When hypnotics are used (particularly, benzodiazepines and nonbenzodiazepines), their use should be reassessed—every 3 to 4 weeks.3,12 Many patients with insomnia do not experience sleep disturbances nightly. Therefore, the use of hypnotics on an as-needed basis or a few times a week helps cut down on the amount and exposure to medication.27
Trazodone and mirtazapine are also widely used for insomnia, as are atypical antipsychotics and herbal preparations. Unfortunately, these agents have not been rigorously studied for insomnia and thus their effectiveness and safety remain unclear.3
CBT-I is an important, widely accepted, multimodal treatment for insomnia and the best-studied of the nonpharmacological approaches for this disorder. It is a manualized treatment that focuses on various components of CBT (ie, cognitive restructuring and the use of psychological interventions, such as the practice of good sleep hygiene, stimulus control, sleep restriction, and relaxation therapy). These methods address negative and distorted cognitions and behaviors that initiate and perpetuate insomnia.9,28 Treatment duration is relatively short. It is administered for 5 hours divided over 4 to 6 weeks and can subsequently be used as a maintenance treatment in monthly sessions. There are approximately 12 well-designed CBT-I trials that have clearly demonstrated that it is a highly effective intervention for insomnia for 1 year or longer.29,30
Studies that compared CBT-I with pharmacotherapy found equivalent efficacy.31 This has led the NIH Consensus and State of the Science Statement to conclude that CBT-I is “as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”3 In contrast to hypnotics, learned CBT-I skills may persist even when active treatment ends.9 Furthermore, some patients may prefer CBT-I over hypnotic drugs because of their possible adverse effects or because of concerns about drug interactions or taking a drug during pregnancy.9
In general, CBT-I is underutilized—only about 1% of patients with chronic insomnia receive this therapy.32 To increase the availability of CBT, it can be administered via self-help strategies (eg, educational books and materials) and in group formats. In addition, the use of the Internet to provide CBT has been shown to be effective. Nonetheless, patients frequently prefer face-to-face contact.33
Besides CBT-I, a number of other nonpharmacological therapies, such as bright light, physical exercise, acupuncture, tai chi, and yoga, have been used to treat insomnia. Unfortunately, the results have been inconsistent.32,34
1. van Mill JG, Hoogendijk WJ, Vogelzangs N, et al. Insomnia and sleep duration in a large cohort of patients with major depressive disorder and anxiety disorders. J Clin Psychiatry. 2010;71:239-246.
2. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105.
3. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults. Sleep. 2005;28:1049-1057.
4. Marcks BA, Weisberg RB. Co-occurrence of insomnia and anxiety disorders: a review of the literature. Am J Lifestyle Med. 2009;3:300-309.
5. Maher MJ, Rego SA, Asnis GM. Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS Drugs. 2006;20:567-590.
6. Harvey AG, Jones C, Schmidt DA. Sleep and posttraumatic stress disorder: a review. Clin Psychol Rev. 2003;23:377-407.
7. Koren D, Arnon I, Lavie P, Klein E. Sleep complaints as early predictors of posttraumatic stress disorder: a 1-year prospective study of injured survivors of motor vehicle accidents. Am J Psychiatry. 2002;159:855-857.
8. Sateia MJ, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 2000;23:243-308.
9. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry. 2004;65(suppl 16):33-40.
10. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193-213.
11. Parrott AC, Hindmarch I. Factor analysis of a sleep evaluation questionnaire. Psychol Med. 1978;8:325-329.
12. Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;15:487-504.
13. Bastien CH. Insomnia: neurophysiological and neuropsychological approaches. Neuropsychol Rev. 2011;21:22-40.
14. Edinger JD, Fins AI. The distribution and clinical significance of sleep time misperceptions among insomniacs. Sleep. 1995;18:232-239.
15. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28:499-521.
16. Boeve BF, Molano JR, Ferman TJ, et al. Validation of the Mayo Sleep Questionnaire to screen for REM sleep behavior disorder in an aging and dementia cohort. Sleep Med. 2011;12:445-453.
17. Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. J Behav Med. 2006;29:223-227.
18. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007;22:1335-1350.
19. Neubauer DN. Current and new thinking in the management of comorbid insomnia. Am J Manag Care. 2009;15:S24-S32.
20. Pollack M, Kinrys G, Krystal A, et al. Eszopiclone coadministered with escitalopram in patients with insomnia and comorbid generalized anxiety disorder. Arch Gen Psychiatry. 2008;65:551-562.
21. Gross PK, Nourse R, Wasser TE. Ramelteon for insomnia symptoms in a community sample of adults with generalized anxiety disorder: an open label study. J Clin Sleep Med. 2009;5:28-33.
22. Fava M, Asnis GM, Shrivastava R, et al. Zolpidem extended-release improves sleep and next-day symptoms in comorbid insomnia and generalized anxiety disorder. J Clin Psychopharmcol. 2009;29:222-230.
23. Roth T, Walsh JK, Krystal A, et al. An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Med. 2005;6:487-495.
24. Roehrs TA, Randall S, Harris E, et al. Twelve months of nightly zolpidem does not lead to dose escalation: a prospective placebo-controlled study. Sleep. 2011;34:207-212.
25. Uchiyama M, Hamamura M, Kuwano T, et al. Long-term safety and efficacy of ramelteon in Japanese patients with chronic insomnia. Sleep Med. 2011;12:127-133.
26. Longo LP, Johnson B. Addiction: Part I. Benzodiazepines—side effects, abuse risk and alternatives. Am Fam Physician. 2000;61:2121-2128.
27. Perlis ML, McCall WV, Krystal AD, Walsh JK. Long-term, non-nightly administration of zolpidem in the treatment of patients with primary insomnia. J Clin Psychiatry. 2004;65:1128-1137.
28. Morin CM, Espie CA. Insomnia: A Clinical Guide to Assessment and Treatment. New York: Kluwer; 2003.
29. Morin CM, Vallières A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301:2005-2015.
30. Wilson SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24:1577-1601.
31. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009;13:205-214.
32. Riemann D, Spiegelhalder K, Espie C, et al. Chronic insomnia: clinical and research challenges—an agenda. Pharmacopsychiatry. 2011;44:1-14.
33. Anderson G. The promise and pitfalls of the Internet for cognitive behavioral therapy. BMC Med. 2010;8:82.
34. Haynes PL, Bootzin RR. Insomnia treatments: moving from efficacy to effectiveness. J Clin Psychol. 2010;66:1131-1136.