A new clinical practice guideline from the American Academy of Sleep Medicine provides updated, evidence-based recommendations on the combined use of behavioural-psychological and pharmacological treatments for adults with chronic insomnia disorder. The guideline, published in the Journal of Clinical Sleep Medicine, is accompanied by a systematic review and meta-analysis evaluating the effectiveness and potential harms of combination therapy compared with single-treatment approaches.
Earlier AASM guidelines released in 2017 and 2021 recommended medications and behavioural interventions such as cognitive behavioural therapy for insomnia (CBT-I) as standalone treatments, but did not assess whether combining these approaches improves outcomes. Despite this, clinicians have frequently used both strategies together in practice, either simultaneously or in sequence.
The updated analysis indicates that CBT-I remains the most effective first-line treatment for chronic insomnia. While combining CBT-I with medication may offer modest improvements in certain outcomes, such as total sleep time, the overall additional benefit appears limited. The guideline issues two conditional recommendations based on low-certainty evidence: combination therapy is suggested over medication alone due to improvements in some sleep outcomes, but it is not recommended over CBT-I alone, as behavioural therapy provides more durable benefits without the risks associated with pharmacological treatment.
According to Daniel J. Buysse, combination therapy is widely used despite limited evidence guiding its application. he noted that CBT-I should remain the foundation of treatment, with medications used selectively. the recommendations are intended to support patient-centred decision-making rather than a one-size-fits-all approach.
Chronic insomnia disorder affects an estimated 10% to 15% of adults and is commonly managed in both primary care and specialised sleep settings. the guideline emphasizes shared decision-making, encouraging clinicians to consider patient preferences, treatment goals, and tolerance for potential risks when selecting a care plan.
The guideline was developed by an expert task force convened by the AASM, which conducted a systematic review of the literature, weighing benefits, harms, patient values, and resource considerations. it underwent public comment before final approval and has received broad professional support, including affirmation from the American Academy of Family Physicians and the American Geriatrics Society, along with endorsements from several national and international organizations. The guideline reinforces CBT-I as the cornerstone of insomnia management while allowing selective use of medications where appropriate, highlighting a shift toward individualized, evidence-informed care in the treatment of chronic insomnia.
- Buysse DJ, Arnedt JT, Buenaver L, Chang JL, Fernandez-Mendoza J, Patel SI, et al. Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2026 Apr 13;22(1):56.