Clinical Scorecard: New Guidance on Chronic Insomnia Treatment

At a Glance

Key Highlights

• CBT-I is the preferred first-line treatment for chronic insomnia.
• Combination therapy offers modest benefits over pharmacotherapy alone but no clinically meaningful improvements over CBT-I alone.
• Pharmacotherapy alone is appropriate when CBT-I is unavailable, unaffordable, or not feasible.

Guideline-Based Recommendations

Diagnosis

• Diagnosis based on clinical evaluation consistent with chronic insomnia disorder criteria.

Management

• Use CBT-I as first-line therapy for chronic insomnia.
• Consider combination therapy (CBT-I plus pharmacotherapy) over pharmacotherapy alone in selected patients prioritizing rapid symptom relief or short-term total sleep time increases.
• Avoid combination therapy over CBT-I alone due to lack of clinically meaningful added benefit.
• Reserve pharmacotherapy alone for patients unable to access or engage in CBT-I.

Monitoring & Follow-up

• Monitor for adverse effects, particularly morning sleepiness, when using combination therapy.
• Assess insomnia severity, sleep continuity, and daytime functioning to guide treatment adjustments.

Risks

• Combination therapy is associated with slightly higher rates of adverse effects compared to pharmacotherapy alone.
• Medication-related adverse effects should be considered, especially when avoiding pharmacotherapy.

Patient & Prescribing Data

Adults with chronic insomnia, including those prioritizing rapid symptom relief or short-term sleep improvements.

Combination therapy may provide small improvements over medication alone but does not enhance outcomes beyond CBT-I alone; pharmacotherapy alone is suitable when CBT-I is inaccessible.

Clinical Best Practices

• Employ shared decision-making incorporating patient preferences, clinical priorities, and access to care.
• Tailor treatment strategies individually, considering the conditional nature of recommendations and evidence limitations.
• Utilize digital CBT-I and telemedicine to improve access where traditional CBT-I is limited.
• Recognize and address disparities in access to behavioral treatments to reduce inequities in insomnia care.

Related Resources & Content

• American Academy of Sleep Medicine Clinical Practice Guideline on Chronic Insomnia