An adequate sleep history should be obtained to exclude alleged or pseudo insomnia. It is furthermore important to explore the ideas and expectations of the patient. A diagnostic landscape should subsequently be set up in order to find the cause of insomnia.
While assessing possible causes, some conditions should be ruled out, such as depression with suicide risk, psychosis, acute alcohol/substance abuse, hyperthyroidism, obstructive sleep apnoea, and narcolepsy.
There is a distinction between acute and chronic insomnia. This distinction is mainly important in view of treatment.
The first line treatment of insomnia contains 3 steps. First of all, any potential underlying cause should be treated. Only when there is no obvious cause to be found, or immediate treatment of the underlying cause is not possible or if causal treatment fails, non-pharmacological interventions should be considered. Hypnotics should only be prescribed under exceptional circumstances (level of evidence 1).
Individualised patient information and stimulus control are the first choice non-pharmacological interventions (level of evidence 1).
Both interventions are feasible and efficient in primary care (level of evidence 3).
Hypnotics may be considered to relieve daytime dysfunction: when insomnia is severe, disabling or causes extreme distress in the patient (level of evidence 3).
When prescribing a hypnotic, a benzodiazepine with an intermediate half-life should be prescribed at the lowest possible dose and for a maximum of one week (level of evidence 1).
Follow-up should be performed for both non-pharmacological and pharmacological treatment.