Insomnia Treatment Restructured

"As far back as the 1800s, patients were prescribed medication for insomnia. While barbiturates were popularized in the early 1900s, they were soon replaced by benzodiazepines, such as Valium (1960s onward), which were relatively safer and better tolerated. In the 1990s, the "Z-drugs" (e.g., Zolpidem) were introduced as a safer and less addictive group. However, we couldn't escape the significant side effects and dependency concerns."

"Also in the 1980s and 1990s, Trazodone (an antidepressant with sedating side effects) started to be used off-label, with fewer dependency concerns. Following this trend, very low doses of Silenor (originally an antidepressant) were FDA-approved for insomnia in 2010. More recently, medications acting on the orexin system came out in 2014 (Belsomra), and as recently as 2022 (Quviviq). Instead of "knocking you out," these medications reduce the wake drive,"

"Alongside concerns about side effects and dependency, the behavioral concepts essential to Cognitive Behavioral Treatment for Insomnia (CBT-I) started to surface in the 1970s (stimulus control; Bootzin, 1972) and 1980s (sleep restriction; Spielman, 1987), influencing Charles Morin and others who combined cognitive restructuring with behavioral elements, forming CBT-I. The CBT-I protocol typically includes 5-8 sessions with a psychologist or behaviorist trained in Behavioral Sleep Medicine."

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the evidence-based first-line treatment and combines stimulus control, sleep restriction, cognitive restructuring, and behavioral strategies. Prescription sleep medications have dominated care since the 1800s, evolving from barbiturates to benzodiazepines, Z-drugs, sedating antidepressants, and orexin receptor antagonists, each with side effects, dependency concerns, and variable effectiveness. CBT-I typically involves 5–8 sessions with a trained clinician who adjusts schedules, recommends behavior changes, and addresses maladaptive thoughts and anxiety about sleep. Access gaps limit CBT-I availability, and tapering off long-term sleep medications shows the greatest success when combined with CBT-I.

Read at Psychology Today