Clinicians should maintain a high index of suspicion for sleep apnea in all patients with a sleep-related complaint, since otherwise it can exert a dramatic negative impact on health and quality of life. Sleep apnea can be confused with primary insomnia. Polysomnography is rarely indicated in initial insomnia evaluation however, if the presentation yields concern for sleep apnea (eg, loud snoring), then such referral is most appropriate. It is important to assess for coexisting medical or psychiatric conditions, as well as for medications or substance use that may be contributing to the sleep difficulties, and always inquire about caffeine consumption. It is crucial to first obtain a complete history from the patient. This article reports the results of a literature search related to pharmacotherapy for insomnia and presents 4 clinical vignettes with corresponding treatment options.Īsk the patient to complete a sleep record for the next 2 weeks.Īny of these choices may be reasonable strategies depending on the presentation. Unfortunately, sleep hygiene is not consistently an effective, stand-alone treatment for insomnia. Recommendations also include avoiding caffeine after lunch, avoiding alcohol consumption after the evening meal, minimizing daytime naps, and not doing exercise in the hours just before going to bed. 3 Sleep hygiene begins with recommendations for encouraging regularized bedtimes and maintaining a quiet, comfortable, and dark atmosphere in the bedroom. Sleep hygiene might be one consideration, which includes teaching habits and behaviors that aim to induce a better nighttime sleep. Subsequently, there must be an individualized management plan to address the patient’s symptoms or impairment. Always consider substance use, coexisting pathology, other sleep disorders, and medications or other agents (eg, caffeine) that cause insomnia. A complete evaluation for insomnia includes assessing the physical and psychiatric conditions associated with sleep difficulties, as well as environmental and social factors or personal concerns.
The most important aspect of an insomnia evaluation is to obtain a thorough sleep history. The sleep difficulty must be present despite adequate opportunity for sleep, must occur at least 3 nights per week, and must be present for at least 3 months. Insomnia cannot be attributed to a substance abuse or primary sleep disorder and is not explained by a coexisting medical or psychiatric disorder. According to DSM-5 criteria, 2 insomnia is concern about poor sleep quantity or quality with 1 or more of the following: difficulty getting to and staying asleep, early awakenings followed by trouble returning to sleep, and personal distress or daytime dysfunction. The term insomnia has various medical meanings, as either a symptom or a specific disorder.
The definitions and diagnoses of insomnia vary widely. Problem sleep is a prominent symptom of many somatic and emotional illnesses. 1 Risk factors for insomnia include older age, female gender, shift work, and comorbid medical or psychiatric conditions. Approximately one-third of all people will suffer from chronic insomnia at some point in their lifetime, and one-tenth of them will have significant daytime impairment as a result. Chronic insomnia is associated with impairments in many aspects of interpersonal difficulties, quality of life, substance abuse, cognition, risk of psychiatric disease, work-related problems, and accident proneness. ■ Besides managing medical and psychiatric conditions, treatment of insomnia includes a variety of sleep hygiene, behavioral interventions, and pharmacotherapies.Īdequate sleep is necessary for normal function and is essential for physical and psychological health.
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