Insomnia Guidelines

Updated: Sep 11, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
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Guidelines

Guidelines Summary

Low-value care

In 2014, as part of the Choosing Wisely® initiative from the American Board of Internal Medicine Foundation (ABIM), the AASM recommended that physicians avoid polysomnography (PSG) in patients with chronic insomnia unless symptoms suggest a comorbid sleep disorder. It further recommended that hypnotics be avoided as primary therapy for chronic insomnia in adults. Instead, clinicians should offer cognitive-behavioral therapy (CBT), reserving medication for adjunctive treatment when necessary. [106]

Evaluation

The American Academy of Sleep Medicine (AASM) guideline consensus is that insomnia is primarily diagnosed by clinical evaluation through a thorough sleep history and detailed medical, substance, and psychiatric history. At a minimum, patients should complete the following evaluations: [1]

  • A general medical and psychiatric questionnaire to detect comorbid disorders

  • A sleepiness assessment, such as the Epworth Sleepiness Scale

  • A 2-week sleep log to define sleep-wake patterns and their variability

Sleep diary data should be collected before and during the course of active treatment and in the case of relapse or reevaluation in the long term.

Other testing (eg, blood, imaging studies) is not indicated for the routine evaluation of chronic insomnia unless there is suspicion for comorbid disorders.

Achieving healthy sleep

In 2015, the American Thoracic Society (ATS) released a policy statement stressing the importance of achieving good-quality sleep and avoiding sleep deprivation. Key recommendations include the following: [107]

  • Good-quality sleep is critical for good health and overall quality of life
  • Short sleep duration (6 hours or less per 24-hour period) is associated with adverse outcomes, including mortality
  • Long sleep duration (>9 to 10 hours per 24-hour period) may also be associated with adverse health outcomes
  • At a population level, the optimal sleep duration in adults for good health is 7 to 9 hours, although individual variability exists
  • Because drowsy driving is an important cause of fatal and nonfatal motor vehicle crashes, all drivers (occupational and nonoccupational) should receive education about how to recognize the symptoms and consequences of drowsiness
  • Better education is needed for the general public and healthcare providers regarding the effect of working hours and shift work on sleep duration and quality and the association of sleepiness with workplace injuries
  • Sleep disorders are common, cause significant morbidity, and have substantial economic impact, but they are treatable; however, many individuals with sleep disorders remain undiagnosed and untreated
  • Age-based recommendations for sleep duration in children should be developed; these should enable the child to awaken spontaneously at the desired time through implementation of regular wake and sleep schedules
  • For adolescents, school start times should be delayed to align with the physiologic circadian propensity of this age group
  • Healthcare providers should receive more education on sleep hygiene and encourage patients to maximize their sleep time
  • Public education programs should be developed to emphasize the importance of sleep for good health
  • Better education/awareness is needed of the importance of early identification of groups at high risk for obstructive sleep apnea (in children and adults)
  • Better education of physicians as to the effectiveness of cognitive-behavior therapy for insomnia rather than immediate implementation of hypnotics and sedatives, and structural changes to increase access to this therapy

Pharmacological treatment for chronic insomnia

The following recommendations from the American Academy of Sleep Medicine (AASM) are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults, when such treatment is indicated. [110]

For patients with primary insomnia (psychophysiologic, idiopathic or paradoxical ICSD-2 subtypes), when pharmacologic treatment is utilized alone or in combination therapy, the recommended general sequence of medication trials is as follows:

  • Short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon—zolpidem, eszopiclone, zaleplon, and temazepam
  • Alternate short-intermediate acting BzRAs or ramelteon if the initial agent has been unsuccessful
  • Sedating antidepressants, especially when used in conjunction with treating comorbid depression/anxiety—trazodone, amitriptyline, doxepin, and mirtazapine
  • Combined BzRA or ramelteon and sedating antidepressant
  • Other sedating agents—anti-epilepsy medications (gabapentin, tiagabine) and atypical antipsychotics (quetiapine and olanzapine)