COMPARISON OF THE TRADITIONAL PHARMACOLOGICAL APPROACH, Z-HYPNOTICS, MELATONIN, AND BEHAVIORAL THERAPIES IN THE TREATMENT OF CHRONIC INSOMNIA

Abstract

Introduction: Chronic insomnia is a prevalent disorder impacting daytime functioning, cognitive health, and overall quality of life. Its pathophysiology relies on hyperarousal and neurochemical alterations within the central nervous system. Objective: To evaluate the efficacy and safety of the main therapeutic strategies used in the management of chronic insomnia, comparing traditional pharmacotherapy, Z-hypnotics, melatonin, and behavioral therapies. Methodology: An integrative review was conducted through systematic searches in PubMed and SciELO databases, covering original articles published between 2020 and 2025 that addressed sleep parameters, safety, and intervention tolerability. Results: Benzodiazepines and Z-hypnotics demonstrated acute efficacy by reducing sleep onset latency and increasing total sleep time. However, prolonged use was associated with rapid tolerance development (within 3 to 14 days), dependence, residual sleepiness, anterograde amnesia, and an increased risk of falls and accidents. Melatonin, particularly in older adults at appropriate doses, exhibited a favorable safety profile, increasing total sleep time and sleep efficiency without inducing rebound or withdrawal symptoms. Cognitive Behavioral Therapy for Insomnia (CBT-I) and dCBT-I produced a reduction of approximately 50% in symptom severity, improving objective sleep metrics and maintaining therapeutic efficacy for up to 24 months. DISCUSSION: Sedative pharmacological treatments offer rapid symptomatic relief but present structural limitations due to unfavorable adverse event profiles and loss of sustained efficacy. In older adults, neurocognitive and motor risks contraindicate the prolonged use of GABAergic hypnotics. Melatonin acts on chronobiological regulation with high tolerability. Meanwhile, CBT-I establishes itself as the first-line intervention by targeting the perpetuating factors of hyperarousal without organic toxicity. Temporary combination of hypnotics with CBT-I emerges as an alternative in refractory cases to enable safe medication tapering. Conclusion: CBT-I is consolidated as the gold-standard, first-line approach in chronic insomnia management due to the durability of its results. Sedative pharmacotherapies should be restricted to acute settings, whereas melatonin represents a safe option for long-term modulation.