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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Insomnia assessment and CBT-I principles

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Sleeplessness with acute danger

Near-total sleep loss with elevated or irritable mood, psychosis, suicidal intent, severe substance withdrawal, delirium or dangerous daytime impairment requires urgent assessment rather than routine sleep advice.

Action: Assess mental state, cognition, substances, physical observations and immediate safety; stop driving or hazardous work when alertness is impaired and arrange same-day acute medical or mental-health review when mania, psychosis, withdrawal or suicidality is suspected.

Synopsis

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 involves difficulty initiating or maintaining sleep, early waking or poor sleep quality together with daytime consequences and adequate opportunity to sleep.
  • A two-week sleep diary clarifies timing, variability, time in bed, naps and the difference between sleep opportunity and estimated sleep.
  • Screen for sleep apnoea, restless legs, circadian delay, parasomnia, narcolepsy, mood elevation, substances, pain and medicines before labelling primary insomnia.
  • CBT-I combines stimulus control, sleep restriction or compression, cognitive work, relaxation and sleep education; sleep hygiene alone is not the full treatment.
  • Fix a consistent rising time and reserve bed for sleep and intimacy, leaving the bed when awake and returning when sleepy where safe and feasible.
  • Sleep restriction consolidates sleep by matching time in bed to observed sleep, then widening gradually; it requires monitoring of sleepiness and comorbidity.
  • Polysomnography is not routine for uncomplicated insomnia but is used when another sleep disorder or unusual behaviour is suspected.
  • NICE recommends daridorexant for defined long-term insomnia only after CBT-I has not worked or when CBT-I is unavailable or unsuitable.

Key red flags

Reduced need for sleep with increased energy, pressured speech, impulsivity or grandiosity suggests mania rather than uncomplicated insomnia.

Loud snoring, witnessed apnoeas, choking, resistant hypertension or high-risk daytime sleepiness warrants assessment for obstructive sleep apnoea.

Uncomfortable evening leg sensations relieved by movement, dream enactment, sleep attacks or cataplexy indicates another sleep disorder.

Drowsy driving, workplace near misses, suicidal thinking, pregnancy or significant sedative and alcohol use changes urgency and treatment safety.

Investigation priorities

01
Two-week sleep diaryFirst step

Record sleep opportunity, estimated sleep, awakenings, rising, naps, substances and daytime effects across work and free days.

Management branches

AssessmentBuild the sleep formulation

Sleep difficulty is persistent, distressing or impairing daytime function.

  1. Complete a 24-hour history, two-week diary and screen for medical, psychiatric, circadian, breathing, movement and substance contributors.
  2. Explain the interaction between sleep drive, circadian timing, arousal, time in bed and learned bed-wake associations using diary examples.
  3. Agree treatment goals based on daytime function, a stable rising time and realistic improvement rather than a guaranteed eight-hour target.

Key medicines

DaridorexantTake 50 mg orally once nightly within 30 minutes before bed; 25 mg once nightly may be used on clinical judgement and is the recommended dose with moderate hepatic impairment or a moderate CYP3A4 inhibitor. The maximum is 50 mg daily.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.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

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.

  • NICE HTG624 Sleepio technologyCBT-I components, digital delivery, assessment and the current NHS care pathway.
  • NICE TA922 daridorexant recommendationsEligibility after CBT-I and mandatory early and continuing treatment review.
  • Daridorexant UK product informationCurrent licensed dose, timing, contraindications, interactions and adverse-effect information.
  • British Association for Psychopharmacology sleep consensusUK expert consensus on insomnia assessment, CBT-I and differential sleep disorders.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom