J Clin Sleep Med
Insomnia guideline update reframes sleep meds, CBT-I
Clinical Takeaway: Start with CBT‑I for most adults with chronic insomnia. Consider adding a sleep medication only when additional short‑term gains (for example, increased total sleep time) matter to the patient, and avoid combination therapy when CBT‑I alone is sufficient.
A new American Academy of Sleep Medicine (AASM) clinical practice guideline, published in the Journal of Clinical Sleep Medicine, addresses a long‑standing gray area in insomnia care: when to combine cognitive behavioral therapy for insomnia (CBT‑I) with pharmacotherapy. Previous AASM guidelines evaluated behavioral and drug treatments separately; this 2026 update directly compares combination therapy vs. monotherapy using a systematic review and the GRADE framework.
The task force issues two conditional recommendations, both based on low‑certainty evidence.
First, the AASM suggests using CBT‑I plus medication rather than medication alone in adults with chronic insomnia. Combination treatment was associated with meaningful improvements in some sleep outcomes, particularly total sleep time, compared with drugs alone.
Second, the guideline suggests against routinely using combination therapy over CBT‑I alone. CBT‑I by itself produces durable improvements without the risks associated with pharmacotherapy, and for most patients, adding medication provides only modest incremental benefit.
Notably, the guideline doesn’t endorse routine concomitant prescribing. Instead, it emphasizes shared decision‑making, with treatment selection guided by patient values and goals. For example, patients who place a high value on increasing total sleep time early in treatment, and a lower value on avoiding medication exposure, may reasonably opt for combination therapy, while others may prefer CBT‑I alone.
Although the evidence base included commonly used hypnotics for sleep‑onset, sleep‑maintenance, and mixed insomnia—such as benzodiazepine receptor agonists, doxepin, orexin receptor antagonists, and melatonin receptor agonists—no specific drug or drug class emerged as a preferred add‑on to CBT‑I. Benefits of combination treatment were small and outcome‑specific.
As lead author Daniel J. Buysse, MD, noted, “CBT‑I by itself is the most efficacious first‑line treatment for insomnia. However, using medication with CBT‑I may provide modest benefit for some specific outcomes, such as total sleep time.”
Bottom line: Prioritize CBT‑I first. Add medication selectively, matching the approach to the individual patient’s goals, weighing benefits against risks, and using the shortest effective duration when drugs are added.
Source: Buysse DJ, et al. (2026, April 13). J Clin Sleep Med. Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline