Insomnia is very common – nearly everyone has it sometimes. Persistent insomnia, defined as a minimum of 1 month, is present in ~15% of the population and estimated at ~25% of patients in primary care practices; with many of these patients the duration has been years.
Despite that incidence and duration, the symptom may not be brought up during an office visit. A previous National Sleep Foundation survey found that with patients having persistent insomnia and coming in for an office visit, the insomnia is never mentioned by 2/3 of these patients.
Since insomnia has been shown to be associated with (and believed to be a cause of) insulin resistance, weight gain, hypertension and others, as well as the overall misery associated with it, there is a missed opportunity to improve the patient’s overall health.
When the symptom of insomnia is discussed, it can begin consuming a lot of time and/or may be addressed with hypnotics only, when just a few more elements in the history might be able to support a more specific treatment, including evidence-based nonpharmacological treatments.
If we could develop an organized and flexible system to sort out the causes of persistent insomnia, we could perhaps better help the patient’s sleep and general health, without steep time demands on the primary care physician.
In this entry, we will introduce an algorithm created to achieve these goals (credit also goes to Espie and others).
Central to the algorithm is the concept of the right action, at the right time and right place, by the right person. By this we mean that not everything has to be done by the physician; the medical assistant could coordinate the algorithm, even computer/EMR based if possible, with your involvement for more focused assessments and decisions as may be needed.
Such a system could also work well in a population-based health care system.
After initial determination of duration of insomnia and time allotted for sleep, the next major decision points may be determined through brief questionnaires. These can apply to Restless Legs, depression, sleepiness, apnea and others, the results of which can then direct the course to behavioral treatment, focused medical assessment, possible sleep study, or possible referral to a sleep specialist as needed or desired. Also, since insomnia is often multifactorial, the algorithm will assess progress with an identified issue, and direct to other contributors as may be needed.
In particular, initial screening also addresses the psychophysiological arousal insomnia elements, including:
- increasing concern/anxiety/arousal as the patient considers sleep or gets near bedtime
- being more awake after going to bed
- laying awake in bed “trying” to sleep, whether reading, watching TV or other.
There is much value in screening for these behavioral elements early, and this can be done with or without an entire algorithm, and there is value in addressing the behavioral elements early, whether or not accompanied by additional pharmacological treatment.
First level behavioral interventions can include getting back up to avoid the ongoing negative conditioning of laying awake in bed, and intentionally shrinking the time allotted for sleep, initially to more closely match the actual sleep being obtained.
Sorting out the presence of behavioral contributions to persistent insomnia can enable a more personalized and complete treatment pathway. Note that several studies now show that non-pharmacological treatments for persistent insomnia can be as effective as medication treatments, or even more so.
We hope the above concepts may prove useful for you and your patients with insomnia, and are interested to hear your thoughts and experiences.
Kenneth N. Wiesert, M.D. is a Sleep Disorders Medicine specialist at the Indiana Sleep Center and the Community Westview Hospital Sleep Center. Sleep specialists work to understand and help those who can’t sleep when desired, fall asleep when not desired, have behavioral activations during sleep, and others. The following entry is intended to increase awareness of the differential diagnosis of insomnia and treatments for it.