Adult with chronic insomnia
Age 18+. Trouble getting to sleep or staying asleep on 3 or more nights a week for 3 months or more, with daytime impairment, despite enough chance to sleep.
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Family MedicineManagement
Chronic Insomnia Evaluation & Management (AASM 2021)
Chronic Insomnia Evaluation & Management (AASM 2021): Adult with chronic insomnia → Sleep history and 2-week sleep diary → Other sleep disorder or untre...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Sleep history and 2-week sleep diary
Describe the insomnia and its effect on the day.
- Sleep diary for 2 weeks: bed and wake times, time to fall asleep, night waking
- Daytime effects: fatigue, mood, concentration; sleepiness (Epworth score) and drowsy driving
- Caffeine, alcohol, other drugs, medicines, screens, bedroom noise and light
- Bed partner report: snoring, stopped breathing, leg kicks, acting out dreams
03Decision Other sleep disorder or untreated contributor?
Screen for sleep apnoea, restless legs, circadian disorder, parasomnia, depression, anxiety, bipolar disorder, substance use, sleep-disturbing medicines, pain and nocturia. Insomnia often coexists with them.
- Sleep apnoea: snoring, witnessed apnoeas, sleepiness; STOP-Bang or OSA50
- Restless legs, circadian rhythm disorder (shift work, delayed sleep phase), parasomnia
- Depression, anxiety, bipolar disorder; alcohol or other substance use
- Medicines that disturb sleep (for example corticosteroids, stimulants, decongestants)
- Pain, nocturia, reflux, breathlessness, menopause symptoms
- If Yes
04Action Contributor found: investigate and treat it alongside the insomnia
Treat the cause and the insomnia together. CBT-I still works when insomnia coexists with another condition.
- Suspected sleep apnoea: sleep study (home or lab) or sleep physician referral. MBS criteria: Epworth 8 or more, plus OSA50 5 or more or STOP-Bang 3 or more
- Sleep apnoea confirmed: treat it (for example CPAP) and still offer CBT-I for the insomnia
- Low mood: assess depression and suicide risk; treat the depression
- Restless legs, circadian disorder or parasomnia: consider sleep physician referral
- Reduce alcohol, caffeine and sleep-disturbing medicines where possible
05Action Chronic insomnia disorder: treat it in its own right
Insomnia persists despite enough chance to sleep. Plan CBT-I, also when a comorbidity is present and in long-term sleeping-pill users.
- Explain the aims: regular sleep schedule, less time awake in bed, less worry about sleep
- Long-term sleeping-pill users: CBT-I helps a gradual taper
06Action CBT-I: first-line treatment
Multicomponent CBT-I (AASM strong recommendation). Caution with sleep restriction: avoid or use specialist-modified CBT-I in bipolar disorder or mania risk, poorly controlled seizures, excessive daytime sleepiness, or safety-critical work (drivers, machine operators).
- Components: sleep restriction, stimulus control, cognitive therapy, relaxation, sleep education
- Delivery: psychologist, trained GP (brief behavioural therapy), group or digital
- Australia: THIS WAY UP Insomnia Program (free, online, 4 modules; a clinician can prescribe and monitor it)
- Usually 4 to 8 visits over 6 to 8 weeks; benefit builds gradually and lasts after treatment ends
- Warn: more sleepiness in the first weeks of sleep restriction; do not drive if drowsy
07Action Sleep hygiene: add to CBT-I, not alone
AASM suggests against sleep hygiene as the only treatment.
- Regular wake time every day
- Limit caffeine, especially after midday; limit alcohol
- Cool, dark, quiet bedroom; wind down and limit screens before bed
- Use the bed only for sleep and sex
08Decision Insomnia improved after CBT-I?
Review the sleep diary and daytime function after the course (about 6 to 8 weeks). Check adherence to sleep restriction and stimulus control first. Re-check for missed sleep apnoea, depression or another contributor before any medicine.
- If Yes
09Outcome Improved: keep the gains
Keep the regular sleep schedule and skills. Booster CBT-I sessions if insomnia returns.
If No10Warning Not improved or CBT-I declined: check risks before any sleeping medicine
Depression or suicide risk: treat the depression first; give a small supply only (overdose risk); no benzodiazepine alone. Also avoid or seek advice with: children under 18, pregnancy or breastfeeding, severe liver disease, alcohol or substance use disorder, past complex sleep behaviour on zolpidem.
- Age 65+: avoid benzodiazepines and Z-drugs (falls, fractures, delirium, crashes)
- Sleep apnoea or severe lung disease: do not use zolpidem or benzodiazepines; myasthenia gravis: no zolpidem
- Opioids, alcohol or other sedatives: risk of respiratory depression and death; zolpidem must not be taken with alcohol
11Action Not improved: add a short-term medicine to CBT-I
Give the medicine with CBT-I, not instead of it (AASM 2026). Lowest dose for the shortest time. Agree a stop plan at the start.
- Zolpidem: complex sleep behaviours (sleep-driving, sleep-walking); stop it for good if they occur
- Take only when 7 to 8 hours of sleep are possible; warn about next-day impairment and driving
- Benzodiazepines (for example temazepam): short term only; tolerance, dependence and withdrawal risk
- Review within 2 to 4 weeks; taper gradually after regular use (rebound insomnia)
12Action Medicine options in Australia
Choose by sleep pattern, age, comorbidities and cost. Check the product information for the full contraindications.
- Zolpidem (sleep onset or maintenance): adults 10 mg at bedtime (US label: 5 mg start in women); 5 mg if hepatic impairment, or if elderly or debilitated and use cannot be avoided; max 4 weeks
- Orexin receptor antagonists: suvorexant 20 mg at bedtime, 15 mg if age 65+ (re-evaluate after 3 months); lemborexant 5 mg, max 10 mg
- Orexin receptor antagonists: not PBS-listed; not in narcolepsy; avoid with moderate or strong CYP3A inhibitors; caution in severe sleep apnoea or lung disease
- Age 55+: prolonged-release melatonin 2 mg 1 to 2 hours before bed, up to 13 weeks (TGA-registered; small effect; AASM suggests against it)
- Not recommended for insomnia: trazodone, sedating antihistamines (for example doxylamine, diphenhydramine), antipsychotics (for example quetiapine)
13Decision Controlled on medicine plus CBT-I?
Review sleep diary, daytime function, adverse effects and next-day impairment.
- If Yes
14Outcome Controlled: taper and stop the medicine
Keep the CBT-I skills. Taper gradually after regular use to limit rebound insomnia and withdrawal. Do not repeat prescriptions without review.
If No15Action Not controlled: refer for specialist care
Do not raise the dose above the maximum or combine sleeping medicines.
- Sleep physician: suspected or confirmed sleep apnoea, restless legs, parasomnia, circadian disorder
- Sleep psychologist: more intensive CBT-I
- Re-check depression, anxiety, substance use and medicines
- Long-term sleeping-pill use: structured gradual withdrawal plan
16Outcome Shared care with the sleep service
GP continues regular review and follows the specialist plan.
If No- Path rejoins step 05Shared downstream outcome
Guideline Source
AASM clinical practice guideline: Behavioral and psychological treatments for chronic insomnia disorder in adults (Edinger et al., J Clin Sleep Med 2021;17(2):255-262); drug advice from AASM pharmacologic guideline 2017 (Sateia et al.) and AASM combination treatment guideline 2026 (Buysse et al.)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Sleeping medicines: short-term only, with CBT-I; avoid benzodiazepines and Z-drugs in age 65+, sleep apnoea, and with opioids or alcohol
- Adults only; not for children, pregnancy or shift-work sleep disorder
- Drug options and doses are for Australia; check local availability and product information elsewhere
- Comorbid sleep disorders (sleep apnoea, restless legs, parasomnia) need their own assessment
Contraindicated Populations
Children and adolescents under 18 yearsPregnancy and breastfeeding (drug steps)
Applicable Regions
USAUUKEU
AU: CBT-I first-line (AJGP 2023). THIS WAY UP Insomnia Program is free online. Orexin receptor antagonists are TGA-registered but not PBS-listed. Low-dose doxepin and ramelteon are not available.
UK: NICE favours CBT-I first-line; check BNF for local hypnotic options.
US: AASM 2017 also suggests low-dose doxepin, ramelteon, eszopiclone, zaleplon and triazolam. Follow FDA labelling for zolpidem doses (lower starting dose in women).
Version 2Next review: 2027-09-30
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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: Behavioral and psychological treatments for chronic insomnia disorder in adults (Edinger et al., J Clin Sleep Med 2021;17(2):255-262); drug advice from AASM pharmacologic guideline 2017 (Sateia et al.) and AASM combination treatment guideline 2026 (Buysse et al.).
What guideline is the Chronic Insomnia Evaluation & Management (AASM 2021) based on?
This algorithm is based on AASM clinical practice guideline: Behavioral and psychological treatments for chronic insomnia disorder in adults (Edinger et al., J Clin Sleep Med 2021;17(2):255-262); drug advice from AASM pharmacologic guideline 2017 (Sateia et al.) and AASM combination treatment guideline 2026 (Buysse et al.) (DOI: 10.5664/jcsm.8986).
What are the limitations of the Chronic Insomnia Evaluation & Management (AASM 2021)?
Known limitations include: Sleeping medicines: short-term only, with CBT-I; avoid benzodiazepines and Z-drugs in age 65+, sleep apnoea, and with opioids or alcohol; Adults only; not for children, pregnancy or shift-work sleep disorder; Drug options and doses are for Australia; check local availability and product information elsewhere; Comorbid sleep disorders (sleep apnoea, restless legs, parasomnia) need their own assessment. Individual patient factors may require deviation from these recommendations.
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