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Veterans Health Administration / Department of DefenseInternal Medicine2025advanced

Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea

Published by Department of Veterans Affairs and Department of Defense · GRADE

29Recommendations
234References
14Tables
4Figures
180 minRead time
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Summary

AI-generated

This clinical practice guideline provides evidence-based recommendations for the screening, diagnosis, and management of chronic insomnia disorder and obstructive sleep apnea (OSA) in adult patients. It emphasizes objective diagnostic testing, prioritizes cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment for chronic insomnia, and advocates for positive airway pressure (PAP) and mandibular advancement devices (MAD) as initial therapies for OSA. The guideline heavily incorporates shared decision-making and patient-centered care.

chronic insomnia disorderobstructive sleep apneaVA/DODinternal medicineguidelinesrecommendationscognitive behavioral therapypositive airway pressure

Key Takeaways

  • 1
    Screen at-risk patients using validated instruments like the Insomnia Severity Index (ISI) and STOP questionnaire.
  • 2
    Diagnose OSA objectively using polysomnography or home sleep apnea testing (HSAT).
  • 3
    Cognitive behavioral therapy for insomnia (CBT-I) is strongly recommended over pharmacotherapy as a first-line treatment for chronic insomnia disorder.
  • 4
    Mild to moderate OSA should be treated initially with a mandibular advancement device (MAD) or positive airway pressure (PAP) therapy.
  • 5
    Avoid the use of antipsychotics, benzodiazepines, trazodone, and diphenhydramine for treating insomnia.
  • 6
    Leverage shared decision-making to tailor therapy choices and improve patient adherence.

What's New in This Version

Updated Algorithm; Reviewed studies focused on specific outcomes to include critical outcomes of adoption of therapy, insomnia severity, and sleep efficiency; Added nine new recommendations; seven reviewed and replaced, eleven amended, and two no change; Used more rigorous application of GRADE methodology; Updated Provider Guide to Sleep Education; Updated Research Priorities.

Key Recommendations

Screening

  • 1

    For screening of patients with sleep complaints, we suggest using validated screening instruments for both insomnia (e.g., Insomnia Severity Index or Athens Insomnia Scale) and obstructive sleep apnea (e.g., STOP) to identify patients who need further evaluation.

    Weak forEvidence: moderateScreening

Obstructive Sleep Apnea Diagnosis

  • 2

    For diagnosis of clinically suspected obstructive sleep apnea, we recommend diagnosis with polysomnography or home sleep apnea testing.

    Strong forEvidence: lowDiagnosis
  • 3

    For diagnosis of obstructive sleep apnea in appropriate patients, we suggest home sleep apnea testing as an alternative to in-laboratory polysomnography.

    Weak forEvidence: very lowDiagnosis
  • 4

    For diagnosis of patients with a non-diagnostic home sleep apnea test, we recommend further sleep testing for obstructive sleep apnea with in-lab polysomnography or HSAT.

    Strong forEvidence: very lowDiagnosis

Treatment of Chronic Insomnia Disorder - Behavioral and Psychological Treatments

  • 5

    For treatment of chronic insomnia disorder, we recommend treatment with CBT-I.

    Strong forEvidence: moderateTreatment
  • 6

    For treatment of chronic insomnia disorder, we suggest treatment with BBT-I.

    Weak forEvidence: moderateTreatment
  • 7

    For treatment of chronic insomnia disorder, we suggest against sleep hygiene education as a stand-alone treatment.

    Weak againstEvidence: lowTreatment

Treatment of Chronic Insomnia Disorder - Pharmacotherapy

  • 8

    For treatment of chronic insomnia disorder, we suggest CBT-I over pharmacotherapy as first-line treatment.

    Weak forEvidence: moderateTreatment
  • 9

    For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, we suggest the use of one of the following agents: Daridorexant, Doxepin, Eszopiclone, Lemborexant, Suvorexant, Zaleplon, Zolpidem.

    Weak forEvidence: lowTreatment
  • 10

    For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, we suggest against the use of: Antipsychotic drugs, Benzodiazepines, Diphenhydramine, Trazodone.

    Weak againstEvidence: very lowTreatment
  • 11

    For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, there is insufficient evidence to recommend for or against the use of ramelteon.

    Neither for nor againstEvidence: very lowTreatment

Treatment of Chronic Insomnia Disorder - Complementary and Integrative

  • 12

    For treatment of chronic insomnia disorder, we recommend against the use of kava.

    Strong againstEvidence: very lowTreatment
  • 13

    For treatment of chronic insomnia disorder, we suggest against the use of cannabis and/or its derivatives.

    Weak againstEvidence: very lowTreatment
  • 14

    For treatment of chronic insomnia disorder, we suggest against the use of: Chamomile, Melatonin, Passionflower, Saffron, Valerian.

    Weak againstEvidence: very lowTreatment
  • 15

    For treatment of chronic insomnia disorder, there is insufficient evidence to recommend for or against the use of magnesium.

    Neither for nor againstEvidence: very lowTreatment
  • 16

    For treatment of chronic insomnia disorder, there is insufficient evidence to recommend for or against: Aerobic exercise, Mindfulness meditation, Qigong, Resistive exercise, Tai chi, Yoga.

    Neither for nor againstEvidence: very lowTreatment

Treatment of Obstructive Sleep Apnea

  • 17

    For treatment of obstructive sleep apnea, we recommend one or more of the following evidence-based therapies, depending on patient values and characteristics: Mandibular advancement devices, Positive airway pressure (PAP), Referral for surgical evaluation.

    Strong forEvidence: lowTreatment
  • 18

    For treatment of mild to moderate obstructive sleep apnea (Event Index <30 per hour), we suggest either mandibular advancement devices or positive airway pressure as first line therapy options.

    Weak forEvidence: lowTreatment
  • 19

    For treatment of newly diagnosed obstructive sleep apnea, we suggest initiating auto-titrating over fixed continuous positive airway pressure to facilitate usage.

    Weak forEvidence: lowTreatment
  • 20

    For treatment of obstructive sleep apnea in patients with overweight or obesity, we suggest evidence-based weight management in combination with other treatments for obstructive sleep apnea.

    Weak forEvidence: lowTreatment
  • 21

    For treatment of positional obstructive sleep apnea, we suggest positional therapy.

    Weak forEvidence: very lowTreatment
  • 22

    For treatment of obstructive sleep apnea in appropriate patients (including with an apnea hypopnea index of 15 or greater per hour) who have not been successful with positive airway pressure therapy, we suggest referral for evaluation for hypoglossal nerve stimulation therapy.

    Weak forEvidence: very lowTreatment
  • 23

    For treatment of obstructive sleep apnea in patients who cannot tolerate other recommended therapies, we suggest against oxygen therapy as a standalone treatment.

    Weak againstEvidence: lowTreatment
  • 24

    For treatment of obstructive sleep apnea, we suggest against atomoxetine or a combination of atomoxetine and oxybutynin.

    Weak againstEvidence: lowTreatment
  • 25

    For treatment of obstructive sleep apnea there is insufficient evidence to suggest for or against these interventions: Expiratory positive airway pressure (EPAP), Inspiratory muscle therapy, Intra-oral negative airway pressure, Myofunctional exercise, Neuromuscular electrical stimulation, Transcutaneous electrical nerve stimulation (TENS).

    Neither for nor againstEvidence: very lowTreatment
  • 26

    For treatment of obstructive sleep apnea in patients who are prescribed positive airway pressure therapy, we suggest the use of in-person or telehealth educational, behavioral, and supportive interventions to improve PAP usage.

    Weak forEvidence: low to very lowTreatment
  • 27

    For treatment of obstructive sleep apnea in appropriate patients, we suggest up to a two-week course of eszopiclone to improve positive airway pressure usage.

    Weak forEvidence: very lowTreatment
  • 28

    For treatment of obstructive sleep apnea in patients with anatomical nasal obstruction as a barrier to positive airway pressure use, we suggest evaluation for nasal surgery.

    Weak forEvidence: very lowTreatment
  • 29

    For treatment of obstructive sleep apnea-related residual excessive daytime sleepiness in patients who are optimally treated with sufficient therapy use, we suggest adding: Armodafinil, Modafinil, Solriamfetol.

    Weak forEvidence: lowTreatment

Scope & Objectives

Clinical Topic

Chronic Insomnia Disorder and Obstructive Sleep Apnea

Objectives

To provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with sleep disorders, specifically chronic insomnia disorder and obstructive sleep apnea, thereby leading to improved clinical outcomes.

Target Patient Population

Adult patients with chronic insomnia disorder and/or obstructive sleep apnea

Diagnostic Criteria

Chronic insomnia disorder: Difficulty initiating or maintaining sleep at least 3 nights per week for over 3 months, causing daytime impairment. OSA: At least 5 predominantly obstructive respiratory events per hour of sleep (with symptoms) or 15+ events per hour (regardless of symptoms) measured via polysomnography or HSAT.

Target Providers

VA providersDOD providersCommunity-based providersSleep specialistsPrimary care providers

Patient Criteria & Setting

Therapeutic Area

Sleep Medicine

Guideline Scope

ScreeningDiagnosisTreatmentManagement

Inclusion Criteria

  • Adults 18 years or older
  • Patients at risk of or experiencing insomnia and/or obstructive sleep apnea

Exclusion Criteria

  • Pediatric patients (under 18 years old)

Care Settings

Veterans Health Administration (VHA) facilitiesMilitary Health System (MHS) facilitiesCommunity-based care settings

Special Populations

VeteransActive-duty military personnelOlder adultsPatients with comorbid mental health disorders (e.g., PTSD, Anxiety)Patients with Traumatic Brain Injury (TBI)

Evidence Grading

System: GRADE

Evidence Distribution

1427abstracts_reviewed
7222citations_identified
56included_publications
598full_length_articles_reviewed

Evidence Levels

LowLow confidence in the quality of the evidence on outcomes that are critical to clinical decision making.
HighHigh confidence in the quality of the evidence on outcomes that are critical to clinical decision making.
ModerateModerate confidence in the quality of the evidence on outcomes that are critical to clinical decision making.
Very LowVery low confidence in the quality of the evidence on outcomes that are critical to clinical decision making.

Recommendation Strength

Weak forWe suggest...
Strong forWe recommend...
Weak againstWe suggest against...
Strong againstWe recommend against...
Neither for nor againstThere is insufficient evidence to recommend for or against...

Safety & Contraindications

Contraindications

  • Active alcohol or drug use disorder (requires delaying CBT-I)
  • Medically unstable patients (requires delaying CBT-I)
  • Uncontrolled seizure disorder (caution with sleep restriction therapy)
  • Severe hepatic impairment (for certain pharmacological therapies)
  • Kava, cannabis/derivatives, valerian, and chamomile are not recommended.

Monitoring Guidance

Providers should actively monitor treatment adherence, especially for PAP and MAD therapies (e.g., assessing device data downloads and side effects). If prescribing medications like non-BZD BzRAs or antipsychotics, monitor for metabolic parameters and complex sleep-related behaviors.

Authors & Contributors

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea Work Group

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Estimated Read Time

180 minutes

Exam Relevance

Sleep Medicine CertificationInternal Medicine Board ExamsPsychiatry Board ExamsPulmonary Medicine Board Exams

Learning Paths

Cognitive Behavioral Therapy for Insomnia (CBT-I)Continuous Positive Airway Pressure (CPAP)Home Sleep Apnea Testing (HSAT)PolysomnographyMandibular Advancement DevicesSleep Medicine