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Chronic Insomnia / Insomnia Disorder

Pharmacological Therapy

Pharmacological therapy is not the recommended 'first-line' treatment or a long-term management approach for insomnia disorder. It may be reasonable to use as a short-term therapy in addition to CBTi for patients with significant distress or for those not responding to CBTi alone.

The decision to use medication however must weigh any potential serious side effects associated with pharmacologic therapy, such as:

  • Adverse cognitive, psychomotor and physiological (including heightened risk of hepatic, renal, respiratory and cardiac disorders) side effects
  • Dependence
  • Increased risk of accidents
  • Risk of mortality with long-term use or abuse

Against potential health risks of not providing treatment, such as:

  • Decreased quality of life
  • Increased risk of medical and mental health disorders
  • Substance use disorder (e.g. alcohol)
  • Decreased performance

Pharmacological therapy for insomnia disorder is therefore not recommended for older adults, as small-to-moderate effects are outweighed by the risk of dependence, side-effects, and adverse events in those aged 65 or over.1,2,3,4

Limiting pharmacotherapy to short-term prescriptions may help to reduce the risk of tolerance and dependence, which differs between specific medications and patients, and develops with repeated use and may result in dose-escalation5, includes:

  • Max 4 weeks use
  • Intermittent, rather than nightly, use
  • Using the lowest possible dose
  • With a specific plan/support to withdraw

Of one of the following medications:

  • Benzodiazepines
  • Z-drugs (e.g. Zolpidem or Zopiclone)
  • Melatonin
  • Orexin antagonist (Suvorexant)

May be considered for the short-term treatment of insomnia disorder.6,7

Following longer-term medication use, the emergence of withdrawal effects upon dose reduction/cessation can make it difficult for a patient to stop using sedative-hypnotics.8,9,10,11

Among patients with benzodiazepine dependence, gradual medication withdrawal strategies to avoid abrupt withdrawal/rebound effects and CBTi techniques can be used, in consideration of the patients’ lifestyle, history, dose, frequency, support structure, and preferred treatment approaches, to gradually improve sleep and reduce medication use.12,13,8,14,15

  • Clinical governance
  • Effectiveness and side-effects of sedative-hypnotic medications
  • Contraindications and precautions for sedative-hypnotic prescriptions
  • Tolerance effects and medication abuse
  • Strategies to reduce risk of dependence
  • Strategies to withdraw patients from sedative-hypnotic medications

Other resources to manage benzodiazepine withdrawal include:

Evidence is lacking regarding the efficacy and safety for medications such as antidepressants, antipsychotics and antihistamines and nutritional substances including valerian for the treatment of insomnia disorder and should therefore not be prescribed to manage insomnia disorder.2,16


AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Quick links


  1. RACGP gplearning ‘Managing insomnia in general practice www.racgp.org.au/education/professional-development/online-learning/gplearning
  2. Winkelman JW. Overview of the treatment of insomnia in adults. In UpToDate, Benca R (ed). Waltham, MA: UpToDate 2020
  3. Psychotropic Drugs Committee. Practice Guideline 5: Guidelines for use of benzodiazepines in psychiatric practice: RANZCP 2008
  4. Schutte-Rodin S, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504
  5. RACGP Prescribing drugs of dependence in general practice, part 2: benzodiazepines 2015
  6. Herring WJ, et al. Suvorexant in patients with insomnia: results from two 3-month randomized controlled clinical trials. Biol Psychiatry 2016;79:136-48
  7. Michelson D, et al. Safety and efficacy of suvorexant during 1-year treatment of insomnia with subsequent abrupt treatment discontinuation: a phase 3 randomised, double-blind, placebo-controlled trial. Lancet Neurol 2014;13:461-71
  8. RACGP Prescribing drugs of dependence in general practice, part 2: benzodiazepines 2015
  9. Wilson SJ, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol 2010;24(11):1577–601
  10. Guideline Development Group for the management of patients with insomnia in primary care. Clinical Practice Guidelines for the management of patients with Insomnia in Primary Care. UETS No 2007/5-1. Madrid: Ministry of Health and Social Policy 2009
  11. Riemann D, et al. The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioural therapies. Sleep Med Rev. 2009;13:205–14
  12. Sweetman A, et al. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Medicine Reviews 2020;101404
  13. Takaesu Y, et al. Psychosocial Intervention for Discontinuing Benzodiazepine Hypnotics in Patients with Chronic Insomnia: A Systematic Review and Meta-analysis. Sleep medicine reviews 2019;101214
  14. Morin CM, et al. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. American Journal of Psychiatry 2004;161(2):332-42
  15. Morgan K, et al. Psychological treatment for insomnia in the management of long-term hypnotic drug use: a pragmatic randomised controlled trial. Br J Gen Pract 2003;53(497):923-8
  16. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults. Sleep 2005;28(9):104957