Chronic insomnia: CBT-I before medication

Defining insomnia

Difficulty initiating or maintaining sleep, or early awakening, at least 3 nights/week for at least 3 months, with daytime impairment (fatigue, irritability, cognitive difficulties). Affects 10-15% of adults.

CBT-I: the gold standard

Cognitive-Behavioral Therapy for Insomnia is more effective long-term than sleeping pills. It combines: sleep restriction, stimulus control (bed = sleep only), relaxation techniques, cognitive restructuring, sleep hygiene. Available in-person or via validated apps.

Medications

• Benzodiazepines and related drugs (zolpidem, zopiclone): short-term only (risk of dependence, cognitive impairment)
• Melatonin: useful for rhythm disorders
• Daridorexant, lemborexant: orexin antagonists, new class
• Mirtazapine, trazodone at low dose: if associated depression

Sleep hygiene

Regular schedule, morning light exposure, avoid screens in the evening, limit caffeine and alcohol, cool and dark room, no late naps.