New Insomnia Guidelines Rank CBT-I First and Clarify When Sleep Drugs Are Safe

Insomnia is one of the most common public health concerns worldwide, characterized by dissatisfaction with sleep duration, continuity, or quality alongside daytime impairment. It disproportionately affects women, middle-aged and older adults, and those with mental or physical comorbidities — populations that are also central to longevity medicine. Beyond quality-of-life impacts, chronic insomnia is associated with elevated risk for cardiovascular, metabolic, and psychiatric conditions, making its treatment a meaningful lever for healthspan extension.

This 2025 narrative review by Ferini-Strambi, based at the Sleep Disorders Center of Vita-Salute San Raffaele University in Milan, synthesizes current evidence and guidelines on insomnia disorder classification, epidemiology, and management. Though the full methodology is not disclosed in the abstract, the review draws on randomized controlled trial data and established clinical guidelines to construct its recommendations.

Cognitive behavioral therapy for insomnia (CBT-I) is firmly endorsed as the first-line treatment for chronic insomnia in adults, consistent with major international guidelines. For cases where CBT-I is ineffective or unavailable, the review provides a structured pharmacological hierarchy. Benzodiazepines and benzodiazepine receptor agonists are appropriate for short-term use (up to four weeks), with triazolam singled out for its favorable short half-life, demonstrated efficacy for both sleep-onset and middle-of-the-night insomnia, and lack of psychomotor impairment. Orexin receptor antagonists extend the pharmacological window to up to three months. Non-nightly dosing is flagged as viable for patients not requiring nightly treatment.

The review cautions against antipsychotics and antihistamines for insomnia, while noting low-dose sedating antidepressants may be considered off-label for short-term use. A practical note is raised that real-world clinical practice often diverges from guideline-based daily dosing studied in RCTs.

A key caveat is the acknowledged gap in cost-effectiveness research for insomnia treatments, limiting health economic guidance. As a review article based only on the abstract, the full evidence base and methodology cannot be fully evaluated.