Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Assess persistent insomnia and its mimics, deliver the behavioural and cognitive components of CBT-I safely, and reserve medication for clearly defined indications with planned review.
Insomnia is assessed across the full 24-hour pattern. Ask about bedtime, latency, awakenings, final waking, rising time, naps, work shifts, light exposure, caffeine, alcohol, drugs, exercise and daytime function. Establish whether there is adequate opportunity and circumstances for sleep. A person choosing a short sleep window has insufficient sleep, while someone unable to sleep despite opportunity may have insomnia; the two can coexist.
A perpetuating cycle often develops after an understandable trigger. Longer time in bed, variable rising, naps and monitoring the clock reduce sleep drive and make the bed a cue for wakeful effort. Catastrophic predictions about the next day increase arousal, while attempts to force sleep make it less automatic. The formulation should also include physical illness, pain, menopause, caring responsibilities, housing and occupational schedules rather than locating all responsibility in behaviour.
CBT-I is a structured multicomponent treatment. Stimulus control rebuilds the bed-sleep association. Sleep restriction or gentler compression narrows time in bed towards average sleep time, with a stable wake time and gradual adjustment as efficiency improves. Cognitive interventions examine rigid beliefs and threat predictions; relaxation reduces arousal; education supports timing and environment. Digital delivery such as Sleepio may increase access, but medical assessment remains necessary when another sleep disorder or special circumstance is possible.
Time to sleep is persistently prolonged despite opportunity, often with clock watching, effort, worry and a bed that has become associated with wakefulness.
Repeated or extended night waking and early final waking cause distress or daytime impairment rather than representing acceptable normal variation.
Fatigue, low mood, irritability, cognitive difficulty or impaired performance establishes clinical impact; sleepiness should also prompt consideration of another sleep disorder.
Sleepiness on the sofa but alertness on entering bed, along with checking and effort, suggests a learned association between bed and wakeful threat.
Consistently normal sleep when allowed a much later or earlier schedule suggests a circadian disorder rather than inability to generate sleep.
Contraindicated in narcolepsy and with strong CYP3A4 inhibitors; use is not recommended in severe hepatic impairment. Use for the shortest possible duration, assess within three months and regularly thereafter, and allow about nine hours before driving or operating machinery. Consider next-day somnolence, falls, alcohol or other CNS depressants, depression or suicidality, pregnancy, sleep paralysis, hallucinations and complex sleep behaviour.
Advice about caffeine, screens and bedrooms may help but does not reproduce the active stimulus-control, sleep-window and cognitive components of CBT-I.
Fatigue is low energy or exhaustion; sleepiness is propensity to fall asleep. Prominent involuntary sleep points towards insufficient sleep or another sleep disorder.
People may underestimate sleep during insomnia, yet repeated diary patterns still guide behavioural timing and show change without requiring routine laboratory measurement.
A consistent rising time stabilises circadian input and sleep drive; repeatedly sleeping late after a poor night can perpetuate the next night's difficulty.
Falls risk, bipolar disorder, epilepsy or caring work may require gentler compression and specialist oversight, not a choice between rigid restriction and no behavioural care.
Calling sleep hygiene alone CBT-I and concluding that evidence-based treatment has failed after giving a leaflet.
Reducing time in bed without a diary, stable wake time, weekly monitoring or discussion of driving and occupational risk.
Missing mania because the person reports little sleep; ask whether sleep is desired and whether energy and behaviour have changed.
Requesting polysomnography routinely for insomnia without features of breathing, movement, parasomnia or central hypersomnolence disorders.
Starting or renewing hypnotics indefinitely without a defined target, review date, interaction check and withdrawal plan.
Assuming digital CBT-I is suitable before assessing pregnancy, severe comorbidity or possible alternative sleep disorders.
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A man with six months of insomnia spends nine hours in bed, estimates five hours asleep and sleeps late after poor nights. Obstructive sleep apnoea and mania are not suspected. Which intervention best reflects CBT-I?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Safety modifies treatment. Initial sleepiness can increase during sleep restriction, so discuss driving, machinery, falls and caring duties. Use caution or specialist input in untreated bipolar disorder, poorly controlled epilepsy, pregnancy and safety-critical work. Treat sleep apnoea, restless legs, circadian disorders and substance problems rather than applying an inflexible generic schedule. Sleep opportunity must not be reduced below a safe service protocol.
Medication decisions are explicit and time limited. Review the target, previous CBT-I, existing sedatives, alcohol, respiratory risk, falls, interactions and next-day functioning. Daridorexant has a NICE-defined place for long-term insomnia; other hypnotic choices follow their own licence and guidance. Every prescription needs a review or stop plan, while long-term benzodiazepines or Z-drugs should be tapered collaboratively rather than withdrawn abruptly.