Chronic Insomnia Disorder and Obstructive Sleep Apnea Clinical Practice Guidelines (VA/DoD, 2020)

Department of Veterans Affairs and US Department of Defense

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 03, 2020

Guidelines for managing chronic insomnia disorder and obstructive sleep apnea were published in 2020 by the Department of Veterans Affairs and the US Department of Defense.[1]


Use the STOP questionnaire for patients who report sleep problems.

Assess for sleep-disordered breathing in patients with a history of cardiovascular or cerebrovascular events, congestive heart failure, and long-term prescription opioid use.

Conduct repeated testing in patients with a high pretest probability of obstructive sleep apnea (OSA) and a nondiagnostic home sleep apnea test.

Use the Insomnia Severity Index or the Athens Insomnia Scale in patients with suspected insomnia disorder.

Treatment of Obstructive Sleep Apnea

Patients with obstructive sleep apnea (OSA) receiving positive airway pressure (PAP) therapy should use this treatment for the entirety of their sleep periods.

Continue PAP therapy in patients with OSA even if the patient uses it for less than 4 hours per night.

Use educational, behavioral, and supportive interventions to improve PAP adherence.

Offer mandibular advancement devices as an alternative to PAP therapy in appropriate patients with mild to moderate OSA.

Consider nasal surgery in patients with anatomical nasal obstruction that prevents PAP use.

Do not use oxygen therapy as a standalone treatment for patients with OSA who cannot tolerate other recommended therapies.

Treatment of Chronic Insomnia Disorder

Use cognitive-behavioral therapy (CBT) as first-line treatment over pharmacotherapy for treating chronic insomnia disorder.

Do not use sleep hygiene education as a standalone treatment for chronic insomnia disorder.

Offer auricular acupuncture with seed and pellet for treatment of chronic insomnia disorder.

In patients who are offered short-term pharmacotherapy, use a low dose of doxepin.

Do not use antipsychotic drugs, benzodiazepines, or trazodone for treating chronic insomnia disorder.

For more Clinical Practice Guidelines, go to Guidelines.

For more information, go to Insomnia and Obstructive Sleep Apnea.


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