It is recommended to rule out medical and psychological causes before deciding on the treatment for insomnia.
Cognitive behavioral therapy is an effective first-line treatment for chronic insomnia. Medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear. As of 2022, many people with insomnia were reported as not receiving overall sufficient sleep or treatment for insomnia.
Non-medication based Non-medication-based strategies have comparable efficacy to
hypnotic medication for insomnia, and they may have longer-lasting effects. Hypnotic medication is only recommended for short-term use because
dependence with
rebound withdrawal effects upon discontinuation or
tolerance can develop. Non-medication-based strategies provide long-lasting improvements to insomnia and are recommended as a first-line and long-term strategy of management. Behavioral sleep medicine offers non-medication strategies to address chronic insomnia including
sleep hygiene,
stimulus control, behavioral interventions,
sleep-restriction therapy,
paradoxical intention, patient education, and
relaxation therapy. Some examples are keeping a journal, restricting the time spent awake in bed, practicing
relaxation techniques, and maintaining a regular sleep schedule and a wake-up time. Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to regulate the
circadian rhythm, and regulating the circadian clock.
EEG biofeedback has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as the quality of sleep. Self-help therapy (defined as a psychological therapy that can be worked through on one's own) may improve sleep quality for adults with insomnia to a small or moderate degree. Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed or sleep in general with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred to interchangeably with the concept of
sleep hygiene. Examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not occur in a reasonably brief period after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating daytime naps. A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with the actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when
sleep efficiency improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock.
Bright light therapy may be effective for insomnia. Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e., essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).
Sleep Hygiene Sleep hygiene is a common term for all of the behaviors that relate to the promotion of good sleep. They include habits that provide a good foundation for sleep and help to prevent insomnia. However, sleep hygiene alone may not be adequate to address chronic insomnia. Sleep hygiene recommendations are typically included as one component of
cognitive behavioral therapy for insomnia (CBT-I). The creation of a positive sleep environment may also help reduce the symptoms of insomnia. On the other hand, a systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include: • Unrealistic sleep expectations. • Misconceptions about insomnia causes. • Amplifying the consequences of insomnia. • Performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process. Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and relaxation therapies.
Hypnotic medications are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to
tolerance. The effects of
CBT-I have sustained and lasting effects on treating insomnia long after therapy has been discontinued. The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long-lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term, when compared to short-term hypnotic medication such as zolpidem, CBT-I still shows significant superiority. Thus, CBT-I is recommended as a first-line treatment for insomnia. Common forms of CBT-I treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleeping environments, relaxation training, paradoxical intention, and biofeedback. Sleep restriction (also called "time-in-bed restriction"), stimulus control and cognitive restructuring are key components. CBT is a well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms has been shown to have adverse side effects. Nevertheless, the downside of CBT is that it may take a lot of time and motivation.
Acceptance and commitment therapy Treatments based on the principles of
acceptance and commitment therapy (ACT) and
metacognition have emerged as alternative approaches to treating insomnia. ACT rejects the idea that behavioral changes can help insomniacs achieve better sleep since they require "sleep efforts" - actions which create more "struggle" and arouse the nervous system, leading to
hyperarousal. The ACT approach posits that acceptance of the negative feelings associated with insomnia can, in time, create the right conditions for sleep.
Mindfulness practice is a key feature of this approach, although mindfulness is not practiced to induce sleep (this in itself is a
sleep effort to be avoided) but rather as a longer-term activity to help calm the nervous system and create the internal conditions from which sleep can emerge. A key distinction between CBT-I and ACT lies in the divergent approaches to time spent awake in bed. Proponents of CBT-i advocate minimizing time spent awake in bed, on the basis that this creates a cognitive association between being in bed and wakefulness. The ACT approach proposes that avoiding time in bed may increase the pressure to sleep and arouse the nervous system further.
Internet Interventions Despite the therapeutic effectiveness and proven success of CBT, treatment availability is significantly limited by a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense. One way to potentially overcome these barriers is to use the Internet to deliver treatment, making this effective intervention more accessible and less costly. The Internet has already become a critical source of health care and medical information. Although the vast majority of health websites provide general information, there is growing research literature on the development and evaluation of Internet interventions. These online programs are typically behaviorally based treatments that have been operationalized and transformed for delivery via the Internet. They are usually highly structured, automated, or human-supported, based on effective face-to-face treatment; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback.
Medications Many people with insomnia use
sleeping tablets and other
sedatives. In some places, medications are prescribed in over 95% of cases. They, however, are a second line treatment. In 2019, the US
Food and Drug Administration (FDA) stated it is going to require warnings for
eszopiclone,
zaleplon, and
zolpidem, due to concerns about serious injuries resulting from abnormal sleep behaviors, including
sleepwalking or driving a vehicle while asleep. The percentage of adults using a prescription sleep aid increases with age. During 2005–2010, about 4% of US adults aged 20 and over reported that they took prescription sleep aids in the past 30 days. Rates of use were lowest among the youngest age group (those aged 20–39) at about 2%, increased to 6% among those aged 50–59, and reached 7% among those aged 80 and over. More adult women (5%) reported using prescription sleep aids than adult men (3%). Non-Hispanic white adults reported higher use of sleep aids (5%) than non-Hispanic black (3%) and Mexican-American (2%) adults. No difference was shown between non-Hispanic black adults and Mexican-American adults in use of prescription sleep aids.
Antihistamines As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking
over-the-counter antihistamines such as
diphenhydramine or
doxylamine. Diphenhydramine and doxylamine are widely used in nonprescription sleep aids. They are the most effective over-the-counter sedatives currently available, at least in much of Europe, Canada, Australia, and the United States, and are more sedating than some prescription
hypnotics. Antihistamine effectiveness for sleep may decrease over time, and
anticholinergic side-effects (such as dry mouth) may also be a drawback with these particular drugs. While addiction does not seem to be an issue with this class of drugs, they can induce dependence and rebound effects upon abrupt cessation of use. However, people whose insomnia is caused by restless legs syndrome may have worsened symptoms with antihistamines.
Antidepressants While insomnia is a common symptom of depression,
antidepressants are effective for treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants, such as
amitriptyline,
doxepin,
mirtazapine,
trazodone, and
trimipramine, can have an immediate sedative effect and are prescribed to treat insomnia. Trazodone was at the beginning of the 2020s the most prescribed drug for sleep in the United States despite not being indicated for sleep. Amitriptyline, doxepin, and trimipramine all have
antihistaminergic,
anticholinergic,
antiadrenergic, and
antiserotonergic properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine's actions are primarily antihistaminergic and antiserotonergic and trazodone's effects are primarily antiadrenergic and antiserotonergic. Mirtazapine is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia.
Agomelatine, a melatonergic antidepressant with claimed sleep-improving qualities that does not cause daytime drowsiness, is approved for the treatment of depression though not sleep conditions in the European Union and Australia. After trials in the United States, its development for use there was discontinued in October 2011 by
Novartis, who had bought the rights to market it there from the European pharmaceutical company
Servier. A 2018
Cochrane review found the safety of taking antidepressants for insomnia to be uncertain with no evidence supporting long term use.
Melatonin agonists Melatonin receptor agonists such as
melatonin and
ramelteon are used in the treatment of insomnia.
Prolonged-release melatonin improves insomnia mainly in adults ≥55, and ramelteon improves sleep generally, with both effective versus placebo but less effective than most licensed insomnia drugs and showing limited long-term benefits. The usage of melatonin as a treatment for insomnia in adults has increased from 0.4% between 1999 and 2000 to nearly 2.1% between 2017 and 2018. While the use of melatonin in the short term has been proven to be generally safe and is shown not to be a dependent medication, side effects can still occur. Most common side effects of melatonin include:
Benzodiazepines ) is a
benzodiazepine commonly prescribed for insomnia and other
sleep disorders. The most commonly used class of hypnotics for insomnia are the
benzodiazepines. Benzodiazepines are
not significantly better for insomnia than
antidepressants. Chronic users of
hypnotic medications for insomnia do not have better sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic medications have more regular night-time awakenings than insomniacs not taking hypnotic medications. Many have concluded that these drugs cause an unjustifiable risk to the individual and to
public health and lack evidence of long-term effectiveness. It is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly. Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of
nonbenzodiazepines. The
benzodiazepine and
nonbenzodiazepine hypnotic medications also have several side effects, such as daytime fatigue, motor vehicle crashes and other accidents, cognitive impairments, and falls and fractures. Elderly people are more sensitive to these side effects. Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer term benzodiazepines can lead to
tolerance,
physical dependence,
benzodiazepine withdrawal syndrome upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as – like
alcohol – they promote light sleep while decreasing time spent in deep sleep. A further problem is, with regular use of short-acting sleep aids for insomnia, daytime
rebound anxiety can emerge. Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase. This is likely due to their addictive nature, both due to misuse and because – through their rapid action, tolerance and withdrawal they can "trick" insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the
long-term use of benzodiazepines and is recommended whenever possible. Benzodiazepines all bind unselectively to the
GABAA receptor. Prescribing of nonbenzodiazepines has seen a general increase since their initial release on the US market in 1992, from 2.3% in 1993 among individuals with sleep disorders to 13.7% in 2010. They are oriented towards blocking signals in the brain that stimulate wakefulness, therefore claiming to address insomnia without creating dependence. There are three
dual orexin receptor antagonist (DORA) drugs on the market:
Belsomra (
Merck),
Dayvigo (
Eisai) and
Quviviq (
Idorsia). However, while common, the use of antipsychotics for this indication is not recommended as the evidence does not demonstrate a benefit, and the risk of adverse effects is significant. A major 2022 systematic review and network meta-analysis of medications for insomnia in adults found that quetiapine did not demonstrate any short-term benefits for insomnia. Some of the more serious adverse effects may also occur at the low doses used, such as
dyslipidemia and
neutropenia. Such concerns of risks at low doses are supported by Danish observational studies that showed an association of use of low-dose quetiapine (excluding prescriptions filled for tablet strengths >50 mg) with an increased risk of major cardiovascular events as compared to use of
Z-drugs, with most of the risk being driven by cardiovascular death. Laboratory data from an unpublished analysis of the same cohort also support the lack of dose-dependency of metabolic side effects, as new use of low-dose quetiapine was associated with a risk of increased fasting triglycerides at one-year follow-up. Concerns regarding side effects are greater in the elderly.
Other sedatives Gabapentinoids like
gabapentin and
pregabalin have sleep-promoting effects, but are not commonly used for the treatment of insomnia. Gabapentin is not effective in helping
alcohol-related insomnia.
Barbiturates, while once used, are no longer recommended for insomnia due to the risk of addiction and other side effects.
Comparative effectiveness Medications for the treatment of insomnia have a wide range of
effect sizes. However, there is no
quality evidence that they are effective and safe.
Acupuncture is often promoted for insomnia, but evidence for its effectiveness is mixed. It is unclear whether acupuncture is helpful for treating insomnia in the general population. In people with
cancer, acupuncture may reduce insomnia severity and improve sleep quality, though its effects are often similar to those of sham acupuncture. While acupuncture can help alleviate insomnia and enhance sleep, it is generally less effective than
cognitive behavioural therapy for insomnia (CBT-I). == Prognosis ==