European guideline for the diagnosis and treatment of insomnia

European guideline for the diagnosis and treatment of insomnia

Diagnostic management of insomnia and its co-morbidities

• The diagnostic procedure for insomnia should include a clinical interview consisting of a thorough evaluation of the current sleep–wake behaviour and sleep history as well as questions about somatic and mental disorders, a physical examination, the use of sleep questionnaires and sleep diaries, and, if indicated, additional measures (blood test, ECG, EEG, CT/MRT, circadian markers; strong recommendation, moderate- to high-quality evidence).
• It is recommended to actively ask for medication and other substance use (alcohol, caffeine, nicotine, illegal drugs), which may disturb sleep (strong recommendation, high-quality evidence).
• Sleep diaries or actigraphy can be used in case of clinical suspicion of irregular sleep–wake schedules or circadian rhythm disorders (strong recommendation, high-quality evidence), and actigraphy can be used to assess quantitative sleep parameters (weak recommendation, high-quality evidence).
• Polysomnography is recommended when there is clinical suspicion of other sleep disorders, like periodic limb movement disorder, sleep apnea or narcolepsy, treatment-resistant insomnia, insomnia in occupational at-risk groups, or suspicion of a large discrepancy between subjectively experienced and polysomnographically measured sleep (strong recommendation, high-quality evidence).

Treatment
In the presence of co-morbidities, clinical judgement should decide whether insomnia or the co-morbid condition is treated first, or whether both are treated at the same time.CBT-I CBT-I is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence).

Pharmacological interventions
A pharmacological intervention can be offered if CBT-I is not effective or not available.
BZ and BZRA
• BZ and BZRA are effective in the short-term treatment of insomnia (≤4 weeks; high-quality evidence).
• The newer BZRA are equally effective as BZ (moderate-quality evidence).
• BZ/BZRA with shorter half-lives may have less side-effects concerning sedation in the morning (moderate-quality evidence).
• Long-term treatment of insomnia with BZ or BZRA is not generally recommended because of a lack of evidence and possible side-effects/risks (strong recommendation, low-quality evidence). In patients using medication on a daily basis, reduction to intermittent dosing is strongly recommended (strong recommendation, low-quality evidence).
Sedating antidepressants
• Sedating antidepressants are effective in the short-term treatment of insomnia; contraindications have to be carefully considered (moderate-quality evidence). Long-term treatment of insomnia with sedating antidepressants is not generally recommended because of a lack of evidence and possible side-effects/risks (strong recommendation, low-quality evidence).
Antihistaminics
• Because of insufficient evidence, antihistaminics are not recommended for insomnia treatment (strong recommendation, low-quality evidence).
Antipsychotics
• Because of insufficient evidence and in light of their side-effects, antipsychotics are not recommended for insomnia treatment (strong recommendation, very low-quality evidence).
Melatonin
• Melatonin is not generally recommended for the treatment of insomnia because of low efficacy (weak recommendation, low-quality evidence).
Phytotherapy
• Valerian and other phytotherapeutics are not recommended for the treatment of insomnia because of poor evidence (weak recommendation, low-quality evidence).
Light therapy and exercise
• Light therapy and exercise regimes may be useful as adjunct therapies (weak recommendation, low-quality evidence).
Complementary and alternative medicine
• Acupuncture, aromatherapy, foot reflexology, homeopathy, meditative movement, moxibustion and yoga are not recommended for the treatment of insomnia because of poor evidence (weak recommendation, very low-quality evidence).