Selecting a Treatment Regimen
Figure 2. Treatment of Chronic Insomnia
Insomnia Disorder
Insomnia comorbid
with other sleep
disorder
Optimize treatment
for other sleep disorder
Not
improved
Improved
Insomnia comorbid
with medical,
psychiatric, drug
"Primary" insomnias
Optimize treatment
for comorbid disorder
Evaluate insomnia treatment
options (cost, preference,
availability)
Psychological and
behavioral treatment
Not
improved
Pharmacologic
treatment
Combined
treatment
CBT
BzRA or ramelteon
Consider switching to
other modality or
combined treatment
Not
improved
Improved
Improved
Not
improved
Improved
Reconsider diagnosis
Other behavioral
treatment
Improved
Follow-up with
periodic review of
efficacy, review of
Tx principles
Re-evaluate especially
for occult or comorbid
disorders
Different BzRA
or ramelteon
Not
improved
Not
improved
Improved
Not
improved
Ongoing follow-up
for efficacy, side
effects, optimal
duration/
discontinuation
Sedating
antidepressant
Other behavioral
treatment 2
Not
improved
Improved
BzRA + sedating
antidepressant
Not
improved
Improved
Improved
