Persistent difficulty with sleep initiation, maintenance, early awakening, or non-restorative sleep with daytime impairment, chronic if ≥3 nights/week for ≥3 months.

Assess sleep hygiene, screen time/caffeine/alcohol, shift work, psychiatric symptoms, medical comorbidities, medication review, snoring/apneas/restless legs symptoms.

Clinical, sleep history/diary (2 weeks). Screen for underlying cause (PHQ-9, GAD-7, medical review).

Polysomnography: not routine, reserved for suspected sleep apnea, periodic limb movement disorder, or diagnostic uncertainty.

Differentials: depression, anxiety, obstructive sleep apnea, restless legs syndrome, circadian rhythm disorders, medication/substance-induced, hyperthyroidism, chronic pain, menopause.

CBT-I: first-line, superior long-term outcome: sleep restriction, stimulus control, cognitive restructuring, relaxation techniques
Sleep hygiene: consistent schedule, avoid caffeine/alcohol near bedtime, limit screens, comfortable environment, avoid disruptive naps
Pharmacotherapy: short-term use only given dependence risk

Z-drugs (zolpidem 5-10mg, zopiclone 3.75-7.5mg nocte): limit to 2-4 weeks
Sedating antidepressants (amitriptyline, trazodone, mirtazapine): off-label, useful with comorbid mood disorder
Melatonin 2-5mg pre-bed: modest evidence, particularly circadian-related insomnia/elderly
Orexin antagonists (suvorexant, lemborexant): newer option, potentially lower dependence
Avoid long-term benzodiazepine/z-drug use: dependence, cognitive impairment, elderly fall risk

Treat underlying cause: comorbid depression/anxiety, pain, nocturia, sleep apnea (polysomnography, CPAP), restless legs (iron studies, ferritin target >75-100)

Referral: sleep medicine for suspected primary sleep disorder, refractory insomnia; psychiatry for significant mood/anxiety disorder.

Insomnia

Overview

Clinical Features

Diagnosis

Management