Insomnia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 5 Apr 2025

Last updated: 24 Jan 2025

Insomnia is one of the most common complaints reported in primary care.

Diagnosis is made primarily by patient interview. Sleep diaries, actigraphy, and polysomnography may assist in confirming diagnosis.

Identification of the correct etiology, contributing factors, and/or comorbidities is essential for adequate treatment of insomnia. Their management is necessary, although often not sufficient, for the resolution of insomnia.

The significant morbidity of insomnia indicates that it is a condition that warrants treatment.

Take an individualized approach to treatment, based on the patient's preferences, the severity of their insomnia, the risks versus benefits of treatment, and the availability of specialist treatment options such as cognitive behavioral therapy.

For most patients, initial treatment with cognitive behavioral therapy for insomnia (CBT-I) is likely to provide the best balance between efficacy and safety.

Definition

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) defines insomnia disorder (i.e., clinical insomnia) as difficulty initiating sleep, difficulty maintaining sleep, or early-morning awakening despite adequate opportunity for sleep; leading to clinically significant distress or impairments in functioning; and with a frequency of 3 or more nights per week and a duration of 3 months or longer.[1] Insomnia is not explained by the presence of mental disorders or medical conditions and is not associated with another sleep-wake disorder.

History and exam

Key diagnostic factors

sleep partner complaints
delayed sleep onset
multiple or long awakenings

Full details

Other diagnostic factors

impairment of functioning
accidents
decreased sleep time
daytime napping
thyrotoxicosis
chronic pain
restless legs syndrome
obstructive sleep apnea

Full details

Risk factors

female sex
advanced age
chronic medical conditions
chronic pain
psychiatric illness
alcohol or substance misuse
stimulant use
poor sleep hygiene
traumatic brain injury
neuropsychiatric illness
use of certain medications
recent travel across time zones
night work
hyperthyroidism
participation in elite sport
sedentary behavior

Full details

Diagnostic tests

1st tests to order

sleep diary
Pittsburgh Sleep Quality Index (PSQI)
Insomnia Severity Index (ISI)
Stanford Sleepiness Scale (SSS)
Epworth Sleepiness Scale (ESS)
Athens Insomnia Scale (AIS)
Generalized Anxiety Disorder-7 (GAD-7)
Patient Health Questionnaire-9 (PHQ-9)

Full details

Tests to consider

polysomnography (PSG)
actigraphy
thyroid-stimulating hormone (TSH)
CBC and iron studies
urine or blood substance use panel

Full details

Treatment algorithm

ACUTE

acute insomnia

ONGOING

chronic insomnia

Contributors

Authors

Joshua Hyong-Jin Cho, MD, PhD

Health Sciences Clinical Professor

Director, UCLA Insomnia Clinic

Cousins Center for Psychoneuroimmunology

Department of Psychiatry & Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Los Angeles

Disclosures

JHC is an author of a reference cited in this topic.

Paul Barkopoulos, MD, MPH

Clinical Professor

Department of Psychiatry & Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Los Angeles

Disclosures

PB is an author of a reference cited in this topic.

Anthony E. Reading, MPhil, PhD

Clinical Professor

Department of Psychiatry & Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Los Angeles

Disclosures

AER declares that he has no competing interests.

Acknowledgements

Dr Joshua Hyong-Jin Cho, Dr Paul Barkopoulos, and Dr Anthony E. Reading would like to gratefully acknowledge Dr John W. Winkelman, Dr Teofilo Lee-Chiong, and Dr Vipin Malik, previous contributors to this topic.

Disclosures

JWW has received honoraria for consulting to Avadel, CVS, Eisai, and Merck, and research grants from Merck and the RLS Foundation. TLC is the Chief Medical Liaison for Philips, a company that makes devices to treat sleep apnea. VM received research funding from Philips Respironics for a study on COPD-OSA overlap.

Peer reviewers

Karl Doghramji, MD

Director

Sleep Disorders Center

Thomas Jefferson University Hospital

Philadelphia

Disclosures

KD is a speaker for Sanofi-Aventis, King Pharmaceuticals, Takeda Pharmaceuticals, Sepracor, and Pfizer; a consultant for Sanofi-Aventis, Takeda Pharmaceuticals, Sepracor, Pfizer, and Neurocrine Biosciences; and has stock in Merck.

Chiadi U. Onyike, MD, MHS

Assistant Professor

Geriatric Psychiatry and Neuropsychiatry

The Johns Hopkins Hospital

Baltimore

Disclosures

CUO declares that he has no competing interests.

Roy Goldberg, MD

Medical Director

Kings Harbor Multicare Center

Bronx

Disclosures

RG declares that he has no competing interests.

Craig Sawchuk, MD

Affiliate Assistant Professor

Department of Psychiatry and Behavioral Sciences

University of Washington Medical Center

Seattle

Disclosures

CS declares that he has no competing interests.

David Cunnington, MD

Director

Melbourne Sleep Disorders Centre

Melbourne

Victoria

Australia

Disclosures

DC has received consulting fees from Sanofi-Aventis and Lundbeck, and honoraria for speaking from Sanofi-Aventis.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.Full text

Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-49.Full text Abstract

Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016 Jul 19;165(2):125-33.Full text Abstract

Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Feb 1;17(2):255-62.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Restless legs syndrome
- Periodic limb movement disorder (PLMD)
- Obstructive sleep apnea (OSA)
More Differentials
Guidelines
- Manual for the scoring of sleep and associated events
- Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults
More Guidelines
Patient information
Insomnia
Sleep apnea in adults (obstructive)
More Patient information
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Insomnia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

acute insomnia

chronic insomnia

Contributors

Authors

Joshua Hyong-Jin Cho, MD, PhD

Disclosures

Paul Barkopoulos, MD, MPH

Disclosures

Anthony E. Reading, MPhil, PhD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Karl Doghramji, MD

Disclosures

Chiadi U. Onyike, MD, MHS

Disclosures

Roy Goldberg, MD

Disclosures

Craig Sawchuk, MD

Disclosures

David Cunnington, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice