New AASM Guideline Sheds Light on Combination Therapy for Chronic Insomnia: Salma Patel, MD

Chronic insomnia, a condition marked by persistent difficulty falling or staying asleep, affects an estimated 10% to 15% of adults, making it one of the most prevalent sleep disorders. In an interview at the American Academy of Sleep Medicine and Sleep Research Society Annual Meeting, Salma Patel, MD, clinical professor, University of Arizona, discussed evolving treatment strategies and a new clinical practice guideline that addresses a key gap in care for these patients.

Historically, the first-line therapy for chronic insomnia has been cognitive behavioral therapy for insomnia (CBT‑I), a structured, nonpharmacologic approach that targets unhelpful thoughts and behaviors around sleep. A well-established guideline already exists to guide clinicians in implementing CBT‑I. When CBT‑I alone is insufficient or not accessible, medication is typically used as a second-line treatment, and a separate guideline outlines best practices for pharmacologic management.

However, in real-world practice, many clinicians use a combination of CBT‑I and medication. Until now, there had been no dedicated guideline to inform when and how to use this combined approach. Patel explained that the new guideline from the American Academy of Sleep Medicine (AASM) was developed to fill this gap. The task force conducted a systematic review of the literature and applied the GRADE framework to evaluate the strength and quality of the evidence.

Rather than issuing strong, one-size-fits-all directives, the panel arrived at 2 conditional recommendations, underscoring the need for clinical judgment and patient-centered care.

First, the AASM guideline recommends a combination of CBT‑I and medication over medication alone for adults with chronic insomnia, reflecting evidence that dual therapy can improve outcomes beyond pharmacotherapy by itself.

Second, the guideline recommends against combination therapy over CBT‑I alone, meaning that CBT‑I by itself remains an appropriate and often preferred approach. However, a key remark attached to this recommendation emphasizes patient and clinician preferences. For individuals who place a high value on more rapid improvements in total sleep time, especially early in the treatment course, starting with combination therapy may be reasonable.

Ultimately, the new guideline supports a flexible, individualized approach to chronic insomnia treatment, helping clinicians balance evidence-based practice with each patient’s values, goals, and sleep-related priorities.