Multimodal Optimized Treatment for Insomnia Framework (MOTIF): A Better Strategy for the Optimal Prescription of Hypnotics

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Sleep Med Res. 2025;16(2):129-132

Publication date (electronic) : 2025 May 30

doi : https://doi.org/10.17241/smr.2025.02873

Seockhoon Chung, MD, PhD^,1,2

¹Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

²Life Care Center for Cancer Patient, Asan Medical Center Cancer Institute, Asan Medical Center, Seoul, Korea

Corresponding Author Seockhoon Chung, MD, PhD Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 86 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel +82-2-3010-3411 Fax +82-2-485-8381 E-mail schung@amc.seoul.kr

Received 2025 March 14; Revised 2025 May 23; Accepted 2025 May 26.

Abstract

INTRODUCTION

Cognitive behavioral therapy for insomnia (CBT-I) is generally recommended as the first-line treatment in treating patients with insomnia over sleeping pills [1]. Generally, sleeping pills are used for a short period, usually less than 4 weeks [2,3]. CBT-I can help patients with insomnia to reduce their chances of taking sleeping pills without a good reason. However, some patients do not respond well to CBT-I and are unable to sleep without medications. Moreover, clinicians often encounter patients who continue taking sleeping pills for a long time, making the “less than four weeks” recommendation meaningless. Therefore, more sophisticated and optimized treatments need to be developed.

INSOMNIA DISORDER AS AN INVOLUNTARY NATURE

For clinicians and patients to avoid unnecessary emotional exhaustion, it is crucial to understand why some patients have trouble falling asleep without medication despite CBT-I. Clinically, many clinicians struggle with deciding whether to continue or stop prescribing sleeping pills. Why does this happen? Take a look at how we treat hypertension. Clinicians do not prescribe antihypertensive medications to patients when they only say, “My blood pressure is high.” Antihypertensive medications are prescribed by doctors after they diagnose the patient with hypertension as a disorder, following “checking” blood pressure multiple times. And, the clinicians instruct patients who have been diagnosed with hypertension to continue taking antihypertensive medications to control their hypertension. If a patient’s high blood pressure is temporary, clinicians will not prescribe antihypertensive medications. What about prescribing hypnotics? Unfortunately, many clinicians prescribe hypnotics to patients who complain of sleep disturbance without “checking” sleep indices or investigating the underlying causes. It is important to explore whether the patients’ insomnia can be improved with non-pharmacological treatment, such as CBT-I. With this information, clinicians can decide to prescribe hypnotics to patients who cannot have a good sleep despite CBT-I. However, because clinicians do not check whether patients can sleep without medications or not, they have difficulty deciding whether to prescribe or instruct patients to quit hypnotics.

How can we understand the phenomenon of patients having difficulty sleeping without medications? Based on the 3-P model of insomnia [4], reducing the precipitating or perpetuating factors might solve sleep disturbance. This model lets us think that sleep disturbance can be cured with CBT-I, without medications. This concept can empower patients with insomnia to minimize their reliance on sleeping pills. However, if overemphasized, it might lead some individuals to believe that hypnotic medications should be discontinued entirely, which may not be appropriate for everyone. For example, if we apply this model to patients with cancer [5], we may face the situation that there are several precipitating factors, such as severe pain [6] or vasomotor symptoms, that cannot be treated without medications. Furthermore, the development of prolonged-release melatonin (PRM) shows that insomnia in certain patients over 55 years of age [7] may be because of decreased melatonin levels, which is related to the aging process.

Evidence suggests that insomnia in certain patients can result from decreased brain function. First, the slow-wave activity (SWA) decreases with aging [8]. According to a previous study, decreased SWA is associated with age-related gray matter atrophy in the medial prefrontal cortex [9]. The aging process reveals that some elderly patients with insomnia may experience sleep disturbances that cannot be resolved without medications. Second, peak melatonin levels decrease with aging, which is part of what contributes to PRM development [7]. PRM is effective in reducing insomnia by mimicking the body’s natural decline in endogenous melatonin production with age. This also shows that some patients with insomnia over 55 years of age may have trouble falling asleep without PRM medications. Third, pineal gland hypofunction is associated with sleep disturbances. PRM is recommended for individuals with autism spectrum disorder [10], among whom pineal gland hypofunction is often observed [11]. This finding indicates that some individuals with pineal gland hypofunction need to take medications for sleep.

MOTIF: MULTIMODAL OPTIMIZED TREATMENT FOR INSOMNIA FRAMEWORK

The clinical practice guidelines for insomnia treatment recommend that CBT-I should be performed first [1] and that sleeping pills should be prescribed for a short duration [2,3]. There are several issues associated with the flow of insomnia treatment. First, the guidelines recommend that CBT-I should be performed first for all patients with insomnia before taking hypnotics. This is reasonable because non-pharmacological treatment should be attempted first and is meaningful because it may decrease the likelihood of taking hypnotics. However, it may not be possible to treat every insomnia patient just with CBT-I in real clinical settings because the implementation of non-pharmacological treatment takes a considerable amount of time and effort. Thus, it is beneficial to identify patients who are likely to benefit from CBT-I before its implementation in all patients with insomnia. Second, the clinical practice guidelines recommend that hypnotics should be prescribed for a short duration because long-term use can lead to dependency, tolerance, cognitive impairment, or falls. Thus, non-pharmacological treatment should be prioritized over the prescription of hypnotics. However, several studies have shown that the long-term use of hypnotics may be safe [12]. Moreover, some patients’ sleep disturbances did not improve despite the treatment with CBT-I. Thus, to provide the best treatment for insomnia, clinicians must determine whether sleep disturbances can be effectively treated with CBT-I or pharmacological treatment.

Multimodal Optimized Treatment for Insomnia Framework (MOTIF) is a model for optimized insomnia treatment (Fig. 1). It begins when the insomnia disorder is finally diagnosed after excluding other sleep disorders (e.g., circadian rhythm sleep–wake disorder, restless legs syndrome, or obstructive sleep apnea syndrome). The first step of MOTIF is differentiating patients with insomnia into “patients who can sleep without hypnotics” and “patients who cannot sleep without hypnotics.” Through this process, we can easily decide whether CBT-I or sleeping pills should be recommended.

Fig. 1.

The MOTIF helps physicians determine whether to recommend CBT-I or hypnotic medications for patients with insomnia. CBT-I is typically recommended as the first-line treatment for patients who are able to sleep without medication. In contrast, hypnotics may be prescribed for patients who are unable to sleep without the aid of medication. *Assessing patients’ preference to take hypnotics. MOTIF, Multimodal Optimized Treatment for Insomnia Framework; CBT-I, cognitive behavioral therapy for insomnia.

For patients who can sleep without hypnotics, CBT-I is recommended over the prescription of hypnotics. Of note, patients’ acceptance of or preference for taking hypnotics needs to be assessed to provide more detailed instructions. Physicians should encourage patients to undergo CBT-I instead of prescribing hypnotics, especially when patients request or insist on medication. Conversely, if patients do not want to take hypnotics, CBT-I is the best treatment option. For patients who are unable to sleep without hypnotics, prescribing hypnotics over CBT-I may be considered as CBT-I alone may not be effective in helping them fall asleep. Furthermore, if a patient wants or agrees to take hypnotics, it is the physician’s duty to prescribe them in an optimized manner with the minimal effective dose [13]. However, if a patient does not want to take hypnotics, sleep disturbances may remain unresolved.

UNMET NEEDS TO BE ADDRESSED FOR OPTIMIZED INSOMNIA TREATMENT

The first challenge that needs to be solved is how to distinguish patients with insomnia who can sleep without medications from those who cannot. CBT-I is an effective treatment for insomnia. However, many patients have trouble sleeping despite this treatment. The compliance of CBT-I was considered to be 60% [14]. According to a previous study, responders to nonpharmacological treatment for insomnia were younger than non-responders [15]. Moreover, in patients with sleep onset latency (SOL), the SOL <30 minutes group showed a longer duration from wake-up time to bedtime (16.5±1.1 hours) than the SOL >30 minutes group (15.8±1.5 hours) [16]. Based on the sleep restriction concept of CBT-I proposed by Spielman et al. [17], shortening the time in bed to match optimal sleep efficiency may reduce sleep disturbance. How can we help patients who are unable to sleep despite sleep restriction therapy? It may be the right time to begin prescribing sleeping pills. Usually, 7 hours of sleep is recommended as an optimal total sleep time [18]. Based on the sleep restriction therapy, time in bed can be reduced to increase sleep efficiency. Suppose a patient cannot sleep even though the patient has exercised 18 hours a day for 3 months. Are you still going to offer CBT-I or recommend to take hypnotics? Thus, I just propose that sleeping pills should be prescribed if a patient cannot sleep for a long time despite 18 hours of activity.

The second challenge is to measure patients’ preferences for hypnotics. The Insomnia Treatment Acceptability Scale (ITAS) is a rating scale that can measure patients’ acceptance of treatment [19]. The ITAS-M (medication), one of the subscales of the ITAS, measures the acceptability of medications. It captures patients’ willingness, perceived suitability, and expected outcomes of treatment. A new rating scale is needed—one that specifically assesses individuals’ beliefs about the involuntary nature of insomnia and their perceived need for medication to achieve better sleep, grounded in the principles of the MOTIF model. We can guide patients’ selection of pharmacological or non-pharmacological treatment more in detail by assessing their preferences for sleeping pills (Fig. 1). In some cases, patients should be advised not to take sleeping pills. However, in other cases, we should suggest that they take sleeping pills. A discrepancy between the clinician’s instruction to discontinue sleeping pills and the patient’s willingness to take sleeping pills for prolonged insomnia occurs when we do not assess whether the patient can sleep without medications.

The third challenge is developing an optimal treatment strategy for insomnia [13]. The clinical practice guidelines recommend evidence-based sleeping pills [2,3]. Clinicians generally know the mechanism of action of each sleeping pill, but they often face the failure of pharmacological treatment. For example, according to previous studies, the administration time of sleeping pills is important for the optimal pharmacological treatment of insomnia [20-22]. If we instruct the patient to take hypnotics 30 minutes before bedtime, they may take hypnotics 30 minutes before they want to go to bed. This may occasionally advance bedtime, making it difficult to fall asleep based on the two-process model [23]. Aligning the time to take hypnotics with the time to get out of bed in the morning is important for patient satisfaction with sleeping pills and may reduce or prevent increasing the dosage of hypnotics. Thus, more detailed methods need to be developed to optimize the effectiveness of hypnotics.

CONCLUSIONS

This paper proposes a framework for the multimodal optimization of insomnia treatment. MOTIF aims to provide a comprehensive approach to optimizing insomnia treatment by considering multiple factors (e.g., the possibility that patients can sleep without medications; patients’ preference for hypnotics; and optimization strategy for prescribing hypnotics based on dosage, timing, and patient satisfaction). By using this framework, clinicians can make more informed decisions with regard to prescribing or discontinuing hypnotics, thereby improving patient outcomes and reducing the risk of overmedication.

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