Management of Chronic Insomnia Disorder in Adults: American College of Physicians Guidelines

Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)

Cognitive behavioral therapy for insomnia consists of a combination of treatments that include cognitive therapy around sleep, behavioral interventions (such as sleep restriction and stimulus control), and education (such as sleep hygiene). It can be performed in primary care. There are various delivery methods for CBT-I, such as individual or group therapy, telephone- or Web-based modules, or self-help books. Most studies focused on in-person CBT-I; however, the data suggest that other delivery methods are also effective.

Cognitive behavioral therapy for insomnia should be considered first-line treatment for adults with chronic insomnia disorder. Although the current evidence is insufficient to show the harms associated with behavioral interventions, any such harms are likely to be mild. Moderate-quality evidence showed that CBT-I improved global outcomes in the general population, including increased remission and treatment response and reduced ISI and PSQI scores compared with controls. Moderate-quality evidence showed that CBT-I also improved sleep outcomes in the general population, including reduced sleep onset latency and wake after sleep onset and improved sleep efficiency and sleep quality. Low- to moderate-quality evidence showed that CBT-I also improved global and sleep outcomes in older adults, including improved PSQI and ISI scores, reduced sleep onset latency, and improved sleep efficiency. Moderate-quality evidence showed that CBT-I reduced wake after sleep onset in older adults.

Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)

Benefits of pharmacologic treatment include improved sleep outcomes, such as sleep onset latency and total sleep time, and in some cases improved global outcomes in the general population and in older adults. Most studies have examined newer medications, whereas commonly used older and generic medications, such as diphenhydramine and trazodone, have not been studied. Low-quality evidence showed that both eszopiclone and zolpidem improved global outcomes in the general population, and low- to moderate-quality evidence showed that eszopiclone, zolpidem, and doxepin improved sleep outcomes, such as sleep onset latency, total sleep time, and wake after sleep onset. Moderate-quality evidence showed that suvorexant, an orexin antagonist recently approved by the FDA, improved treatment response and sleep outcomes in mixed general and adult populations. Low-quality evidence showed no statistically significant difference between ramelteon and placebo for sleep outcomes in the general population.