You cannot fall asleep, or you cannot stay asleep
Chronic insomnia is persistent difficulty falling or staying asleep, with a daytime consequence, despite having the opportunity to sleep. The recommended first-line treatment is a structured therapy rather than a medicine, and that has been the guideline position since 2021.
What chronic insomnia is
Chronic insomnia is persistent difficulty falling asleep, staying asleep, or waking too early, together with a daytime consequence, occurring despite an adequate opportunity to sleep. The daytime half matters: insomnia is not measured only by what happens at night.
The first-line treatment is not a sleeping pill
Cognitive behavioural therapy for insomnia, usually shortened to CBT-I, is the recommended first-line treatment for chronic insomnia in adults. That is the position of the AASM’s 2021 clinical practice guideline on behavioural and psychological treatments, and it has not been displaced since.
CBT-I is a structured course rather than a conversation about sleep hygiene. It addresses the behaviours and thoughts that maintain insomnia after whatever started it has passed.
What the 2026 guideline added
The 2017 guideline covered medicines and the 2021 guideline covered CBT-I, but neither answered the practical question: should you start both at once?
The AASM published a clinical practice guideline on combination treatment for chronic insomnia on 13 April 2026. It makes two conditional recommendations, both at low certainty of evidence, and they point in different directions:
- Conditionally for combination treatment over medication alone.
- Conditionally against combination treatment over CBT-I alone.
Read together, that is not a wash. CBT-I on its own remains the most efficacious first-line approach; adding a medicine gives a modest additional benefit on some outcomes, such as total sleep time, at the cost of medication exposure. If you are going to take something, taking it alongside CBT-I beats taking it alone.
The guideline frames the choice as shared decision-making. Someone who places a high value on an early increase in total sleep time, and who accepts the medication exposure, may reasonably choose combination treatment. Someone who does not should have CBT-I on its own.
The honest problem with CBT-I
The guideline itself flags access as a real barrier. CBT-I requires a trained clinician and a course of sessions, and there are not enough of them. Telling you it is first-line is only useful if you can actually start it.
What happens here
An insomnia assessment starts with what is keeping you awake, what you have already tried, and whether something else is doing it. Insomnia frequently sits on top of another sleep disorder, and treating the sleeping difficulty without looking for that is how people end up on a hypnotic for years.
Been taking something to sleep for longer than you meant to?
That is one of the commonest reasons people call. It is worth reviewing what you are on and whether the underlying problem was ever addressed.
Call (614) 898-9340Sources
- Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline, Buysse DJ et al., published 13 April 2026. https://doi.org/10.1007/s44470-025-00038-8
- AASM press release on the combination treatment guideline. https://aasm.org/combination-treatment-chronic-insomnia-guideline/
- AASM 2021 clinical practice guideline on behavioural and psychological treatments for chronic insomnia.