Practice Clinical updates

Chronic insomnia: diagnosis and non-pharmacological management

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5819 (Published 16 November 2016) Cite this as: BMJ 2016;355:i5819
  1. David Cunnington, sleep physician and director1,
  2. Moira Junge, psychologist1 2
  1. 1Melbourne Sleep Disorders Centre, East Melbourne, Victoria 3002, Australia
  2. 2School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
  3. Correspondence to: D Cunnington david.cunnington@msdc.com.au

What you need to know

  • Establish whether insomnia is acute or chronic as management differs

  • Chronic insomnia persists even when lifestyle factors adversely affecting sleep are addressed

  • Cognitive behavioural therapy for insomnia (CBT-I) is the recommended first line treatment for chronic insomnia

  • Medications may be used as an adjunct to CBT-I, but their long term effectiveness and safety have not been well assessed

Surveys of adults show that 13-33% of the adult population have regular difficulty either getting to sleep or staying asleep.1 2 3 Insomnia is dissatisfaction with sleep quantity or quality with one of more of difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening. The sleep disturbance causes significant distress or impairment of functioning. There may be a feeling of having been awake all night even when getting some sleep.

People with comorbid disorders of physical or mental health, such as depression, have higher rates of insomnia. Depression and sleep disturbance are the first and third most common psychological reasons for patient encounters in general practice.4 Untreated, insomnia increases the risk of development or exacerbation of anxiety, depression, hypertension, and diabetes.5 6 This article outlines current concepts in insomnia and provides up to date information on treatment.

When does acute insomnia become chronic insomnia?

Most people will experience sleep disturbance or acute insomnia at some point in any given year. This often occurs around predictable times of stress or when sleep patterns are disrupted, such as with travel, busy periods at work, illness, or emotional upset. While people may be distressed about sleep loss during acute insomnia, once the trigger factors are removed, sleep usually returns to normal.

Insomnia becomes chronic when someone has difficulty either getting to sleep or staying asleep for at least three nights a week (not necessarily every night) for at least three months and is distressed by their sleep symptoms. …

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