Insomnia Algorithm · Reasoning GP

The full reasoning pathway — treat insomnia with sleep hygiene and CBT-I first, exclude secondary causes, reserve short-term hypnotics for severe disabling cases, reinforce lifestyle, and safety-net.StartDecisionInvestigateActionReferStop / Admit

PresentationInsomnia

Sleep onset/maintenance, duration, daytime impact, sleep habits, caffeine/alcohol, shift work. Sleep diary; screen mood, pain, OSA.

Step 1 · Safety — exclude secondary causeSecondary cause / comorbidity / trigger?

Depression/anxiety/stress, chronic pain, OSA (snoring/sleepiness), restless legs, substance/alcohol use, medications, COPD, heart failure, GORD, menopause, circadian rhythm disorders; or an occupational at-risk group (drivers, machinery operators).

YES

Stop · EscalateTreat cause

Treat the underlying disorder (mood, pain, OSA, RLS); OSA + sleepiness → DVLA advice.

AssessBy pattern

History + assessment guide management.

Step 7 · all patients: sleep hygiene + digital CBT-I

Short-term (<3m), severe/acute

Digital CBT-I ± short Z-drug

If likely to resolve soon (bereavement, stressor) → zopiclone (1st) / zolpidem (2nd) for 3–7 days as temporary adjunct.

Chronic, aged ≥55

Melatonin MR 2 mg

After food, 1–2h before bed. ISI + agreed goals. Stop if no benefit by 13 weeks.

Chronic, CBT-I failed/unsuitable

Daridorexant (TA922)

Within 30 min of bed. Review 1 & 3 months; stop by 12 weeks if no benefit.

review 2–4 weeks

Step 6 · review 2–4 weeks

Step 6 · Refer / reassessIf no improvement

Reassess, consider alternative diagnosis & need for referral: Sleep clinic suspected OSA / refractory insomnia; Mental health if mood-driven; Digital CBT-I for all. Avoid long-term Z-drugs.

Step 8 · sleep hygiene & lifestyle

Step 8 · Lifestyle & sleep hygieneThe durable intervention

Consistent wake time, get up if not asleep within ~20 min, bed for sleep only · reduce caffeine (afternoon), alcohol and nicotine · limit daytime naps · daytime activity/exercise (not late) · wind-down routine, dark/cool room, screens off before bed · manage worry (journaling, relaxation). Treat coexisting pain, reflux, nocturia, menopause and mood.

Step 9 · safety-net & follow-up

Step 9 · Safety-net & follow-upDrug cautions & when to return

Limit Z-drugs/hypnotics to 3–7 days and warn about next-day sedation and driving (DVLA — don't drive if impaired); avoid dependence. Review melatonin/daridorexant at the set milestones and stop if no benefit. Return if loud snoring + daytime sleepiness (OSA), low mood, or insomnia worsens despite measures.

⚠️ CBT for insomnia is first-line and more durable than drugs: reserve hypnotics for short-term use in severe cases, and always look for an underlying mood, pain or sleep-apnoea cause.

Safety

Red Flags — Exclude Dangerous Causes & Serious Comorbidity

Done

Insomnia is extremely common (affecting ~35% of adults) but these red flags demand urgent action before routine management.

Suicidal ideation Severe insomnia is an independent risk factor for suicide — actively screen with PHQ-9 Q9 at every consultation. Immediate crisis referral if active ideation.

Witnessed apnoeas + snoring Obstructive sleep apnoea (OSA) — cardiovascular risk, road accident risk. Epworth ≥10 → urgent sleep study. DVLA implications — must advise to stop driving until treated.

Excessive daytime somnolence Falling asleep involuntarily during activities → OSA, narcolepsy, idiopathic hypersomnia. Epworth Sleepiness Scale >10. Occupational and driving safety risk.

Night sweats + weight loss Lymphoma, TB, malignancy — do not attribute to "menopause" without investigation in at-risk patient. ESR, CRP, CXR, FBC.

Nocturnal chest pain / dyspnoea Nocturnal angina, paroxysmal nocturnal dyspnoea (heart failure) — same-day ECG, BNP.

Nocturnal seizures Tongue biting, incontinence, post-ictal confusion on waking — EEG + neurology referral.

Substance withdrawal Alcohol, benzodiazepine, opioid withdrawal cause severe insomnia — rebound insomnia on cessation. Withdrawal management required.

Severe psychiatric symptoms Mania (reduced need for sleep with elevated mood / racing thoughts) → same-day psychiatric assessment. Psychotic insomnia → urgent CMHT.

Insomnia is a significant independent risk factor for suicide — meta-analyses show a 2.2× increased suicide risk in people with insomnia, independent of depression. Every insomnia consultation should include a brief suicide risk screen. OSA is underdiagnosed in 80% of cases in the UK — it causes hypertension, type 2 diabetes, atrial fibrillation, and stroke, and carries a 7× increased road traffic accident risk. Patients with untreated OSA must be advised not to drive until the condition is assessed and treated (DVLA Group 1 licence regulations). Reduced need for sleep (as opposed to insomnia) is a classic prodrome of mania — missing this leads to delayed bipolar diagnosis.

Diagnose

History — Characterise the Sleep Problem

Done

Targeted history distinguishes insomnia disorder from other sleep disorders and identifies maintaining factors.

Type of insomnia

Sleep-onset (difficulty falling asleep → hyperarousal, anxiety, delayed sleep phase) vs sleep-maintenance (waking in the night → depression, pain, OSA, nocturia) vs early morning waking (EMW → depression, advanced sleep phase, alcohol)

Duration

Acute (<3 months — identifiable trigger: bereavement, stress, illness) vs chronic (≥3 months, 3+ nights/week — perpetuating psychological factors). Chronic insomnia requires CBT-I.

Sleep diary (2 weeks)

Bedtime, sleep onset latency (SOL >30 min = significant), wake after sleep onset (WASO), total sleep time, rise time, daytime naps, sleep quality (1–10). Essential for diagnosis and CBT-I.

Daytime impact

Fatigue, concentration, mood, work performance, accidents. Daytime impairment is required for diagnosis of insomnia disorder (not just poor sleep without consequences).

Sleep habits & environment

Bed / wake times consistency, bed for activities other than sleep, bedroom (temperature, noise, light), partner disturbance, shift work, screen exposure.

Psychiatric screen

PHQ-9 (depression — early morning waking is cardinal feature), GAD-7 (anxiety → sleep onset insomnia), PTSD screen (nightmares, hypervigilance), bipolar history.

Substance use

Alcohol (initially sedating, reduces REM, rebound waking after 3–4 hrs), caffeine (half-life 5–7 hrs — afternoon coffee disrupts sleep), cannabis (disrupts sleep architecture long-term), recreational drugs.

Medications

Beta-blockers (reduce melatonin), SSRIs (insomnia side effect — especially fluoxetine), steroids, decongestants, stimulants, diuretics (nocturia), theophylline.

The type of insomnia (onset vs maintenance vs EMW) is highly diagnostically discriminating. Early morning waking (waking ≥2 hours before intended time and unable to return to sleep) is a biological marker of depression — PHQ-9 must be completed. Sleep-onset insomnia with racing thoughts and worry is the hallmark of anxiety and hyperarousal. A 2-week sleep diary is the cornerstone of CBT-I assessment — it quantifies sleep efficiency (time asleep / time in bed × 100) and guides sleep restriction therapy dose. Sleep efficiency <85% indicates clinically significant insomnia disorder. Caffeine has a half-life of 5–7 hours — a 3pm coffee contains active caffeine at midnight, perpetuating sleep-onset difficulty.

Diagnose

Differential Diagnosis — Beyond Primary Insomnia

Done

Primary (chronic) insomnia

Insomnia disorder — hyperarousal, conditioned arousal, dysfunctional sleep beliefs. Most common. Perpetuated by compensatory behaviours (early to bed, napping, lying awake worrying). First-line: CBT-I.

Obstructive sleep apnoea

Snoring, witnessed apnoeas, nocturnal waking (unrefreshing sleep), obesity, neck circumference >40 cm. Epworth Sleepiness Scale. STOP-BANG questionnaire. Refer for sleep study.

Restless legs syndrome (RLS)

Irresistible urge to move legs at rest, worse in evenings/night, relieved by movement. Primary (idiopathic) or secondary (iron deficiency — ferritin <50, pregnancy, CKD, peripheral neuropathy). Check ferritin.

Circadian rhythm disorders

Delayed sleep phase (teenagers/young adults — can't sleep until 2–4am, can't wake in morning) vs advanced sleep phase (elderly — sleepy at 7pm, wake at 3am). Light therapy ± melatonin.

Depression / anxiety

Most common psychiatric comorbidity. Insomnia both a symptom and a risk factor for depression. Treat the depression — insomnia usually improves. CBT-I effective even with comorbid depression.

Periodic limb movement disorder

Repetitive limb movements during sleep — partner reports leg kicking. Disrupts sleep maintenance. Diagnosed on polysomnography. Dopamine agonists effective.

Paradoxical insomnia

Patient perceives severe insomnia but sleep study shows near-normal sleep duration. Significant distress. CBT-I — cognitive restructuring for misperception of sleep state.

Drug / alcohol related

Alcohol dependence → chronic insomnia (alcohol suppresses slow-wave and REM sleep, causes rebound waking). Benzodiazepine rebound insomnia on cessation (much worse than original insomnia).

Restless legs syndrome (Willis-Ekbom disease) affects 5–10% of adults and is significantly underdiagnosed. Secondary RLS due to iron deficiency is common — ferritin <50 µg/L warrants iron supplementation before any pharmacological treatment, which often resolves symptoms completely. Delayed sleep phase syndrome is extremely common in teenagers (developmental circadian shift) and is frequently misdiagnosed as insomnia or depression — the key is that patients sleep normally once permitted to follow their natural schedule. Paradoxical insomnia (sleep state misperception) accounts for 5–10% of chronic insomnia presentations — actigraphy or polysomnography reveals normal sleep duration despite severe reported insomnia. CBT-I is equally effective.

Diagnose

Targeted Examination & Investigations

Done

BMI & neck circumference

BMI >30 and neck circumference >40 cm (M) / >35 cm (F) → OSA risk. Mallampati score (posterior oropharynx visibility). Tonsillar hypertrophy.

Epworth Sleepiness Scale

8-item questionnaire. Score ≥10 = excessive daytime somnolence → sleep study referral. Scores 8–9 = borderline. Brief and validated — complete in clinic.

STOP-BANG score

Snoring / Tired / Observed apnoea / Pressure (hypertension) / BMI >35 / Age >50 / Neck >40 cm / Gender (male). Score ≥3 = intermediate risk, ≥5 = high risk for moderate-severe OSA.

Targeted bloods

Ferritin (RLS — treat if <50 µg/L) · TFTs (hyperthyroidism → insomnia) · HbA1c (nocturnal hypoglycaemia) · CRP / FBC (if systemic cause suspected)

Mood & anxiety scales

PHQ-9 (depression — score ≥10 = moderate) · GAD-7 (anxiety — score ≥10 = moderate) · ISI (Insomnia Severity Index — validated outcome measure for insomnia treatment; score >14 = moderate-severe insomnia)

NOT routinely

Polysomnography — not needed for primary insomnia diagnosis. Reserve for suspected OSA (where home oximetry insufficient), PLMD, or narcolepsy. EEG only if nocturnal seizures suspected.

The Insomnia Severity Index (ISI) is a 7-item validated questionnaire that takes 2 minutes and quantifies insomnia severity — it is the recommended outcome measure for monitoring CBT-I response (typically see 5–7 point reduction over 6–8 weeks). The STOP-BANG questionnaire has 94% sensitivity for moderate-severe OSA — it should be used in all patients with snoring, daytime somnolence, obesity, or hypertension presenting with sleep complaints. Iron is the cofactor for dopamine synthesis — ferritin <50 µg/L is the treatment threshold for RLS even in the absence of anaemia, as dopaminergic neurons require adequate iron stores for neurotransmitter production.

Refer

Referral Pathways

Done

Urgent same-day

Active suicidal ideation with insomnia → crisis team / 999. Suspected acute mania (no need to sleep + elevated mood + grandiosity) → same-day psychiatric assessment.

Sleep clinic (respiratory)

STOP-BANG ≥3 or Epworth ≥10 → refer for home overnight oximetry or full polysomnography. Urgency increased if professional driver, HGV/PSV licence, or history of road incidents.

IAPT / NHS Talking Therapies

CBT-I is NICE first-line for chronic insomnia (NICE CKS Insomnia, 2024). Self-refer to NHS Talking Therapies for guided self-help or individual CBT(-I). Also treats comorbid depression and anxiety concurrently.

Neurology

Suspected narcolepsy (cataplexy — sudden muscle weakness with emotion, hypnagogic hallucinations, sleep paralysis) → multiple sleep latency test (MSLT). Also: REM sleep behaviour disorder (acting out dreams — RBD is a prodrome of Parkinson's in 80% of cases).

Psychiatry / CMHT

Severe depression or anxiety not responding to primary care treatment. Bipolar disorder (reduced sleep need). PTSD with nightmares (trauma-focused CBT, not hypnotics).

Endocrinology

Confirmed hypothyroidism (TFTs), hyperthyroidism causing insomnia, Cushing's (nocturnal cortisol excess), menopausal insomnia — if HRT appropriate, via relevant specialist.

REM sleep behaviour disorder (RBD — acting out vivid dreams, sometimes violently) is a critical diagnosis: 80% of patients with idiopathic RBD develop Parkinson's disease, Lewy body dementia, or multiple system atrophy within 10–15 years. It is a synucleinopathy prodrome and should prompt neurology referral for monitoring and neuroprotective trial eligibility. Narcolepsy with cataplexy is often misdiagnosed for 8–10 years — the combination of excessive daytime somnolence plus sudden bilateral muscle weakness triggered by strong emotion (laughter, surprise) is pathognomonic. DVLA licensing implications are significant in untreated narcolepsy.

Treat

First-Line: CBT-I — Components & Delivery

Done

CBT-I is more effective than any medication for chronic insomnia — it produces durable improvements (vs medication's temporary effects). NICE CKS Insomnia positions CBT-I as first-line.

Sleep restriction therapy

Most powerful CBT-I component. Restrict time in bed to actual sleep time (e.g. if sleeping 5 hrs, only allow 5 hrs in bed). Builds sleep pressure (homeostatic drive). Gradually extend by 15–30 min/week once efficiency >85%. Avoid <5 hrs total.

Stimulus control

Bed only for sleep and sex — not reading, TV, phones, worrying. If awake >20 mins → get up, go to another room, return only when sleepy. Trains brain to associate bed with sleep.

Cognitive restructuring

Challenge dysfunctional sleep beliefs: "I must get 8 hours", "One bad night ruins everything". Sleep need varies (6–9 hrs normal range). Catastrophising about poor sleep perpetuates hyperarousal.

Relaxation techniques

Progressive muscle relaxation, diaphragmatic breathing (4–7–8 breathing), mindfulness-based stress reduction (MBSR). Reduces physiological arousal at bedtime. Prescribe specific technique to practise.

Sleep compression

Alternative to full sleep restriction for older adults / those with excessive daytime fatigue — gradually compress time in bed over weeks rather than acute restriction.

Digital CBT-I

Sleepio (NICE MTG70 — NHS-funded in some areas; free for cancer patients via Macmillan), Sleepstation (local funding), and the free self-help Sleepful.org.uk if other programmes can't be accessed. Equivalent efficacy to face-to-face for mild–moderate insomnia. Offered to all patients regardless of step.

CBT-I is superior to pharmacotherapy in every head-to-head trial — it produces larger effect sizes (Cohen's d 0.9–1.0 vs 0.5–0.7 for hypnotics), no rebound insomnia on stopping, no dependence risk, and effects lasting 12+ months post-treatment. Sleep restriction therapy works by increasing homeostatic sleep pressure (adenosine drive) — restricting time in bed temporarily consolidates fragmented sleep, then gradually extending allows the circadian clock and homeostatic system to re-synchronise. Stimulus control breaks conditioned arousal (the classical conditioning of bed = wakefulness and anxiety) — one of the most powerful maintaining factors in chronic insomnia.

Treat

Stepped-Care Decision — Short-Term vs Long-Term Insomnia (CG046)

Done

Once sleep hygiene + a sleep diary are in place and comorbidities/triggers are treated, assess the duration of insomnia — this drives the stepped-care decision. Offer digital CBT-I (or other local services) to ALL patients at every step; drugs are adjunctive and gated.

Short-term insomnia (<3 months)

Digital CBT-I ± short Z-drug

Offer digital CBT-I. If severe symptoms / acute exacerbation AND likely to resolve soon (e.g. bereavement, short-term stressor) → consider a short course of a Z-drug (3–7 days) as a temporary adjunct. Review at end of course or sooner.

Long-term (chronic) insomnia

≥3 nights/week for ≥3 months

… AND daytime functioning considerably affected. Offer digital CBT-I for all, then consider pharmacotherapy by the gates below — guided by the ISI and agreed goals.

Chronic + aged ≥55

Melatonin MR 2 mg

Consider melatonin MR 2 mg for short-term treatment of primary persistent insomnia characterised by poor sleep quality in patients aged 55 or over (drug detail in Step 8).

Chronic + CBT-I failed / unsuitable / refused

Daridorexant (NICE TA922)

Consider daridorexant for chronic insomnia with daytime functioning considerably affected — only if digital CBT-I has been tried but not worked, or is unavailable/unsuitable (or refused by the patient). See Step 8.

At initiation (melatonin / daridorexant)

Complete the ISI (Insomnia Severity Index) and agree clear treatment goals/outcomes that define whether to continue.

Review at 2–4 weeks

If symptoms have not improved (timing per clinical situation), reassess — including duration of insomnia — consider an alternative diagnosis and the need for referral. Use the ISI to support efficacy assessment.

Stop rules

Stop if agreed goals/outcomes are not reached. Melatonin: stop if no improvement by 13 weeks. Daridorexant: stop if no improvement by 12 weeks.

Treatment failure

If measures fail at review → reassess diagnosis, optimise CBT-I engagement, and consider referral (digital CBT-I, sleep clinic, mental health — Step 5).

The Coventry & Warwickshire CG046 pathway (Jan 2025) operationalises NICE CKS Insomnia and NICE TA922: digital CBT-I is offered to everyone, short courses of Z-drugs are reserved for severe short-term insomnia expected to resolve, and the chronic-insomnia drug choice is gated by age (melatonin MR for ≥55s) and by whether CBT-I has been tried/failed/is unsuitable (daridorexant). Anchoring continuation to the ISI and pre-agreed treatment goals — with explicit 13-week (melatonin) and 12-week (daridorexant) stop points — prevents open-ended hypnotic prescribing.

Treat

Pharmacological Treatment — Drug Detail & Prescribing

Done

Medication is adjunctive to CBT-I, not a substitute. Use only when: acute/situational insomnia causing severe impairment, or as short-term bridge while awaiting CBT-I.

Melatonin ≥55 years

Melatonin 2 mg MR (Circadin)

Melatonin MR 2 mg OD, 1–2 hrs before bed and after food, for primary persistent insomnia (poor sleep quality) in ≥55s. Initial course 3 weeks, up to 13 weeks total; if there is a response, continue a further 10 weeks only. Stop if no improvement by 13 weeks. Avoid in hepatic impairment. No dependence/hangover. Complete ISI + agree goals at initiation.

Short-term hypnotic (Z-drug)

Zopiclone 1st / zolpidem 2nd

Zopiclone 7.5 mg (1st line; 3.75 mg elderly) or zolpidem 10 mg (2nd line; 5 mg elderly) at night. Short-term only: 3–7 days preferred, not exceeding 2 weeks, when non-drug measures have failed and insomnia is severe/disabling. Temporary adjunct alongside digital CBT-I. Risks: falls, dependence, rebound, next-morning driving impairment (12 h). Avoid in COPD/OSA, severe hepatic impairment.

Depression + insomnia

Mirtazapine 15–30 mg nocte

Sedating antidepressant via H1 + 5-HT2C antagonism. Improves both depression and insomnia. 15 mg is more sedating than 30 mg (paradoxical dose-sedation relationship). Weight gain side effect — useful in weight-loss depression.

Low-dose sedating antidepressant

Amitriptyline 10–25 mg nocte

Off-label for insomnia. Effective but anticholinergic side effects (dry mouth, constipation, urinary retention, cognitive effects). Avoid in elderly. Do not use if cardiac arrhythmia risk (QTc prolongation).

RLS — iron deficiencyFerrous sulfate 200 mg BD if ferritin <50 µg/L — often curative for secondary RLS. Recheck ferritin at 3 months. Consider IV iron if oral not tolerated.

RLS — refractoryPramipexole 0.088 mg nocte (dopamine agonist) or ropinirole 0.25 mg — effective for idiopathic RLS. Risk of augmentation with long-term dopamine agonists — specialist oversight.

Circadian disorderMelatonin 0.5–3 mg taken 2–6 hrs before desired sleep time (delayed sleep phase) or morning bright light therapy. Chronotherapy under sleep specialist guidance for severe cases.

DaridorexantDaridorexant 50 mg (25 mg if moderate hepatic impairment, or moderate CYP3A4 inhibitors / ciclosporin / ciprofloxacin) within 30 min of bed. NICE TA922 — only if CBT-I tried but not worked, or unavailable/unsuitable. No other hypnotics for 1 month before starting; dual orexin-receptor antagonist. Review at 1 month & 3 months; stop by 12 weeks if no benefit; no down-titration; reassess ≥6-monthly (efficacy beyond 1 year uncertain).

Z-drugs (zopiclone, zolpidem, zaleplon) carry significant risks: dependence develops in 40% of patients using them for >4 weeks, rebound insomnia is severe on withdrawal, and morning sedation impairs driving ability for 12 hours (legal liability). Zolpidem is not licensed in the UK for driving and DVLA specifically advises patients not to drive. Melatonin modified-release (Circadin) is the preferred first-line pharmacological option in over-55s — no dependence, no next-day sedation, no rebound, and modest but clinically meaningful benefit (reduces sleep latency by 15–20 minutes, improves sleep quality). Daridorexant (an orexin-2 receptor antagonist) represents the newest class — it blocks the wakefulness-promoting orexin system specifically without the dependence profile of benzodiazepines/Z-drugs.

Lifestyle

Sleep Hygiene & Non-Pharmacological Foundations

Done

Sleep hygiene alone is insufficient for chronic insomnia but underpins all other treatments. Combine with CBT-I techniques.

Fixed wake time (anchor) The single most evidence-based intervention — set the same wake time 7 days/week regardless of how the night went. This anchors the circadian clock. Do not compensate with lie-ins.

No napping after 3pm Daytime napping reduces homeostatic sleep pressure (adenosine drive). If napping is essential (elderly, shift workers) — limit to 20 minutes before 3pm only.

Bedroom environment Cool (16–18°C optimal), dark (blackout curtains), quiet. Bedroom is for sleep and sex only. Remove screens, work materials. Consistent pre-sleep routine signals sleep to the circadian system.

Caffeine cut-off No caffeine after 2pm (half-life 5–7 hrs). Sources: coffee, tea, cola, energy drinks, some medications (co-codamol with caffeine), dark chocolate. Switch to herbal tea in evenings.

Alcohol advice Alcohol is not a sleep aid — it suppresses REM and slow-wave sleep, causes rebound waking 3–4 hours after sleep onset. Target <14 units/week. Avoid within 3 hours of bed.

Exercise timing Regular aerobic exercise improves sleep quality — but avoid vigorous exercise within 2–3 hours of bed (raises core temperature and cortisol). Morning exercise + natural light is optimal.

Screen / blue light Blue light from screens suppresses melatonin secretion for up to 2 hours. No screens 1 hour before bed. Night mode or blue-light glasses if unavoidable. Replace with reading or relaxation.

Sleep diary 2-week prospective diary (bedtime, rise time, SOL, WASO, naps, alcohol, rating) — guides CBT-I and monitors progress. Apps: Sleepio, Sleepstation. Essential for accurate assessment.

A fixed wake time is the cornerstone of circadian regulation — it consistently outperforms all other sleep hygiene measures in randomised trials because it regulates the homeostatic sleep drive (builds adequate adenosine pressure) and entrains the circadian clock simultaneously. Sleep hygiene education alone has an effect size of 0.2 (small) compared to 0.9 for CBT-I (large) — it is necessary but not sufficient as a standalone treatment. Alcohol-related insomnia is a common trap — patients use alcohol to initiate sleep, which works short-term, but the rebound waking 3–4 hours later paradoxically worsens insomnia and creates a cycle of increasing alcohol use.

Safety

Follow-Up, Z-Drug Review & Safety-Netting

Done

2–4 weeks

CBT-I progress — ISI score. Sleep diary review. Reinforce techniques. Is patient actually doing sleep restriction? Address barriers. Z-drug check: started? Stop at 4 weeks maximum.

6–8 weeks

Full CBT-I review — ISI should have improved ≥5 points. Sleep efficiency >85%? If not responding → consider IAPT referral, Sleepio, or comorbidity (depression, OSA not yet diagnosed).

Z-drug deprescribing

If established on Z-drugs: structured withdrawal — reduce by 25% every 2 weeks using diazepam equivalent conversion. Warn of rebound insomnia for 1–2 weeks — this is temporary. CBT-I concurrently dramatically improves withdrawal success.

Zopiclone driving

Warn explicitly: zopiclone impairs driving for 12 hours after taking — do not drive the next morning. MHRA guidance. Document in notes.

Melatonin review

Reassess after 3–6 months — is it still needed? Reassess for other CBT-I engagement. Long-term melatonin use is considered safe but prescriptions should be regularly reviewed.

Safety-net — 999

Suicidal crisis, acute mania with no sleep (72+ hrs), respiratory arrest (hypnotic overdose + alcohol)

Same-day GP

New suicidal ideation (insomnia is a risk factor), acute mania symptoms, severe rebound insomnia during Z-drug withdrawal causing functional collapse

Long-term Z-drug use (zopiclone, zolpidem) affects up to 1.5 million people in the UK — many were started for "2 weeks" and never stopped. Structured withdrawal with concurrent CBT-I has a 90% success rate vs 60% for withdrawal alone. Diazepam conversion (zopiclone 7.5 mg = diazepam 5 mg equivalent) allows a gradual taper that prevents severe withdrawal. The rebound insomnia that occurs 1–2 weeks after stopping is a predictable pharmacological effect, not a return of the original insomnia — patients must be forewarned or they will restart the medication immediately. Insomnia is a bidirectional risk factor for suicide — each standard deviation increase in insomnia severity increases suicide risk by 40% independently of depression severity.