Insomnia disorder is the most common sleep complaint and one of the most under-effectively treated conditions in medicine. The DSM-5 criteria: dissatisfaction with sleep quantity or quality with one or more symptoms (difficulty initiating, maintaining, or early awakening), occurring at least 3 nights per week for at least 3 months, producing clinically significant distress or impairment, occurring despite adequate opportunity for sleep, not better explained by another sleep disorder, substance, or medical condition.
The fundamental shift in modern practice: CBT-I (cognitive-behavioral therapy for insomnia), not pharmacotherapy, is the first-line treatment. Multiple guidelines (AASM, ACP) explicitly recommend CBT-I before medication. Effect sizes for CBT-I are larger and more durable than for hypnotic medications. The shift from "give a sleeping pill" to "refer for CBT-I" is the most important change in modern insomnia practice.
CBT-I components:
Sleep restriction — the most powerful component. Limit time in bed to actual sleep time initially (no naps; consolidate sleep efficiency). As efficiency improves, gradually extend time in bed. The intervention initially produces some sleep deprivation but rapidly improves sleep consolidation.
Stimulus control — bed is for sleep and sex only. Get out of bed if not asleep within 15-20 minutes. Return when sleepy. Rebuilds the cognitive association between bed and sleep that chronic insomnia disrupts.
Cognitive restructuring — challenge unhelpful sleep beliefs ("I need 8 hours," "If I don't sleep I'll be useless tomorrow," "Once I'm awake I can't get back to sleep"). These beliefs perpetuate anxious arousal.
Sleep hygiene — consistent schedule, bedroom environment, caffeine and alcohol management, exercise timing. Supports the other components but not sufficient alone.
Relaxation training — progressive muscle relaxation, breathing techniques to reduce pre-sleep arousal.
Access to CBT-I: in-person therapists, group programs, increasingly digital (Sleepio, SHUTi, CBT-i Coach app from VA). Digital CBT-I has good evidence and dramatically improves access. Many primary care clinicians can refer or recommend.
When pharmacotherapy is needed:
Z-drugs (zolpidem, eszopiclone, zaleplon) — most commonly prescribed. Short-term use only — chronic use produces dependence, cognitive effects, fall risk in older adults. Avoid in older adults (Beers Criteria).
Ramelteon — melatonin receptor agonist (MT1, MT2). Non-controlled, no dependence, useful particularly for sleep onset insomnia.
Orexin antagonists (suvorexant, lemborexant, daridorexant) — newer mechanism, useful for sleep maintenance. Less dependence concern than benzodiazepines/z-drugs.
Doxepin at very low dose (3-6 mg) — H1 antagonism without significant anticholinergic effects at this dose. Useful for sleep maintenance.
Avoid: chronic benzodiazepines, chronic diphenhydramine and other anticholinergic antihistamines (anticholinergic burden in older adults), trazodone (off-label, limited evidence, often misused for primary insomnia).
Treat comorbid conditions: sleep apnea, restless legs, depression, anxiety, chronic pain. Insomnia is often a symptom of treatable underlying conditions.
When you encounter a patient with chronic insomnia, refer for CBT-I first. Reserve medication for short-term use or as adjunct. The shift from medication-first to CBT-I-first produces dramatically better outcomes.