Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive behavioral therapy, and reserve medication for adjunctive treatment when necessary.

Rationale and Comments

Cognitive behavioral therapy for chronic insomnia involves a combination of behavioral modification, such as stimulus control and sleep restriction, and cognitive strategies, such as replacement of unrealistic fears about sleep with more positive expectations. In clinical trials, cognitive behavioral therapy is generally as effective as or more effective than hypnotics at improving sleep, and can be effective over an extended period of time without side effects associated with hypnotics. Some patients may benefit from a limited course of hypnotics while cognitive behavioral therapy for chronic insomnia is initiated. Patients who have successfully used hypnotics for extended periods and are reluctant to discontinue their current treatment regimen may be reasonable candidates for continued pharmacologic treatment.

Sponsoring Organizations

• American Academy of Sleep Medicine

Sources

• Randomized controlled trials

Disciplines

• Psychiatric and Psychologic

References

• Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285(14):1856-64.
  
• Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(14):2851-8.
  
• Morin CM, Valliéres A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005-15.