Insomnia in Primary Care

This is one of the most commonly asked questions that we get and probably one of the most difficult to manage as really >95% of it is behavioral and/or anxiety related and not truly a neurologic problem with sleep…

There was a really great recent New England Journal of Medicine review article on this topic that does a nice job of describing the evidence behind the thoughts on this subject. [1]

In brief, the majority of patient reported insomnia falls into one of (or a combination of) the following causes:

·         Poor sleep hygiene / behavioral

·         Untreated anxiety

·         Life stressors

·         Substances that disrupt sleep (alcohol, stimulants)

·         Neurologic disorders (REM sleep disorders, dementia, Parkinson’s)

Number 5 (above) is actually usually not what we are talking about in primary care, but that is really what most of the medications are targeted at. The majority of treatment for insomnia should really focus on treating problems 1-4 in the above list. This can include CBT-I, or more informally ‘sleep hygiene,’ for which there is a large body of research.

CBT-I

As such, cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for persistent insomnia. CBT-I includes strategies such as modifying sleep habits, regulating sleep–wake schedules, reducing arousal, and reframing unhelpful beliefs about sleep. This recommendation is strongly supported by current guidelines, which emphasize CBT-I’s effectiveness in producing rapid and sustained improvements in insomnia symptoms, sleep-onset latency, and time awake after sleep onset. The rationale for prioritizing CBT-I is its superior long-term efficacy and safety profile compared to pharmacologic options, which are reserved for cases where behavioral therapy is unavailable, ineffective, or not preferred by the patient.

Sleep Hygiene

Common offenders in this category include using phones/tablets within 1 hour of bed time, not keeping a regular schedule, having things in the bedroom environment (pets) that wake the patient up, etc.

Sleep hygiene refers to a set of behavioral and environmental practices intended to promote healthy, restorative sleep. These practices include maintaining a consistent sleep schedule, limiting caffeine, alcohol, and nicotine intake (especially close to bedtime), engaging in regular physical activity (but not within a few hours of bedtime), optimizing the sleep environment (dark, quiet, and comfortable), avoiding heavy meals and excessive fluid intake before bed, reducing exposure to screens and bright light in the evening, and using the bed only for sleep and sex (not watching TV). [2]

Untreated Anxiety

Anecdotally I think this is probably the most common problem when patients complain to primary care doctors about insomnia. As such, the commonly prescribed drugs for insomnia (trazadone, mirtazapine, Seroquel) are really anti-anxiety drugs that happen to have a sleepiness/drowsiness side effect. I think really in these instances the patient’s anxiety is being treated, there happens to be a side effect of drowsiness and the problem gets better but really the underlying issue is anxiety and not a neurologic sleep disorder.

Life Stressors

Often, something negative will be happening in a patient’s life and they will be sleeping poorly due to this. When patients come to us to discuss insomnia in this context, we are really not discussing a medical problem; rather this is a life stressor that needs to be addressed. In addition to things such as therapy, exercise, meditation etc. can be helpful in these instances. This is not a situation where consideration for medications would be appropriate and likely would not be effective anyway until the life stressor is removed.

Substances That Disrupt Sleep

Alcohol is known to significantly disrupt sleep-wake cycles, in particular by reducing time in deep REM, which is when we are felt to have the most restorative sleep. Caffeine, ADHD medications, and other stimulants obviously activate the brain and can affect sleep. Other prescription medications similarly can have an activating effect. Some other over the counter agents also have stimulant or caffeine-like properties. Before proceeding to considering medications for insomnia, a review of substances and prescriptions that may be contributing to insomnia should be undertaken first to avoid the concept of ‘polypharmacy’ (prescribing a medication to alleviate the side effect of another substance or medication).

Medications

Medications approved by the FDA for insomnia—are recommended only as alternative or adjunctive treatments, due to weaker supporting efficacy in most patients.

In the instances where medication specifically for insomnia needs to be considered, there are FDA-approved medications for insomnia:

· dual orexin receptor antagonists (suvorexant, Lemborexant, daridorexant) [Controlled substances due to risk for addiction]

· nonbenzodiazepine receptor agonists (zolpidem, zaleplon, eszopiclone) [Controlled substances due to risk for addiction]

· low-dose doxepin

· Ramelteon

Within the above class of medications, different considerations include:

· Is the problem with falling asleep or staying asleep (initiation vs maintenance)

· Is the problem persistent or only short lived (i.e. time zone change or shift worker syndrome)

· Other medication interactions

· Alcohol or other substance use or a history of substance use

· Cost (only doxepin is generic the others can be fairly expensive)

Guidelines emphasize using the lowest effective dose for the shortest duration ideally with the notion of not taking these medications regularly and discontinuing them once CBT-I and other interventions have been initiated.

Importantly, both sleep medicine and geriatrics guidelines in particular recommend avoiding benzodiazepines, antihistamines, and tricyclic antidepressants. [2]

Interestingly, while commonly used in practice, there is insufficient evidence to support trazodone, mirtazapine, melatonin, or most alternative agents for insomnia disorder.[2] While these agents have less side effect profile and are generally well tolerated, there is not strong studies that show that they are particularly effective.

Of the FDA approved medications, the one with the longest history of use is doxepin. This is the sleep medicine guideline recommended treatment for sleep-maintenance insomnia (staying asleep). The other agents are newer. The ‘Z-drug’ class of medications (zolpidem, zaleplon, and Lunesta) are related to the benzodiazepine class of medications and are generally avoided due to the association with dementia especially with long term use.

Summary

Most patients in primary care who complain of insomnia really do not have a neurologic sleep disorder that requires specific medications, but rather usually have a combination of other factors that should be addressed, namely behavioral issues with sleep, anxiety and life stressors. Medications for insomnia should be reserved for select cases, used ideally only temporarily, and selection of particular agent should be guided by the type of sleep problem (onset versus initiation) and other factors including the possible addicting nature of some of these medications.

References

1.      Management of Insomnia. Morin and Buysse N Engl J Med 2024;391:247-258. (Link)

2.      Sleep Hygiene - What Do We Mean? A Bibliographic Review. De Pasquale C, El Kazzi M, Sutherland K, et al. Sleep Medicine Reviews. 2024;75:101930. (Link)

3.      Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria. Steinman MA. Journal of the American Geriatrics Society. 2025;73(9):2657-2677. (Link)