Managing Insomnia: A Review of Pharmacological and Non-Pharmacological Approaches
DOI:
https://doi.org/10.12775/QS.2025.42.60430Keywords
insomnia, pharmacological treatment of insomnia, non-pharmacological treatment of insomnia, cognitive behavioral therapy for insomnia, hypnotic medicationsAbstract
Introduction and Aim: Insomnia is one of the most common sleep disorders, affecting about 10% of the population. It poses a significant public health concern due to its association with increased risk of depression, hypertension, obesity, diabetes, substance abuse, and suicide. Given its impact on health and quality of life, effective treatment is essential. This review aims to present pharmacological and non-pharmacological treatment methods for insomnia with proven scientific efficacy.
Materials and Methods: A literature review was conducted using PubMed and Google Scholar, focusing on studies published between 2000 and 2024. Keywords related to pharmacological and non-pharmacological treatments of insomnia were used, and the most relevant articles were selected.
Brief Description of the State of Knowledge: Cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line treatment. It provides short-term efficacy comparable to pharmacotherapy, with longer-lasting benefits and fewer side effects. Pharmacological treatments should be used when CBT-I is unavailable or insufficient. Benzodiazepines and non-benzodiazepine hypnotics may be effective short term but carry significant risks, especially in older adults. Newer agents, such as melatonin receptor agonists, low-dose doxepin, and orexin receptor antagonists, offer additional options with improved safety profiles.
Conclusions: Effective management of insomnia requires an individualized approach. CBT-I remains the preferred option, with pharmacotherapy considered when necessary. Proper treatment improves patient well-being and reduces the broader social and economic consequences of untreated insomnia.
References
1. Grandner MA. Sleep, Health, and Society. Sleep Med Clin. 2017;12(1):1-22. https://doi.org/10.1016/j.jsmc.2016.10.012 2. Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019;18(3):337-352. https://doi.org/10.1002/wps.20674
3. Morin CM, Drake CL, Harvey AG, et al. Insomnia disorder. Nat Rev Dis Primers. 2015;1:15026. Published 2015 Sep 3. https://doi.org/10.1038/nrdp.2015.26
4. Bos SC, Macedo AF. Literature review on insomnia (2010–2016). Biol Rhythm Res. 2019;50(1):94-163. https://doi.org/10.1080/09291016.2017.1413766
5. Riemann D, Espie CA, Altena E, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023;32(6):e14035. https://doi.org/10.1111/jsr.14035 6. Freeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ. Sleep disturbance and psychiatric disorders. Lancet Psychiatry. 2020;7(7):628-637. https://doi.org/10.1016/S2215-0366(20)30136-X
7. Riemann D, Benz F, Dressle RJ, et al. Insomnia disorder: State of the science and challenges for the future. J Sleep Res. 2022;31(4):e13604. https://doi.org/10.1111/jsr.13604
8. Roach M, Juday T, Tuly R, Chou JW, Jena AB, Doghramji PP. Challenges and opportunities in insomnia disorder. Int J Neurosci. 2021;131(11):1058-1065. https://doi.org/10.1080/00207454.2020.1773460 9. Masters PA. In the clinic. Insomnia. Ann Intern Med. 2014;161(7):ITC1-ITC16. https://doi.org/10.7326/0003-4819-161-7-201410070-01004 10. Morin CM, Bélanger L, LeBlanc M, et al. The natural history of insomnia: a population-based 3-year longitudinal study. Arch Intern Med. 2009;169(5):447-453. https://doi.org/10.1001/archinternmed.2008.610
11. K Pavlova M, Latreille V. Sleep Disorders. Am J Med. 2019;132(3):292-299. https://doi.org/10.1016/j.amjmed.2018.09.021 12. Stepanski EJ, Wyatt JK. Use of sleep hygiene in the treatment of insomnia. Sleep Med Rev. 2003;7(3):215-225. https://doi.org/10.1053/smrv.2001.0246 13. Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. J Behav Med. 2006;29(3):223-227. https://doi.org/10.1007/s10865-006-9047-6 14. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Med Rev. 2015;22:23-36. https://doi.org/10.1016/j.smrv.2014.10.001 15. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006;29(11):1415-1419. https://doi.org/10.1093/sleep/29.11.1415
16. van Straten A, van der Zweerde T, Kleiboer A, Cuijpers P, Morin CM, Lancee J. Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Med Rev. 2018;38:3-16. https://doi.org/10.1016/j.smrv.2017.02.001 17. Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(3):191-204. https://doi.org/10.7326/M14-2841 18. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(2):263-298. https://doi.org/10.5664/jcsm.8988
19. van der Zweerde T, Bisdounis L, Kyle SD, Lancee J, van Straten A. Cognitive behavioral therapy for insomnia: A meta-analysis of long-term effects in controlled studies. Sleep Med Rev. 2019;48:101208. https://doi.org/10.1016/j.smrv.2019.08.002 20. Espie CA, Emsley R, Kyle SD, et al. Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial. JAMA Psychiatry. 2019;76(1):21-30. https://doi.org/10.1001/jamapsychiatry.2018.2745 21. Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis. JAMA Intern Med. 2015;175(9):1461-1472. https://doi.org/10.1001/jamainternmed.2015.3006 22. Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;13:40. Published 2012 May 25. https://doi.org/10.1186/1471-2296-13-40 23. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. https://doi.org/10.5664/jcsm.6470 24. Jaqua EE, Hanna M, Labib W, Moore C, Matossian V. Common Sleep Disorders Affecting Older Adults. Perm J. 2023;27(1):122-132. https://doi.org/10.7812/TPP/22.114 25. Abad VC, Guilleminault C. Pharmacological treatment of sleep disorders and its relationship with neuroplasticity. Curr Top Behav Neurosci. 2015;25:503-553. doi:10.1007/7854_2014_365 26. Edinoff AN, Nix CA, Hollier J, et al. Benzodiazepines: Uses, Dangers, and Clinical Considerations. Neurol Int. 2021;13(4):594-607. Published 2021 Nov 10. https://doi.org/10.3390/neurolint13040059 27. Holbrook AM, Crowther R, Lotter A, Cheng C, King D. Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ. 2000;162(2):225-233. 28. Matheson E, Hainer BL. Insomnia: Pharmacologic Therapy. Am Fam Physician. 2017;96(1):29-35.
29. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis. Arch Clin Neuropsychol. 2004;19(3):437-454. https://doi.org/10.1016/S0887-6177(03)00096-9 30. Guina J, Merrill B. Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives. J Clin Med. 2018;7(2):17. Published 2018 Jan 30. https://doi.org/10.3390/jcm7020017 31. Capiau A, Huys L, van Poelgeest E, et al. Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review. Eur Geriatr Med. 2023;14(4):697-708. https://doi.org/10.1007/s41999-022-00731-4 32. Gunja N. The clinical and forensic toxicology of Z-drugs. J Med Toxicol. 2013;9(2):155-162. https://doi.org/10.1007/s13181-013-0292-0 33. Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. BMJ. 2012;345:e8343. Published 2012 Dec 17. https://doi.org/10.1136/bmj.e8343 34. Brandt J, Leong C. Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D. 2017;17(4):493-507. https://doi.org/10.1007/s40268-017-0207-7 35. Krystal AD, Erman M, Zammit GK, Soubrane C, Roth T; ZOLONG Study Group. Long-term efficacy and safety of zolpidem extended-release 12.5 mg, administered 3 to 7 nights per week for 24 weeks, in patients with chronic primary insomnia: a 6-month, randomized, double-blind, placebo-controlled, parallel-group, multicenter study. Sleep. 2008;31(1):79-90. https://doi.org/10.1093/sleep/31.1.79 36. Rösner S, Englbrecht C, Wehrle R, Hajak G, Soyka M. Eszopiclone for insomnia. Cochrane Database Syst Rev. 2018;10(10):CD010703. Published 2018 Oct 10. https://doi.org/10.1002/14651858.CD010703.pub2
37. Madari S, Golebiowski R, Mansukhani MP, Kolla BP. Pharmacological Management of Insomnia. Neurotherapeutics. 2021;18(1):44-52. https://doi.org/10.1007/s13311-021-01010-z 38. Ferguson SA, Rajaratnam SM, Dawson D. Melatonin agonists and insomnia. Expert Rev Neurother. 2010;10(2):305-318. https://doi.org/10.1586/ern.10.1 39. Choi K, Lee YJ, Park S, Je NK, Suh HS. Efficacy of melatonin for chronic insomnia: Systematic reviews and meta-analyses. Sleep Med Rev. 2022;66:101692. https://doi.org/10.1016/j.smrv.2022.101692 40. Choi K, Lee YJ, Park S, Je NK, Suh HS. Efficacy of melatonin for chronic insomnia: Systematic reviews and meta-analyses. Sleep Med Rev. 2022;66:101692. https://doi.org/10.1016/j.smrv.2022.101692
41. Spadoni G, Bedini A, Rivara S, Mor M. Melatonin receptor agonists: new options for insomnia and depression treatment. CNS Neurosci Ther. 2011;17(6):733-741. https://doi.org/10.1111/j.1755-5949.2010.00197.x 42. Wade AG, Ford I, Crawford G, et al. Efficacy of prolonged release melatonin in insomnia patients aged 55-80 years: quality of sleep and next-day alertness outcomes. Curr Med Res Opin. 2007;23(10):2597-2605. https://doi.org/10.1185/030079907X233098 43. Lemoine P, Garfinkel D, Laudon M, Nir T, Zisapel N. Prolonged-release melatonin for insomnia - an open-label long-term study of efficacy, safety, and withdrawal. Ther Clin Risk Manag. 2011;7:301-311. https://doi.org/10.2147/TCRM.S23036 44. Liu J, Wang LN. Ramelteon in the treatment of chronic insomnia: systematic review and meta-analysis. Int J Clin Pract. 2012;66(9):867-873. https://doi.org/10.1111/j.1742-1241.2012.02987.x 45. Kuriyama A, Honda M, Hayashino Y. Ramelteon for the treatment of insomnia in adults: a systematic review and meta-analysis. Sleep Med. 2014;15(4):385-392. https://doi.org/10.1016/j.sleep.2013.11.788 46. Muehlan C, Roch C, Vaillant C, Dingemanse J. The orexin story and orexin receptor antagonists for the treatment of insomnia. J Sleep Res. 2023;32(6):e13902. https://doi.org/10.1111/jsr.13902
47. Bragg S, Benich JJ, Christian N, Visserman J, Freedy J. Updates in insomnia diagnosis and treatment. Int J Psychiatry Med. 2019;54(4-5):275-289. https://doi.org/10.1177/0091217419860716 48. Jiang F, Li H, Chen Y, Lu H, Ni J, Chen G. Daridorexant for the treatment of insomnia disorder: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2023;102(7):e32754. https://doi.org/10.1097/MD.0000000000032754 49. Kunz D, Dauvilliers Y, Benes H, et al. Long-Term Safety and Tolerability of Daridorexant in Patients with Insomnia Disorder. CNS Drugs. 2023;37(1):93-106. https://doi.org/10.1007/s40263-022-00980-8 50. Yeung WF, Chung KF, Yung KP, Ng TH. Doxepin for insomnia: a systematic review of randomized placebo-controlled trials. Sleep Med Rev. 2015;19:75-83. https://doi.org/10.1016/j.smrv.2014.06.001 51. Weber J, Siddiqui MA, Wagstaff AJ, McCormack PL. Low-dose doxepin: in the treatment of insomnia. CNS Drugs. 2010;24(8):713-720. https://doi.org/10.2165/11200810-000000000-00000 52. Krystal AD, Durrence HH, Scharf M, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010;33(11):1553-1561. https://doi.org/10.1093/sleep/33.11.1553 53. Everitt H, Baldwin DS, Stuart B, et al. Antidepressants for insomnia in adults. Cochrane Database Syst Rev. 2018;5(5):CD010753. Published 2018 May 14. https://doi.org/10.1002/14651858.CD010753.pub2 54. Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26(6):675-700. https://doi.org/10.1111/jsr.12594 55. Vande Griend JP, Anderson SL. Histamine-1 receptor antagonism for treatment of insomnia. J Am Pharm Assoc (2003). 2012;52(6):e210-e219. https://doi.org/10.1331/JAPhA.2012.12051 56. Thompson W, Quay TAW, Rojas-Fernandez C, Farrell B, Bjerre LM. Atypical antipsychotics for insomnia: a systematic review. Sleep Med. 2016;22:13-17. https://doi.org/10.1016/j.sleep.2016.04.003
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Martyna Kłossowska, Magdalena Badziąg, Karolina Skonieczna, Paulina Szulc, Laura Kurczoba, Olimpia Wiciun, Olga Kądziołka, Kacper Ordon
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 234
Number of citations: 0
