Insomnia Complaint
Difficulty falling/staying asleep, ≥3x/week for ≥3 months, with daytime impairment
All Pathways
Family MedicineManagement
Chronic Insomnia Evaluation & Management (AASM 2021)
Chronic Insomnia Evaluation & Management (AASM 2021): Insomnia Complaint → Comprehensive Sleep History → Secondary Causes? → Consider Sleep Study → Chro...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action 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
03Decision 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
04Action 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
05Action 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
06Action 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)
07Action 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
08Decision CBT-I Response?
Assess after 4-8 sessions
09Outcome CBT-I Success
Maintain gains, booster sessions if needed
10Action 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)
11Action 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)
12Warning Refractory Insomnia
Specialty referral
- Sleep medicine referral
- Consider undiagnosed comorbidities
- Intensive outpatient CBT-I
- Address perpetuating factors (anxiety about sleep)
- Path rejoins step 05Shared downstream outcome
Guideline Source
AASM Clinical Practice Guideline for Chronic Insomnia in Adults
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CBT-I delivery methods vary in availability
- Sleep study indications simplified
- Pharmacotherapy duration recommendations simplified
- Does not address shift-work sleep disorder
- Comorbid sleep disorders require specialized evaluation
Applicable Regions
USAUUKEU
AU: RACGP recommends CBT-I first-line
UK: NICE insomnia pathway favors behavioral approaches
US: AASM guidelines - CBT-I first-line
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Chronic Insomnia Evaluation & Management (AASM 2021)?
The Chronic Insomnia Evaluation & Management (AASM 2021) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on AASM Clinical Practice Guideline for Chronic Insomnia in Adults.
What guideline is the Chronic Insomnia Evaluation & Management (AASM 2021) based on?
This algorithm is based on AASM Clinical Practice Guideline for Chronic Insomnia in Adults (DOI: 10.5664/jcsm.8236).
What are the limitations of the Chronic Insomnia Evaluation & Management (AASM 2021)?
Known limitations include: CBT-I delivery methods vary in availability; Sleep study indications simplified; Pharmacotherapy duration recommendations simplified; Does not address shift-work sleep disorder; Comorbid sleep disorders require specialized evaluation. Individual patient factors may require deviation from these recommendations.
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