The New First-Line Treatment for Adult Insomnia

Are You Prepared to Deliver It?

Neil Skolnik, MD


November 10, 2021

I'm Dr Neil Skolnik, and today we're going to talk about the 2021 behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine (AASM) clinical practice guideline. Let me say from the outset that if we choose to integrate these recommendations into our practice, they will change our approach to insomnia. Since its initial set of recommendations in 1999, not just the American Academy of Sleep Medicine, but also the British guidelines, the European guidelines and the guidelines from the American College of Physicians have all recommended that adult patients receive cognitive-behavioral therapy (CBT) as first-line treatment for chronic insomnia.

In 2017, the AASM issued a guideline that addressed pharmacologic treatment, and the guideline was clear. Let me quote from it:

All patients with chronic insomnia should receive CBT II as a primary intervention. Medications for chronic insomnia should be considered mainly in patients who are unable to participate in CBT II, who still have symptoms despite having done behavioral treatments or in select cases as a temporary adjunct to CBT.

Now that's a large statement and one we need to heed. Let's look at the details and then talk about how to make them actionable.

The guidelines give their highest recommendation — a strong recommendation — that clinicians use multicomponent CBT II for treatment of insomnia. This recommendation is based on 49 studies of patients with and without medical and psychiatric comorbidities. The beauty of CBT II is that while it can be more expensive than medicines in the short term, it only needs to be done for four to eight sessions, and effective CBT II can be long-lasting.

Conditional Recommendations

A conditional recommendation is given for multicomponent, brief therapies for insomnia because there are only seven studies. These are, in essence, abbreviated versions of CBT that typically run from one to four sessions. They emphasize addressing behaviors that promote or interfere with sleep with a tailored behavioral approach (such as consistent wake time, going to bed only when sleepy, relaxation therapy, sleep-restriction therapy, and cognitive therapy). An advantage of brief therapy over CBT is that it's shorter and therefore less expensive.

Conditional recommendations are given as well for single-component therapies, and that includes stimulus control, sleep-restriction therapy, and relaxation therapy. Of interest, there's a conditional recommendation against something most of us routinely do in the office, which is sleep-hygiene education. Remember, sleep hygiene is about avoiding excessive caffeine or alcohol intake, having a set bedtime and wake time, and exercising a reasonable amount.

The recommendation against sleep hygiene doesn't mean we shouldn't be educating on sleep hygiene. We should. It's important, but what this means is that sleep hygiene education alone is not a sufficient intervention for chronic insomnia, and that it needs to be used as a part of a broader behavioral approach.

Easy for PCPs?

In my opinion, given the emphasis on behavioral therapy in the guidelines based on really strong evidence, most of us in primary care should understand how to do one or two of the single-component therapies. The easiest one to learn is progressive relaxation therapy. You can look up online how to do that. Also, we ought to have someone to refer to locally for CBT. And because that's often hard to find and can be expensive, find an online resource for CBT to refer patients to. Here are a couple of recommendations for online resources:

Cleveland Clinic: Go! to Sleep


This is certainly not a comprehensive list, but I picked them because they do have some published studies to show that they're effective.

This is an important guideline. And if we pay attention to the guideline, it can really change the way we approach insomnia and our practices for the better. I'm Neil Skolnik, and this is Medscape.

Neil Skolnik, MD, is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington – Jefferson Health. He has published over 350 articles, essays, poems, and op-eds in the medical and nonmedical literature, as well as four medical textbooks and a book of short stories. In addition, he is the host of the American Diabetes Association's monthly Diabetes Core Update podcast. Follow him or direct-message on Twitter: @NeilSkolnik

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