Insomnia Management
Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for chronic insomnia disorder. [1]
In adults with chronic insomnia disorder, CBT-I may be used with insomnia medication only in selected circumstances, based on patient values and treatment priorities. [2]
Initial Clinical Assessment
Chronic insomnia disorder should be evaluated in the context of comorbid sleep disorders, including obstructive sleep apnea (OSA). [2]
First-Line Nonpharmacologic Treatment
CBT-I is recommended as first-line insomnia treatment. [1]
Medication Selection Algorithm
Insomnia medication selection should be considered only after prioritizing CBT-I as the first-line treatment. [1]
Monotherapy vs Combination Therapy
Combination therapy with CBT-I plus insomnia medication is suggested over insomnia medication alone for adults with chronic insomnia disorder. [2]
Combination therapy with CBT-I plus insomnia medication is suggested against (i.e., should not be routinely preferred) over CBT-I alone for adults with chronic insomnia disorder. [2]
Treatment Initiation Thresholds
CBT-I is recommended for initiation as first-line therapy for chronic insomnia disorder. [1]
Combination therapy may be selected when patient priorities favor earlier improvement in sleep duration. [2]
Key Evidence Supporting This Recommendation
The AASM combination-therapy guideline assigns conditional recommendations with low certainty of evidence for CBT-I plus medication versus medication alone and for CBT-I plus medication versus CBT-I alone. [2]
Common Pitfalls to Avoid
Avoid selecting insomnia medication monotherapy as the default treatment strategy when chronic insomnia disorder management is planned. [1]
Avoid routinely preferring combination therapy over CBT-I alone in adults with chronic insomnia disorder. [2]
Treatment Goals
The treatment approach should align with patient-valued outcomes, including prioritization of increased total sleep time early in treatment when combination therapy is selected. [2]