What are the recommended first-line treatments for chronic insomnia in primary care settings?

First-line treatment for chronic insomnia in primary care settings focuses primarily on non-pharmacological approaches, particularly sleep hygiene education and behavioural interventions. Patients should be advised on establishing a consistent bedtime routine, avoiding caffeine and stimulating activities before sleep, and creating a conducive sleep environment. These general sleep hygiene measures form the foundation of management and are recommended as initial steps to improve sleep quality ¹.

Cognitive behavioural therapy for insomnia (CBT-I) is considered the most effective first-line treatment for chronic insomnia. It involves structured interventions such as stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring. In populations such as children and young people with autism spectrum disorder, CBT can be adapted with visual aids and parental involvement to enhance engagement and effectiveness ¹,³ (Malow et al., 2012).

Pharmacological treatments are generally reserved for short-term use when non-pharmacological measures are insufficient or when insomnia severely impacts functioning. NICE guidelines recommend cautious use of hypnotic drugs such as zaleplon, zolpidem, and zopiclone for short-term management, with awareness of their potential for misuse and dependency. Sedative antihistamines may be considered but are not licensed for insomnia and require informed consent ¹.

In summary, the recommended first-line treatments for chronic insomnia in primary care are:

• Sleep hygiene advice and behavioural strategies as the initial approach ¹.
• CBT tailored to the patient's needs, including adaptations for specific populations like autistic children ¹,³ (Malow et al., 2012).
• Short-term pharmacological treatment only if necessary, with careful monitoring and consideration of risks ¹.

This integrated approach aligns with both UK NICE guidelines and evidence from clinical literature emphasizing behavioural interventions as the cornerstone of chronic insomnia management in primary care.