Insomnia: CBT-I first, medication last — the AU general practice approach

What insomnia actually is

Insomnia is the difficulty initiating sleep, maintaining sleep, or experiencing non-restorative sleep, with consequent daytime impairment. Daytime impairment is the diagnostic threshold — feeling fine despite short sleep doesn’t meet criteria.

Chronic insomnia requires symptoms ≥3 nights/week for ≥3 months. About 10–15% of Australian adults meet criteria for chronic insomnia at any given time, with prevalence rising in middle and older adulthood.

The biological model: hyperarousal — sympathetic activation, HPA-axis activation, elevated cortisol, raised core body temperature, alpha-EEG patterns during sleep, increased metabolic rate. This is sustained by behavioural and cognitive factors that often start as appropriate responses to acute stressors and become self-perpetuating.

The clinical question is: what’s driving and maintaining the insomnia? Treatment follows from the answer.

A. Core clinical — the AU general practice framework

History to take

The Sleep Health Foundation and Australasian Sleep Association recommend structured insomnia assessment:

• Pattern — onset latency, awakenings, early-morning awakening, total sleep time, sleep efficiency
• Duration — acute (under 3 months) vs chronic (≥3 months)
• Daytime impairment — fatigue, mood, cognition, function at work/study/relationships
• Sleep environment — light, noise, temperature, partner, pets, child wakings
• Pre-sleep routine — screens, news, alcohol, caffeine timing, exercise timing
• Substance use — caffeine (incl. tea, soft drinks, dark chocolate), alcohol, nicotine, recreational drugs
• Medications — corticosteroids, decongestants, certain antidepressants, theophylline, beta-blockers (vivid dreams)
• Mood screen — PHQ-9, GAD-7
• Sleep apnoea screen — STOP-BANG questionnaire; snoring, witnessed apnoeas, daytime sleepiness, hypertension, BMI, age, neck circumference, sex
• Restless legs screen — urge to move legs at rest, evening worsening, partial relief by movement
• Comorbidities — chronic pain, GORD, nocturia (especially men over 50 — BPH; women — overactive bladder), urinary frequency

Workup

• Sleep diary for 1–2 weeks — patient-completed; informs both diagnosis and CBT-I planning
• Bloods — ferritin (RLS), TSH, B12 in selected patients
• Sleep study (home or in-lab) if OSA features present — referred via Sleep Health Foundation directory or general practitioner-initiated for eligible patients
• Actigraphy — wrist accelerometer for 1–2 weeks; useful in suspected circadian rhythm disorders

Treatment hierarchy

The American Academy of Sleep Medicine, European Sleep Research Society guideline (Riemann 2017), and AU primary tier converge:

1. Identify and treat underlying conditions — OSA, RLS, mood disorders, alcohol, caffeine
2. CBT-I as first-line for chronic insomnia
3. Medication only if CBT-I fails, is unavailable, or in acute severe distress as a bridge
4. Sleep hygiene alone is not enough — sleep hygiene without CBT-I doesn’t work for established chronic insomnia

B. Evidence appraisal — CBT-I first

Why CBT-I

The Trauer Ann Intern Med 2015 meta-analysis — 20 RCTs of CBT-I for chronic insomnia — showed:

• Sleep-onset latency reduced by ~19 minutes
• Wake-after-sleep-onset reduced by ~26 minutes
• Sleep efficiency improved by ~10%
• Effect sizes equal to medication short-term
• Durable long-term — effects sustained at 12+ months, unlike medication

CBT-I components:

• Sleep restriction — initially restrict time in bed to actual sleep time + 30 minutes; expand as efficiency improves
• Stimulus control — bed only for sleep and sex; out of bed if not asleep in 20 min
• Cognitive restructuring — challenge catastrophic thoughts about sleep
• Sleep education — normal variation, age-related changes, expectations
• Relaxation training — progressive muscle relaxation, breathing exercises (our free guided breathing tool walks you through several slow-breathing patterns)

AU access pathways

Psychologist via Mental Health Treatment Plan — MBS items 2715/2717, 10 subsidised sessions/year. Not every psychologist is CBT-I trained; ask specifically.

Online programs:

• This Way Up — AU-developed, evidence-aligned, free or low-cost
• MoodGYM — anxiety + depression with insomnia components
• Sleep Reset, CBT-i Coach, SHUTi — international apps, AU users

Sleep Health Foundation directory — practitioners trained in CBT-I.

When medication is appropriate

Acute insomnia with clear precipitant — short-term hypnotic (≤2 weeks) is reasonable. Avoid creating a chronic dependency from a transient situation.

Chronic insomnia with severe distress — short-term bridge while CBT-I starts; planned taper.

CBT-I failed or unavailable — pharmacotherapy as ongoing treatment after appropriate trial of behavioural approaches.

Pharmacotherapy options

Per eTG and AMH:

Agent	Pros	Cons
Temazepam (10–20 mg)	Effective; short half-life	Benzodiazepine — tolerance, dependence, falls in elderly
Zolpidem (5–10 mg), Zopiclone (3.75–7.5 mg)	Effective sleep onset	Z-drug — falls in elderly, parasomnia events, dependence at higher doses
Prolonged-release melatonin (Circadin 2 mg)	Adults ≥55; less abuse potential	Modest effect size
Suvorexant (Belsomra)	Orexin antagonist; lower abuse potential	Less PBS access; cost
Low-dose doxepin (3–6 mg)	Sleep maintenance; favourable safety	Off-label; less commonly prescribed in AU
Mirtazapine (low dose, 7.5–15 mg)	When comorbid depression	Weight gain; not strictly hypnotic
Trazodone (low dose, 25–100 mg)	Sometimes used; not first-line	Off-label; specialist context

Avoid:

• Long-term benzodiazepine or Z-drug use — Choosing Wisely Australia recommends against
• Antihistamines (promethazine, doxylamine) — anticholinergic burden, daytime sedation, falls in elderly
• Quetiapine for insomnia — metabolic side effects, not appropriate without other indication
• Cannabis-based products as first-line — insufficient AU primary-tier evidence; specific TGA Schedule 8 pathways for medical cannabis

C. Sleep hygiene — necessary but not sufficient

Common AU sleep hygiene recommendations that contribute when stacked:

• Consistent wake time (more important than bedtime), even on weekends
• Bedroom dark, cool (~18°C), quiet, comfortable
• No screens 30–60 min before bed
• No caffeine after midday (later for fast metabolisers, earlier for slow)
• Alcohol moderation — fragments sleep architecture
• Regular exercise (not within 3 hours of bed for most)
• Light exposure in the morning (10–30 min outdoor light)
• Avoid clock-watching during awakenings
• Bed for sleep only — not work, not phone, not TV
• Wind-down ritual (book, bath, music)

Sleep hygiene alone doesn’t treat chronic insomnia — it’s part of CBT-I, not a substitute. Patients told to “improve sleep hygiene” without CBT-I typically don’t improve.

D. Special populations

Older adults. Increased risk from hypnotics — falls, fractures, cognitive impairment. Aim for non-pharmacological approaches; if medication needed, prefer melatonin PR or non-benzodiazepine alternatives.

Pregnancy. Most hypnotics avoided. Sleep hygiene + CBT-I-style behavioural strategies. Specialist input if severe.

Shift workers. Specific approach addressing circadian misalignment — strategic light exposure, melatonin timing, scheduled napping, caffeine timing. Australasian Sleep Association has shift-work resources.

Children and adolescents. Behavioural approaches dominate; medication rarely first-line. School-age “sleep hygiene” includes screen limits, consistent schedule, anxiety screen. Adolescent delayed sleep phase is common and often misdiagnosed as insomnia.

Postpartum. Common, often resolves with infant sleep maturation; severity warranting workup deserves it (PND, OSA, anxiety disorders).

When to escalate

Refer or escalate when:

• Sleep apnoea suspected — for sleep study and management
• Restless legs not improving with iron repletion + first-line agents
• Suspected narcolepsy, parasomnia, REM sleep behaviour disorder
• Severe insomnia refractory to CBT-I + appropriate medication
• Comorbid severe depression or anxiety
• Suicidal ideation
• Substance use disorder driving insomnia

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — Therapeutic Guidelines, AMH, NPS MedicineWise, Sleep Health Foundation, Australasian Sleep Association, Choosing Wisely Australia — and major insomnia trials. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatment, including medication choices, are made with your own GP and treating clinicians.

For Australian consumer-friendly sources: Sleep Health Foundation, HealthDirect — Insomnia, Better Health Channel, This Way Up.

For acute mental-health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

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Sources cited

1. Sleep Health Foundation
2. Australasian Sleep Association
3. RACGP
4. Therapeutic Guidelines (eTG)
5. Australian Medicines Handbook
6. NPS MedicineWise
7. Choosing Wisely Australia
8. Better Access Initiative
9. This Way Up
10. HealthDirect — Insomnia
11. Better Health Channel — Sleep
12. TGA
13. Trauer JM et al. — CBT-I meta-analysis (Ann Intern Med 2015)
14. Riemann D et al. — European insomnia guideline (J Sleep Res 2017)