New Guidance Clarifies the Role of Medications in Chronic Insomnia Care

A new clinical practice guideline from the American Academy of Sleep Medicine provides evidence-based recommendations on the combined use of behavioral-psychological and pharmacological therapies to treat chronic insomnia disorder in adults.

The guideline, published in the Journal of Clinical Sleep Medicine, is accompanied by a systematic review, meta-analysis, and evaluation of the comparative efficacy and potential harms of combination therapy.

Previous AASM clinical practice guidelines published in 2017 and 2021 recommended pharmacological therapy and behavioral-psychological treatment, such as cognitive behavioral therapy for insomnia, as individual treatment options for chronic insomnia disorder.

However, those guidelines did not evaluate whether combining medications and CBT-I improves outcomes compared with either approach alone.

Despite this lack of comparative evidence, pharmacological and behavioral-psychological treatments are frequently used together in clinical practice, either initiated simultaneously or added sequentially.

“Combination therapy for insomnia is widely used in clinical practice, yet the evidence guiding how and when to combine treatments has been surprisingly limited,” said lead author Dr. Daniel J. Buysse, professor of psychiatry, medicine, and clinical and translational science at the University of Pittsburgh.

“Our analysis suggests that CBT-I by itself is the most efficacious first-line treatment for insomnia. However, using medication with CBT-I may provide modest benefit for some specific outcomes, such as total sleep time. These recommendations are meant to support thoughtful, patient‑centered decision‑making rather than a one‑size‑fits‑all approach.”

Chronic insomnia disorder occurs in roughly 10% to 15% of adults and is commonly encountered in both primary care and specialty sleep medicine settings.