What are the American Association of Sleep Medicine (AASM) treatment guidelines for insomnia?

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

The American Association of Sleep Medicine (AASM) guideline states that the 2 primary goals of treatment are to improve sleep quality and to improve related daytime impairments. [1] Strategies for achieving these goals will vary depending on the underlying etiology. If the patient has a medical, neurologic, or sleep disorder, treat the disorder. In particular, adequate pain control can greatly relieve the insomnia associated with pain syndromes. In 2017, the AASM released an updated guideline for the pharmacologic treatment of chronic insomnia in adults. [6]

The AASM guideline recommends psychological and behavioral interventions (including, but not limited to, cognitive-behavioral therapy [CBT]) as effective in the treatment of chronic comorbid insomnia as well as primary insomnia. The guideline also encourages these interventions as initial therapy when appropriate. [1]

The treatment of primary (psychophysiologic) insomnia begins with education about the sleep problem and appropriate sleep hygiene measures (elements of good sleep hygiene are described in Patient Education). Before therapy is instituted, most patients are asked to maintain a sleep diary for 1-2 weeks (see Sleep Diary). This provides a clearer picture of the degree of sleep disturbance and allows development of a tailored treatment.

Strong evidence supports the use of nonpharmacologic interventions (eg, CBT) for insomnia. Head-to-head comparison has shown that the long-term benefits of nonpharmacologic interventions are superior to those of medication. [67, 68, 69] CBT is now considered the most appropriate treatment for patients with primary insomnia. [3, 4, 5] Use of this therapy is based on the fact that primary insomnia is associated with physiologic, emotional, and cognitive arousal and conditioning to arousal in bed.

If the patient has a psychiatric disorder, the disorder should be treated. Management may involve medications, psychotherapy, and possible referral to a psychiatrist, psychologist, or therapist. If the insomnia is related to medication or drug abuse, the offending medication or drug must be slowly tapered and withdrawn.

Even when comorbid causes of insomnia (ie, medical, psychiatric) are treated, however, variable degrees of insomnia persist that require additional interventions. These patients can benefit from CBT [16] and a short course of a sedative-hypnotic or melatonin receptor agonist. In the case of a psychiatric disorder (eg, depression [70] or anxiety), CBT and a short-term sedative-hypnotic in conjunction with an antidepressant can be beneficial.


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