Executive summary
- Define it: difficulty initiating/maintaining sleep or early waking with daytime impairment.
- First-line is non-pharmacological: CBT-I principles (stimulus control, sleep restriction, cognitive strategies) outperform hypnotics long-term.
- Always check drivers: depression/anxiety, alcohol/cannabis/caffeine, pain, nocturia, medications, shift work, and sleep apnoea symptoms.
- Hypnotics are short-term only (lowest dose, shortest duration, clear stop plan) due to tolerance, dependence, and next-day impairment risk.
- Consider NICE TA922 eligibility for daridorexant in selected adults with long-term insomnia where CBT-I failed or is unavailable/unsuitable (local access pathways vary).
Assessment (what to ask to avoid missing the real problem)
- Duration: acute vs chronic; onset trigger (stress, illness, shift change) and perpetuating factors (napping, time in bed, worry).
- Pattern: sleep onset latency, awakenings, early morning waking, total sleep time, variability, and weekend “catch-up”.
- Daytime impairment: fatigue, function, accidents, mood, cognitive performance.
- Screen comorbidity: anxiety/depression, PTSD, pain syndromes, restless legs, nocturia, reflux.
- Screen OSA: snoring, witnessed apnoea, choking/gasping, daytime sleepiness; consider referral if high probability.
- Substances/meds: caffeine timing, alcohol, stimulants, steroids, SSRIs/SNRIs activating effects, decongestants, recreational drugs.
CBT-I principles (the “core bundle” to give today)
- Stimulus control: bed only for sleep/sex; get up if awake and frustrated; return when sleepy; consistent wake time.
- Sleep restriction (time-in-bed matching): reduce time in bed to approximate average sleep time, then gradually expand as sleep efficiency improves (requires careful guidance).
- Cognitive strategies: postpone worry time, challenge catastrophic beliefs about sleep, and reduce clock-watching.
- Sleep hygiene (supporting role): light exposure in morning, exercise earlier in day, avoid heavy meals late, reduce alcohol, keep bedroom dark/cool/quiet.
- Digital/structured CBT-I: signpost to local options where available; use a sleep diary as the backbone for follow-up.
Medication (only if needed — prescribing guardrails)
- When to consider short-term hypnotics: severe short-term distress/impairment where CBT-I measures alone are insufficient and risks are manageable.
- How to prescribe safely: lowest effective dose, shortest duration (often days to 2 weeks), warn about next-day impairment and driving, avoid alcohol, and avoid in high-risk falls/elderly if possible.
- Typical options (local formulary governs): short course of a Z-drug (e.g., zopiclone) with a stop date; avoid repeating prescriptions without review.
- Melatonin: may be considered in selected groups per local guidance (e.g., older adults) — expectations should be modest.
- Daridorexant (TA922): consider only if long-term insomnia with significant daytime impairment and CBT-I has failed or is unavailable/unsuitable, and after checking interactions/contraindications.
Frequently asked questions
What is the highest-yield first step?
A sleep diary plus stimulus control (consistent wake time, bed only for sleep, get up if awake). Combine with targeted screening for anxiety/depression, substances, pain and OSA.
Do “sleep hygiene” tips alone work?
Often not. Sleep hygiene is supportive, but CBT-I components (stimulus control, sleep restriction, cognitive strategies) drive the biggest sustained benefits.
How do I avoid hypnotic dependence?
Use the lowest dose for the shortest duration, set a stop date, avoid repeats, and schedule a review. Treat comorbid drivers and build CBT-I behaviours concurrently.
When should I suspect sleep apnoea instead of insomnia?
Loud snoring, witnessed apnoeas, choking/gasping, and prominent daytime sleepiness — especially with obesity or hypertension — should trigger OSA evaluation.
Who might be eligible for daridorexant?
Adults with long-term insomnia (≥3 months, ≥3 nights/week) with considerable daytime impairment, only after CBT-I has failed or is unavailable/unsuitable, per NICE TA922 and local access.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.