Insomnia — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 11: Mental disorders in adults · Médecins Sans Frontières, Current online edition (November 2021 update)

MSF guidance on diagnosis and management of insomnia in adults, addressing organic, substance-related and psychosocial causes.

In one sentenceInsomnia (≥3 times/week for ≥1 month) requires identifying underlying causes (organic, substance-related, mental disorder); short-term treatment with promethazine or hydroxyzine 25 mg for 7–10 days is appropriate for life-event-related insomnia.

Issuer: Médecins Sans Frontières
Edition: Current online edition (November 2021 update)
Audience: Clinicians working in resource-limited settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF guideline section provides a structured approach to managing insomnia in adults, defined as difficulty falling or remaining asleep, early morning waking, nightmares or fatigue occurring at least three times a week for at least one month. The guidance emphasises identifying and treating underlying causes before considering symptomatic treatment.

Management is stratified by aetiology: organic causes (e.g. pain) require treatment of the underlying condition; substance-related insomnia (alcohol, drugs, medications such as corticosteroids, beta blockers, levodopa/carbidopa, fluoxetine, levothyroxine) requires substance-specific management; and insomnia related to life events may warrant short-term sedative therapy. First-line pharmacological options are promethazine 25 mg or hydroxyzine 25 mg once daily at bedtime for 7–10 days, with diazepam 2–5 mg once daily at bedtime for maximum 7 days as a last resort due to addiction risk.

Persistent insomnia warrants re-evaluation for underlying mental health disorders—depression, post-traumatic stress disorder and anxiety disorders—where the primary disorder should be addressed rather than treating insomnia in isolation.

Key points

For clinicians — doses and thresholds as stated in the guideline

Insomnia is defined as symptoms (difficulty falling/staying asleep, early waking, nightmares, fatigue) occurring at least three times per week for at least one month
Treat organic causes first (e.g. administer analgesics for pain-related insomnia)
Medications that may cause insomnia include corticosteroids, beta blockers, levodopa/carbidopa, fluoxetine and levothyroxine
For insomnia related to life events, first-line treatment is promethazine 25 mg PO once daily at bedtime for 7–10 days
Alternatively, hydroxyzine 25 mg PO once daily at bedtime for 7–10 days may be used if promethazine is unavailable
Diazepam 2–5 mg PO once daily at bedtime for maximum 7 days should only be used as a last resort due to addiction risk
Persistent insomnia requires re-evaluation for underlying depression, post-traumatic stress disorder or anxiety disorders
When insomnia is a feature of another mental disorder, address the underlying disorder rather than treating insomnia symptomatically

Pharmacological management of insomnia related to life events

Table extracted from the guideline

Agent	Dose	Duration	Notes
Promethazine	25 mg PO once daily at bedtime	7–10 days	First-line option
Hydroxyzine	25 mg PO once daily at bedtime	7–10 days	If promethazine unavailable
Diazepam	2–5 mg PO once daily at bedtime	Maximum 7 days	Last resort; risk of addiction

Source: Médecins Sans Frontières, Insomnia — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“If insomnia persists, re-evaluate the patient. Insomnia is a common feature in depression, post-traumatic stress disorder and anxiety disorders.”

— Médecins Sans Frontières, Insomnia — MSF Clinical guidelines, Management section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that this MSF guidance addresses a common but frequently mismanaged presentation in our primary care settings. The structured diagnostic approach—distinguishing organic, substance-related and psychosocial causes—is particularly valuable for Georgian clinicians who may have limited access to specialist psychiatric consultation. I would stress to colleagues the importance of the short duration limits (7–10 days maximum) for pharmacological treatment and the explicit caution about benzodiazepine use, as we have observed problematic long-term benzodiazepine prescribing in some Georgian healthcare facilities. The main implementation challenge will be ensuring that promethazine and hydroxyzine are consistently available in rural primary care facilities, and that clinicians receive adequate training in recognising the underlying mental health disorders (depression, PTSD, anxiety) that often present as insomnia.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

This guidance is highly applicable to Georgia and the South Caucasus region, where mental health presentations in primary care are common but often under-recognised. Georgian national programmes would need to ensure availability of first-line agents (promethazine, hydroxyzine) in primary healthcare facilities, as benzodiazepine overuse remains a concern in the region. The emphasis on identifying underlying mental health disorders aligns with Georgia’s evolving mental health reform and integration into primary care. Clinicians should be aware that substance-related insomnia may include locally prescribed medications, and the short-duration pharmacological approach helps mitigate risks of benzodiazepine dependence in settings with limited specialist mental health services.

Questions this guideline answers

Quick answers

What defines clinically significant insomnia requiring intervention?

Symptoms (difficulty falling/staying asleep, early waking, nightmares, or fatigue) occurring at least three times per week for at least one month.

Which medications should I consider as potential causes of insomnia?

The main drugs known to cause sleep problems are corticosteroids, beta blockers, levodopa/carbidopa, fluoxetine and levothyroxine.

What is the first-line pharmacological treatment for insomnia related to a life event?

Promethazine 25 mg PO once daily at bedtime for 7–10 days, or hydroxyzine 25 mg at the same regimen if promethazine is unavailable.

When should diazepam be used for insomnia and what are the risks?

Diazepam 2–5 mg PO once daily at bedtime should only be used as a last resort for maximum 7 days due to risk of addiction.

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Insomnia — MSF Clinical guidelines

What this guideline says

Key points

Pharmacological management of insomnia related to life events

From the guideline