What is the first-line nonpharmacologic therapy for chronic insomnia?

• A. Cognitive Behavioral Therapy for Insomnia (CBT-I) with sleep hygiene education.
• B. Long-term benzodiazepine use.
• C. Over-the-counter sedating antihistamines.
• D. Melatonin as first-line treatment.

Answer: (A)

Cognitive Behavioral Therapy for Insomnia (CBT-I) with sleep hygiene education is the preferred first-line nonpharmacologic approach for chronic insomnia. This therapy targets the behaviors and thoughts that perpetuate sleep problems, not just the symptoms. It typically includes components like stimulus control (training your brain to link bed with sleep and to leave the bed if you can’t sleep), sleep restriction (limiting time in bed to increase sleep efficiency), cognitive strategies to reframe worried thoughts about sleep, and relaxation techniques, along with practical sleep-hygiene guidance (regular wake times, a conducive sleep environment, avoiding caffeine or heavy meals close to bedtime, and limiting daytime napping).

The strength of CBT-I lies in its solid evidence base showing improvements in sleep onset, wake-after-sleep (maintenance), total sleep time, and daytime functioning, with benefits that often last beyond the treatment period. It also avoids medication-related risks like dependence, tolerance, and daytime sedation. If access is limited, digital or guided self-help versions can still provide meaningful benefits.

Other options aren’t first-line nonpharmacologic approaches. Long-term use of benzodiazepines carries dependency and other safety concerns; over-the-counter sedating antihistamines can cause next-day grogginess and anticholinergic side effects, and melatonin, while sometimes helpful for certain sleep issues, does not address the behavioral and cognitive perpetuators of chronic insomnia and is not considered a comprehensive first-line nonpharmacologic therapy.