and expectations that can be modified include: unrealistic sleep expectations. misconceptions about insomnia causes. amplifying the consequences of insomnia. performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process. numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies. hypnotic medications are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to tolerance. the effects of cbt-i have sustained and lasting effects on treating insomnia long after therapy has been discontinued. the addition of hypnotic medications with cbt-i adds no benefit in insomnia. the long lasting benefits of a course of cbt-i shows superiority over pharmacological hypnotic drugs. even in the short term when compared to short-term hypnotic medication such as zolpidem, cbt-i still shows significant superiority. thus cbt-i is recommended as a first line treatment for insomnia. common forms of cbt-i treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleeping environments, relaxation training, paradoxical intention, and biofeedback. cbt is the well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms have been shown to have adverse side effects. nevertheless, the downside of cbt is that it may take a lot of time and motivation. acceptance and commitment therapy treatments based on the principles of acceptance and commitment therapy (act) and metacognition have emerged as alternative approaches to treating insomnia. act rejects the idea that behavioral changes can help insomniacs achieve better sleep, since they require "sleep efforts" - actions which create more "struggle" and arouse the nervous system, leading to hyperarousal. the act approach posits that acceptance of the negative feelings associated with insomnia can, in time, create the right conditions for sleep. mindfulness practice is a key feature of this approach, although mindfulness is not practised to induce sleep (this in itself is a sleep effort to be avoided) but rather as a longer-term activity to help calm the nervous system and create the internal conditions from which sleep can emerge. a key distinction between cbt-i and act lies in the divergent approaches to time spent awake in bed. proponents of cbt-i advocate minimizing time spent awake in bed, on the basis that this creates cognitive association between being in bed and wakefulness. the act approach proposes that avoiding time in bed may increase the pressure to sleep and arouse the nervous system further. research has shown that "act has a significant effect on primary and comorbid insomnia and sleep quality, and ... can be used as an appropriate treatment method to control and improve insomnia". internet interventions despite the therapeutic effectiveness and proven success of cbt, treatment availability is significantly limited by a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense. one way to potentially overcome these barriers is to use the internet to deliver treatment, making this effective intervention more accessible and less costly. the internet has already become a critical source of health-care and medical information. although the vast majority of health websites provide general information, there is growing research literature on the development and evaluation of internet interventions. these online programs are typically behaviorally-based treatments that have been operationalized and transformed for delivery via the internet. they are usually highly structured; automated or human supported; based on effective face-to-face treatment; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback. there is good evidence for the use of computer based cbt for insomnia. medications many people with insomnia use sleeping tablets and other sedatives. in some places medications are prescribed in over 95% of cases. they, however, are a second line treatment. in 2019, the us food and drug administration stated it is going to require warnings for eszopiclone, zaleplon, and zolpidem, due to concerns about serious injuries resulting from abnormal sleep behaviors, including sleepwalking or driving a vehicle while asleep. the percentage of adults using a prescription sleep aid increases with age. during 2005–2010, about 4% of u.s. adults aged 20 and over reported that they took prescription sleep aids in the past 30 days. rates of use were lowest among the youngest age group (those aged 20–39) at about 2%, increased to 6% among those aged 50–59, and reached 7% among those aged 80 and over. more adult women (5%) reported using prescription sleep aids than adult men (3%). non-hispanic white adults reported higher use of sleep aids (5%) than non-hispanic black (3%) and mexican-american (2%) adults. no difference was shown between non-hispanic black adults and mexican-american adults in use of prescription sleep aids. antihistamines as an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking over-the-counter antihistamines such as diphenhydramine or doxylamine. diphenhydramine and doxylamine are widely used in nonprescription sleep aids. they are the most effective over-the-counter sedatives currently available, at least in much of europe, canada, australia, and the united states, and are more sedating than some prescription hypnotics. antihistamine effectiveness for sleep may decrease over time, and anticholinergic side-effects (such as dry mouth) may also be a drawback with these particular drugs. while addiction does not seem to be an issue with this class of drugs, they can induce dependence and rebound effects upon abrupt cessation of use. however, people whose insomnia is caused by restless legs syndrome may have worsened symptoms with antihistamines. antidepressants while insomnia is a common symptom of depression, antidepressants are effective for treating sleep problems whether or not they are associated with depression. while all antidepressants help regulate sleep, some antidepressants, such as amitriptyline, doxepin, mirtazapine, trazodone, and trimipramine, can have an immediate sedative effect, and are prescribed to treat insomnia. amitriptyline, doxepin, and trimipramine all have antihistaminergic, anticholinergic, antiadrenergic, and antiserotonergic properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine's actions are primarily antihistaminergic and antiserotonergic and trazodone's effects are primarily antiadrenergic and antiserotonergic. mirtazapine is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia. agomelatine, a melatonergic antidepressant with claimed sleep-improving qualities that does not cause daytime drowsiness, is approved for the treatment of depression though not sleep conditions in the european union and australia. after trials in the united states, its development for use there was discontinued in october 2011 by novartis, who had bought the rights to market it there from the european pharmaceutical company servier. a 2018 cochrane review found the safety of taking antidepressants for insomnia to be uncertain with no evidence supporting long term use. melatonin agonists melatonin receptor agonists such as melatonin and ramelteon are used in the treatment of insomnia. the evidence for melatonin in treating insomnia is generally poor. there is low-quality evidence that it may speed the onset of sleep by 6 minutes. ramelteon does not appear to speed the onset of sleep or the amount of sleep a person gets. usage of melatonin as a treatment for insomnia in adults has increased from 0.4% between 1999 and 2000 to nearly 2.1% between 2017 and 2018. most melatonin agonists have not been tested for longitudinal side effects. prolonged-release melatonin may improve quality of sleep in older people with minimal side effects. studies have also shown that children who are on the autism spectrum or have learning disabilities, attention-deficit hyperactivity disorder (adhd) or related neurological diseases can benefit from the use of melatonin. this is because they often have trouble sleeping due to their disorders. for example, children with adhd tend to have trouble falling asleep because of their hyperactivity and, as a result, tend to be tired during most of the day. another cause of insomnia in children with adhd is the use of stimulants used to treat their disorder. children who have adhd then, as well as the other disorders mentioned, may be given melatonin before bedtime in order to help them sleep. benzodiazepines normison (temazepam) is a benzodiazepine commonly prescribed for insomnia and other sleep disorders. the most commonly used class of hypnotics for insomnia are the benzodiazepines.: 363 benzodiazepines are not significantly better for insomnia than antidepressants. chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs not taking medications. in fact, chronic users of hypnotic medications have more regular night-time awakenings than insomniacs not taking hypnotic medications. many have concluded that these drugs cause an unjustifiable risk to the individual and to public health and lack evidence of long-term effectiveness. it is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly. between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the us, coinciding with the first release of nonbenzodiazepines. the benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side-effects such as day time fatigue, motor vehicle crashes and other accidents, cognitive impairments, and falls and fractures. elderly people are more sensitive to these side-effects. some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer term benzodiazepines can lead to tolerance, physical dependence, benzodiazepine withdrawal syndrome upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods of time. benzodiazepines, while inducing unconsciousness, actually worsen sleep as – like alcohol – they promote light sleep while decreasing time spent in deep sleep. a further problem is, with regular use of short-acting sleep aids for insomnia, daytime rebound anxiety can emerge. although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase. this is likely due to their addictive nature, both due to misuse and because – through their rapid action, tolerance and withdrawal they can "trick" insomniacs into thinking they are helping with sleep. there is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the long-term use of benzodiazepines and is recommended whenever possible. benzodiazepines all bind unselectively to the gabaa receptor. some theorize that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α1 subunit of the gabaa receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α1 subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics – alprazolam and diazepam, in turn, have higher activity at the α2 subunit compared to triazolam and temazepam, making them superior anxiolytic agents). modulation of the α1 subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). modulation of the α2 subunit is associated with anxiolytic activity and disinhibition. for this reason, certain benzodiazepines may be better suited to treat insomnia than others. z-drugs nonbenzodiazepine or z-drug sedative–hypnotic drugs, such as zolpidem, zaleplon, zopiclone, and eszopiclone, are a class of hypnotic medications that are similar to benzodiazepines in their mechanism of action, and indicated for mild to moderate insomnia. their effectiveness at improving time to sleeping is slight, and they have similar—though potentially less severe—side effect profiles compared to benzodiazepines. prescribing of nonbenzodiazepines has seen a general increase since their initial release on the us market in 1992, from 2.3% in 1993 among individuals with sleep disorders to 13.7% in 2010. orexin antagonists orexin receptor antagonists are a more recently introduced class of sleep medications and include suvorexant, lemborexant, and daridorexant, all of which are fda-approved for treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance. antipsychotics certain atypical antipsychotics, particularly quetiapine, olanzapine, and risperidone, are used in the treatment of insomnia. however, while common, use of antipsychotics for this indication is not recommended as the evidence does not demonstrate a benefit, and the risk of adverse effects are significant. a major 2022 systematic review and network meta-analysis of medications for insomnia in adults found that quetiapine did not demonstrate any short-term benefits for insomnia. some of the more serious