Diagnostic features

• Difficulty initiating sleep, maintaining sleep, or waking too early despite adequate opportunity, occurring at least 3 nights/week for ≥3 months with daytime consequences (fatigue, concentration problems, mood disturbance).
• Insomnia may be classified as sleep‑onset, sleep‑maintenance, early‑morning awakening, or mixed.
• Differentiate primary insomnia from insomnia comorbid with medical, psychiatric, substance use or other sleep disorders (OSA, RLS).

Epidemiology & impact

• Insomnia symptoms affect ~30% of adults; chronic insomnia disorder affects ~6–10%.
• Associated with reduced quality of life, increased risk of mood disorders, impaired workplace performance and higher healthcare use.

Assessment checklist

1. Sleep history: sleep schedule, sleep latency, wake after sleep onset, total sleep time, naps, sleep opportunity and variability (use sleep diary for 1–2 weeks).
2. Screen for contributing factors: caffeine, alcohol, nicotine, medications (SSRIs, steroids, beta‑blockers), pain, nocturia, medical illness, mood disorders and shift work.
3. Assess for other sleep disorders (OSA, RLS, circadian disorders) and psychiatric comorbidity using validated scales (PHQ‑9, GAD‑7, ISI — Insomnia Severity Index).
4. Examine sleep environment and behaviours: bed use, electronic device use, light exposure, exercise timing and sleep hygiene practices.

Non‑pharmacologic first‑line: CBT‑I

• CBT‑I components: sleep restriction therapy, stimulus control, cognitive therapy (addressing unhelpful beliefs about sleep), relaxation techniques and sleep hygiene education.
• Evidence: CBT‑I produces durable improvements, reduces sleep latency and wakefulness, and has longer‑term benefits over hypnotics for relapse prevention.
• Delivery: individual, group or guided digital programmes — effective when delivered by trained clinicians or validated online platforms when access is limited.

Practical CBT‑I techniques (brief)

1. Sleep restriction: limit time in bed to approximate actual sleep time (but not <5 hours) to increase sleep efficiency; gradually increase time in bed as efficiency improves.
2. Stimulus control: go to bed only when sleepy, use bed only for sleep/sex, leave bed if unable to sleep after ~20 minutes, return when sleepy, maintain consistent rise time.
3. Cognitive strategies: identify catastrophic thoughts about sleep, use worry time earlier in the day, practise cognitive restructuring and acceptance techniques.
4. Relaxation: diaphragmatic breathing, progressive muscle relaxation, mindfulness or guided imagery to reduce physiological arousal before bed.

Pharmacologic options — principles & short‑term use

• Use medication adjunctively when CBT‑I unavailable or while awaiting CBT‑I, for short‑term symptom relief, or in severe distress — aim for lowest effective dose and shortest duration.
• Common options: short‑term benzodiazepine receptor agonists (zolpidem, zopiclone), low‑dose sedating antidepressants (mirtazapine, trazodone) for comorbid depression/insomnia, doxepin low dose for sleep maintenance, and melatonin (2 mg prolonged‑release) in older adults or circadian issues.
• Risks: dependence, tolerance, daytime sedation, cognitive impairment (especially in older adults), falls risk — avoid long‑term benzodiazepines when possible and review regularly.
• Consider suvorexant (orexin receptor antagonist) where available — monitor for excessive daytime sleepiness and safety in patients with sleep apnea or narcolepsy history.

Special populations & considerations

• Older adults: prefer non‑pharmacologic therapy; melatonin PR and low‑dose doxepin may be safer options; avoid long‑acting hypnotics.
• Comorbid psychiatric disorder: treat underlying mood/anxiety disorder alongside CBT‑I; some antidepressants can help insomnia but may worsen sleep architecture in others.
• Shift workers: tailored behavioural strategies, strategic light exposure, melatonin timing and targeted short‑term pharmacotherapy when needed.

Practical quick tips for clinicians

• Offer brief sleep hygiene but prioritise CBT‑I components (stimulus control, sleep restriction) early.
• Use sleep diaries to guide sleep restriction; set realistic expectations (improvement over weeks).
• If prescribing hypnotics, set a clear plan for review, tapering and stopping; combine with CBT‑I when possible.

Key takeaways

• Insomnia disorder is common and often chronic—CBT‑I is first‑line and has durable benefits.
• Assess for contributing medical, psychiatric and other sleep disorders; tailor interventions to individual needs and risks.
• Use pharmacotherapy judiciously for short‑term relief or where CBT‑I unavailable, with clear review and deprescribing plans.