Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline

Introduction: This guideline establishes clinical practice recommendations for combination treatment of chronic insomnia disorder in adults, defined here as treatment with cognitive-behavioral therapy for insomnia (CBT-I) started concurrently with pharmacotherapy. Methods: The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths to those recommendations based on a systematic review of the literature and an assessment of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process. The task force provided a summary of the relevant literature, the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. Recommendations: The following recommendations are intended as a guide for clinicians on the use of combination treatment for chronic insomnia disorder in adults. Each recommendation statement is assigned a strength (“Strong” or “Conditional”). A “Strong” recommendation (i.e., “We recommend…”) is one that clinicians should follow under most circumstances. A “Conditional” recommendation (i.e., “We suggest…”) is one that requires that the clinician use clinical knowledge and experience and strongly consider the patient’s values and preferences to determine the best course of action. One recommendation includes a remark that provides additional context to guide clinicians with implementation of this recommendation. Conditional recommendation for: 1. In adults with chronic insomnia disorder, the AASM suggests the use of combination treatment with CBT-I plus insomnia medication over insomnia medication alone. (Conditional recommendation, low certainty of evidence). Conditional recommendation against: 2. In adults with chronic insomnia disorder, the AASM suggests against the use of combination treatment of CBT-I plus insomnia medication over CBT-I alone. (Conditional recommendation, low certainty of evidence). Remark: Patients who place higher value on increasing total sleep time early in the course of treatment, and/or who place lower value on reducing daytime symptoms with treatment, may reasonably select combination treatment versus CBT-I alone.