Insomnia: Why CBT-I Comes First, Which Drugs When, and the Older-Adult Rules

Chronic insomnia is treated with cognitive behavioral therapy for insomnia (CBT-I) first, for every adult, and medication is a second, usually short-term step. The American College of Physicians (2016) gives CBT-I a strong recommendation as initial treatment, and the American Academy of Sleep Medicine behavioral guideline (2021) does the same. When a drug is added, the AASM 2017 pharmacologic guideline matches the agent to sleep onset or sleep maintenance problems, and the Beers Criteria rule out most hypnotics for adults 65 and older.

Assessment

Defining chronic insomnia

ICSD-3 and DSM-5 define chronic insomnia disorder by:

• Difficulty initiating sleep, maintaining sleep, or early morning awakening (in children, resisting bedtime or needing a parent to sleep).
• Daytime consequences: fatigue, poor attention or memory, mood disturbance, errors, reduced performance.
• Adequate opportunity and circumstances for sleep.
• Occurring at least 3 nights per week for at least 3 months.

Symptoms of shorter duration are short-term insomnia, often tied to a stressor, and usually resolve with the stressor and basic counseling.

History and tools

• Sleep diary for 1 to 2 weeks: bedtime, sleep latency, awakenings, final wake time, time out of bed, naps, caffeine and alcohol. It drives CBT-I and measures response.
• Severity scale: the Insomnia Severity Index is widely used to quantify severity and track change.
• Screen for sleep disorders that need different treatment: obstructive sleep apnea (snoring, witnessed apneas, daytime sleepiness, STOP-BANG), restless legs syndrome (urge to move the legs in the evening, relieved by movement; check ferritin), circadian rhythm disorders (delayed sleep phase in adolescents, advanced phase in older adults), parasomnias.
• Psychiatric conditions: depression, anxiety, PTSD, bipolar disorder and substance use. Insomnia that persists after depression improves needs its own treatment.
• Medical conditions: pain, nocturia, GERD, heart failure, COPD, hyperthyroidism, menopause.
• Medications and substances: caffeine, alcohol, nicotine, stimulants, decongestants, activating antidepressants taken at night, corticosteroids, beta-agonists, diuretics late in the day.

Polysomnography is not needed to diagnose insomnia; it is ordered when sleep apnea, periodic limb movement disorder or a parasomnia is suspected.

Why CBT-I comes first

ACP 2016 recommends that all adult patients receive CBT-I as the initial treatment for chronic insomnia disorder (strong recommendation, moderate-quality evidence). CBT-I improves sleep latency, wake after sleep onset and global outcomes, the gains last after treatment ends, and it has no drug interactions, dependence or falls. Hypnotics work while they are taken, their benefit fades after they stop, and their harms grow with age.

The 2021 AASM behavioral guideline recommends multicomponent CBT-I (strong) and gives conditional recommendations for brief behavioral therapy for insomnia, stimulus control, sleep restriction therapy and relaxation therapy as single components. It suggests against sleep hygiene education as a single-component therapy.

The components of CBT-I

CBT-I is usually delivered over about 4 to 8 sessions by a trained therapist, in groups, by telehealth or through validated digital programs, which widens access in primary care. Sleep restriction should be used cautiously in patients with bipolar disorder, seizure disorders or high fall risk, and in drivers or operators of heavy machinery while daytime sleepiness lasts.

When to add a medication

ACP 2016 recommends a shared decision about adding pharmacologic therapy for adults whose insomnia does not improve with CBT-I alone (weak recommendation, low-quality evidence), with a discussion of benefits, harms and costs of short-term use. The AASM 2017 guideline sorts drugs by the sleep problem they target, with all recommendations rated weak because the evidence quality was low or very low.

Lemborexant and daridorexant, newer orexin receptor antagonists, were approved after the 2017 guideline; their place is not graded in it, so confirm current recommendations before using them on an exam answer.

Prescribing principles

• Use the lowest effective dose for the shortest period, with a plan to taper or stop.
• Take the drug only when able to stay in bed for 7 to 8 hours, to avoid next-morning impairment.
• Never combine with alcohol, opioids or other sedatives. Benzodiazepines and opioids together carry an FDA boxed warning for respiratory depression and death.
• Complex sleep behaviors. Since 2019, eszopiclone, zaleplon and zolpidem carry a boxed warning for sleepwalking, sleep driving and other activities while not fully awake, which have caused serious injuries and deaths. A patient who has had such an episode must not take these drugs again.
• Antidepressants. When insomnia coexists with depression, an antidepressant that treats the depression (and sometimes a sedating one such as mirtazapine) is chosen for the depression; it is not an insomnia treatment in itself.

The older-adult rules

Older adults have lighter, more fragmented sleep, earlier sleep timing and more sleep apnea, pain and nocturia, so the workup is broader and the drug threshold is higher.

What is left for an older adult: CBT-I first (it works as well in older adults), attention to the causes listed above, and if a drug is needed, low-dose doxepin for sleep maintenance or ramelteon for sleep onset, with suvorexant as another maintenance option per AASM. For an older adult already taking a benzodiazepine or Z-drug, the answer is a slow, collaborative taper combined with CBT-I.

Monitoring and follow-up

• Review the sleep diary and severity score every few weeks during CBT-I; sleep efficiency (time asleep divided by time in bed) of 85 percent or more is the usual target for widening the sleep window.
• When a hypnotic is started, reassess within a few weeks for benefit, next-day impairment, falls, memory problems and complex sleep behaviors.
• Reassess the need for the drug at every visit, and plan discontinuation, ideally while CBT-I is in place to prevent rebound insomnia.
• If insomnia persists despite CBT-I, re-examine the diagnosis: undiagnosed sleep apnea, restless legs, depression or a circadian disorder.

Referral triggers

• Suspected obstructive sleep apnea, narcolepsy, periodic limb movement disorder or a parasomnia: sleep medicine and polysomnography.
• Insomnia that does not respond to CBT-I plus a reasonable drug trial.
• Complex sleep behaviors on a hypnotic.
• Coexisting severe psychiatric illness, bipolar disorder, or suicidal thoughts (give the 988 Suicide and Crisis Lifeline number for any suicidal thinking).
• Long-term benzodiazepine or Z-drug use that cannot be tapered in primary care.

Patient and caregiver education

• Keep the same wake time every day, including weekends, even after a bad night.
• Use the bed for sleep only; if awake about 20 minutes, get up and do something quiet in dim light.
• Expect sleep restriction to make the first 1 to 2 weeks harder before sleep improves.
• Limit caffeine after noon and avoid alcohol as a sleep aid; it fragments the second half of the night.
• Over-the-counter "PM" products contain diphenhydramine or doxylamine and are not safe for older adults.
• Caregivers of older adults should watch for nighttime confusion, falls and memory problems on any sleep medicine.
• Take a prescribed hypnotic only when ready for bed with enough time to sleep, and never drive the morning after if drowsy.

How the exam tests this

• Medication first. A vignette that offers zolpidem before CBT-I in a patient with chronic insomnia is testing whether the candidate knows ACP's strong recommendation.
• Sleep hygiene as the answer. Sleep hygiene alone is the trap; CBT-I is the correct choice.
• Trazodone. Common in practice, suggested against by AASM 2017.
• Older adult on diphenhydramine. Beers: stop it.
• Zolpidem 10 mg in a woman or an older adult. Wrong dose; the starting dose is 5 mg.
• Matching drug to problem. Ramelteon or zaleplon for trouble falling asleep, suvorexant or low-dose doxepin for waking at 3 a.m.
• Snoring and daytime sleepiness. That is a sleep apnea question, not an insomnia question.
• Sleep driving. Stop the Z-drug permanently.

Practice question

A 74-year-old woman reports 6 months of waking at 2 or 3 a.m. and being unable to return to sleep, at least four nights a week, with daytime fatigue. She falls asleep within 15 minutes. She has no snoring or witnessed apneas, no leg discomfort and a PHQ-9 of 3. She has been taking an over-the-counter diphenhydramine product nightly for 2 months. She completed 6 weeks of CBT-I with partial improvement and asks for something to help her stay asleep. In addition to stopping the diphenhydramine, which of the following is the most appropriate choice?

• A. Zolpidem 10 mg at bedtime
• B. Trazodone 50 mg at bedtime
• C. Doxepin 3 mg at bedtime
• D. Temazepam 15 mg at bedtime

Answer: C. Her problem is sleep maintenance, she has had CBT-I first, and low-dose doxepin is an AASM 2017 suggested option for maintenance insomnia that Beers 2023 permits at 6 mg per day or less. Option A is a Z-drug that Beers advises avoiding in older adults, and 10 mg exceeds the 5 mg starting dose for women and older adults. Option B is a drug the AASM guideline suggests against for insomnia, and it adds orthostatic hypotension and fall risk. Option D is a benzodiazepine, which Beers lists to avoid in adults 65 and older because of falls, fractures and cognitive impairment.

Key points

Related NPPace guides

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• Anxiety Disorders for the NP Exam: GAD-7, Panic, First-Line Drugs and When Benzodiazepines Are Wrong
• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
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