Reasoning GP · Algorithm · 1-page summary
Insomnia and sleep problems — adults
For: adults with difficulty getting to sleep, staying asleep or early waking. Not for: children (use the sleep problems in children algorithm). Daytime dozing is the main problem: use the excessive daytime sleepiness algorithm.
Core rule: find the cause first (mood, mania, OSA, withdrawal), then CBT-I is first-line for chronic insomnia; hypnotics only for severe impairment, shortest course, with an agreed stop date and no automatic repeat.
0Stop — call 999 now — before any history
- Hypnotic overdose, especially with alcohol, or immediate danger to life → 999
- Nocturnal chest pain or breathlessness → acute chest pain, breathlessness or heart-failure pathway — not insomnia
1Triage — duration and pattern
| Picture | First move |
|---|---|
| Acute (under 3 months) | Find and treat the trigger; behavioural advice; diary if persistent |
| Chronic (3+ nights a week, 3+ months) | Exclude causes → structured CBT-I |
| Long-term hypnotic user | Engage; patient-paced taper with CBT-I |
| Onset, racing thoughts | Anxiety, hyperarousal, delayed phase |
| Maintenance or early waking | Depression, pain, OSA, nocturia, alcohol |
2Screen — one row is enough
- Suicidal intent, imminent risk or unable to stay safe → crisis assessment Same-day; PHQ-9 item 9 is not a risk assessment
- Mania: reduced need for sleep with elevated mood, energy, grandiosity → Same-day if acute mania, psychosis or risk
- OSA with sleepiness (2+ features, NG202) → must not drive until controlled; Group 2 or safety-critical → rapid sleep-service assessment
- Nocturnal seizures → epilepsy specialist within 2 weeks
- Night sweats with unexplained lymphadenopathy or splenomegaly → consider Suspected cancer pathway (NG12)
- Substance withdrawal → manage the withdrawal, not sedation
3Assess — diary first, tests only on suspicion
☐ 2-week sleep diary ☐ ISI for severity ☐ Epworth and STOP-BANG as aids ☐ BMI, neck, airway ☐ Caffeine, alcohol, nicotine, cannabis; medicine timing (SSRI, steroid, diuretic) ☐ PHQ-9/GAD-7
Tests by suspicion: ferritin and iron status (restless legs); TFTs (thyroid features). No fixed insomnia blood panel; no polysomnography for insomnia alone.
4Classify — only if the screen is negative
- Chronic insomnia disorder — hyperarousal, unhelpful sleep beliefs → CBT-I.
- OSA → sleep service per NG202; sedatives only with individual caution.
- Restless legs → ferritin, correct iron deficiency, review caffeine, alcohol, medicines.
- Depression, anxiety, PTSD → treat alongside CBT-I; assess risk.
- Circadian or shift work → timing, not sedation.
- Uncertain — re-run the causes at review before any more tablets.
5Treat today — doses: SPC, local formulary
- CBT-I: sleep restriction or compression (window usually ≥5 h, BAP/expert), stimulus control, cognitive work; face-to-face preferred, Sleepio where commissioned. Supervise in bipolar, epilepsy, pregnancy, frailty, untreated OSA.
- Severe short-term: Z-drug — zopiclone 7.5 mg (3.75 mg older or frail); a few days, rarely beyond 2 weeks; stop date; no automatic repeat.
- Chronic, CBT-I tried or unsuitable: daridorexant 50 mg (TA922 criteria); review within 3 months. Melatonin MR 2 mg (55+) not routine locally.
- Every prescription: next-day driving warning; avoid alcohol, opioids, sedatives. Long-term users: 5–10% reduction every 2–4 weeks (expert), patient-paced; never stop abruptly.
6Refer routinely
- Suspected OSA, severe parasomnia, circadian disorder not responding → sleep service.
- Narcolepsy, REM sleep behaviour disorder, complex RLS → neurology or sleep medicine.
- Refractory despite genuine CBT-I → insomnia service. Complex dependence → drug service.
7Never reassure by
- A sleep-hygiene leaflet as the treatment for chronic insomnia.
- An automatic hypnotic repeat.
- "Can't sleep" without asking about mood and mania.
- Sedating someone with untreated OSA or alcohol withdrawal.
- Sedating antihistamines, amitriptyline or quetiapine as routine insomnia treatment.
- Stopping a long-term benzodiazepine abruptly.
8Safety-net — say it, then document it
999 “Call 999 if you are in immediate danger or have taken too many tablets, especially with alcohol.” Same-day “If you have thoughts of ending your life or feel you can’t keep yourself safe, call NHS 111 option 2 today. If you feel drowsy the morning after a sleeping tablet, don’t drive. Loud snoring with pauses in breathing and daytime sleepiness needs its own assessment — tell us.”
Follow-up: 2–4 weeks after CBT-I or a hypnotic; Z-drug at the stop date; daridorexant within 3 months; melatonin by 13 weeks.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Sleep diary and causes reviewed
OSA, mood and driving assessed
CBT-I offered; any hypnotic has a stop date
Safety-net given; review booked
Summary of the full Reasoning GP insomnia and sleep problems algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE TA922, HTG624, TA77, NG202, NG217, NG12; DVLA; MHRA; SPCs; local formulary; SPS. Clinical reference — follow local pathways and check doses in the SPC and your local formulary.