
Long-term treatment with medication alone is not the optimal treatment strategy for patients with insomnia.
Ann Intern Med. 2016
- Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.
Ann Intern Med. 2015;163(3):191.
- Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis.
JAMA Intern Med. 2015 Sep;175(9):1461-72.
- Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis.
Lancet Neurol. 2014 May;13(5):461-71.
- Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration.
- The use of exogenous melatonin in delayed sleep phase disorder: a meta-analysis.
- Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.
- Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.
- Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial.
- Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.