For insomnia diagnosis and treatment, first "do no harm!" Do NOT prescribe medications as first-line therapy for "insomnia."
The International Classification of Sleep Disorders lists close to 100 sleep disorders, and as many as 50% of these have "insomnia" as a presenting complaint. It is of paramount importance for clinicians to keep in mind that "insomnia" is a symptom and NOT a diagnosis. With the use of a comprehensive approach to sleep assessment, it is possible in most cases to make a precise diagnosis of the condition causing the insomnia symptom and to treat the underlying condition appropriately.
By Dr. Michael Varenbut
At least 50% of those who come to our sleep disorders center with a diagnosis of "insomnia" will have another comorbid condition, most often another psychiatric diagnosis, such as anxiety or depression. It’s also important to learn about sleep-wake patterns and other sleep symptoms like snoring. Furthermore, all substances of abuse affect sleep.
Insomnia diagnosis requires associated daytime dysfunction, and is primarily diagnosed through a clinical evaluation. A comprehensive sleep history should be obtained and should cover at least: specific insomnia complaints, pre-sleep conditions (comorbid medical psychiatric and substance use disorders), sleep-wake patterns, other sleep-related symptoms (for example, snoring), and specific daytime consequences.
According to the International Classification of Sleep Disorders, the diagnostic criteria for insomnia include:
• A complaint of difficulty initiating sleep, difficulty maintaining sleep or waking up too early, or sleep that is chronically nonrestorative or poor in quality.
• The sleep difficulty occurs despite adequate opportunity and circumstances for sleep.
• At least one of the following forms of daytime impairment related to the nighttime sleep difficulty is reported by the patient: Fatigue or malaise; impairment in attention, concentration, or memory; mood disturbance or irritability; daytime sleepiness; reduction in motivation, energy, or initiative; proneness for errors and accidents at work or while driving; tension, headaches, or gastrointestinal symptoms in response to sleep loss; and concerns or worries about sleep.
Numerous evaluation instruments are available for sleep disorders, but it is important to include at least the following: self- administered questionnaire (general medical and psychiatric, to identify comorbid disorders), sleep logs or diaries (for at least 2 weeks), symptom check lists, and bed partner interviews.
It is also important to conduct a physical and mental status examination to gather information about comorbid conditions and to help with a differential diagnosis.
Overnight sleep studies (polysomnograms) are not indicated in routine evaluation of chronic insomnia, but might be quite useful if there is a suspicion of a breathing disorder (sleep apnea, for example) or movement disorder (for example, periodic limb movement disorder), or when the diagnosis is uncertain or initial treatment attempts have failed.
With the above in mind, and once a more specific diagnosis for the insomnia complaint can be teased out, a comprehensive treatment approach can then be tailored. If for example, it is found that the cause of the symptoms is obstructive sleep apnea, the ideal therapy might be weight loss and the use of a CPAP (Continuous Positive Airway Pressure) device. On the other hand, if the insomnia complaint is found to be caused by an underlying drug or substance dependence, medical condition or mental disorder, treatment of the primary condition is of paramount importance to resolve the symptoms. Insomnia caused by "inadequate sleep hygiene" or "psycho-physiological insomnia," might be best treated with a comprehensive cognitive-behavioral therapy approach, which could include education on proper sleep hygiene, sleep restriction therapy, or "stimulus control therapy."
If the above treatment approaches fail, and it is deemed that a prescription medication is indicated to treat the "insomnia" symptoms, then a very cautious, well thought-out and time-limited approach could be initiated. It is important to keep in mind that many, if not most medications used for sleep, carry potential side effects and might also have long-term dependence potential. Prescriptions for sleep medications (hypnotics) should always be at the lowest possible dose, and for the shortest duration of time. Caution should be used in prescribing these medications to patients with an active or past substance abuse diagnosis, and those who have other significant medical or psychiatric conditions.
In conclusion, it is important to remember that not all insomnia is the same and that insomnia is a symptom and not a diagnosis. Insomnia complaints are extremely common with significant implications on multiple levels. There is a high rate of concurrent disorders, such as medical, psychiatric, and addiction conditions. Each clinician treating patients with insomnia complaints should have a simple yet comprehensive approach to assessment, diagnosis, and treatment of the underlying conditions – and their resulting dysfunction.