Chronic Insomnia Evaluation & Management (AASM 2021)

Algorithm Steps

1. ▶

   Start

   Insomnia Complaint

   Difficulty falling/staying asleep, ≥3x/week for ≥3 months, with daytime impairment

   1. ●

      Action

      Comprehensive Sleep History

      Characterize the insomnia

      • Sleep diary (2 weeks): bed/wake times, time to fall asleep, awakenings
      • Daytime consequences: fatigue, mood, concentration
      • Sleep environment: noise, light, temperature
      • Caffeine, alcohol, screen time patterns
      • Bed partner report: snoring, movements, apneas
      1. ◆

         Decision

         Secondary Causes?

         Rule out other sleep disorders and contributors

         • Sleep apnea (STOP-BANG screen)
         • Restless legs syndrome
         • Depression/anxiety
         • Substance use
         • Medications causing insomnia
         • Pain, nocturia, other medical
         1. ●

            Action

            Consider Sleep Study

            If sleep apnea suspected

            • Home sleep test or PSG if STOP-BANG ≥3
            • PSG if treatment-refractory insomnia
            • Rule out PLMD, REM behavior disorder
            1. ●

               Action

               Chronic Insomnia Disorder

               Primary insomnia or comorbid insomnia

               • ≥3 months duration
               • Adequate sleep opportunity but difficulty sleeping
               • Daytime impairment present
               • Often perpetuated by maladaptive behaviors
               1. ●

                  Action

                  CBT-I (First-Line)

                  Cognitive Behavioral Therapy for Insomnia

                  • AASM STRONGLY recommends as first-line
                  • Components: sleep restriction, stimulus control, cognitive restructuring
                  • Delivered in-person, group, or digital (e.g., Sleepio, Somryst)
                  • 6-8 sessions typical
                  • Durable benefits (unlike medications)
                  1. ●

                     Action

                     Sleep Hygiene Education

                     Supportive but not sufficient alone

                     • Regular sleep-wake schedule
                     • Avoid caffeine after noon
                     • Limit alcohol (disrupts sleep architecture)
                     • Cool, dark, quiet bedroom
                     • No screens 1h before bed
                     • Use bed only for sleep and intimacy
                  2. ◆

                     Decision

                     CBT-I Response?

                     Assess after 4-8 sessions

                     1. ✓

                        Outcome

                        CBT-I Success

                        Maintain gains, booster sessions if needed

                     2. ●

                        Action

                        Pharmacotherapy (Second-Line)

                        If CBT-I insufficient or unavailable

                        • Short-term use preferred (<4 weeks)
                        • Suvorexant (orexin antagonist) - AASM recommended
                        • Low-dose doxepin (3-6mg)
                        • Z-drugs (zolpidem) - higher risk, short-term only
                        • Avoid benzodiazepines (tolerance, dependence)
                        1. ●

                           Action

                           Medication Selection

                           Based on insomnia phenotype

                           • Sleep-onset: suvorexant, zolpidem, ramelteon
                           • Sleep maintenance: suvorexant, doxepin, extended-release zolpidem
                           • Comorbid depression: trazodone, mirtazapine
                           • Avoid diphenhydramine (anticholinergic, tolerance)
                           1. ⚠

                              Warning

                              Refractory Insomnia

                              Specialty referral

                              • Sleep medicine referral
                              • Consider undiagnosed comorbidities
                              • Intensive outpatient CBT-I
                              • Address perpetuating factors (anxiety about sleep)