Assessment and Management of Insomnia

Abstract

INSOMNIA IS A COMMON TREATABLE disorder of insufficient or poorquality sleep, with adverse daytime consequences. Insomnia presents as trouble falling asleep (long-sleep latency), trouble staying asleep (excessive or prolonged awakenings), or feeling nonrestored from sleep. Insomnia can be a primary disorder emerging in childhood or later, a conditioned (psychophysiological) disorder, or comorbid with a psychiatric, medical, or other sleep disorder. Insomnia can be transient (related to stress, illness, travel) or chronic (occurring nightly for 6 months). Persistent untreated insomnia is a strong risk factor for major depression. Insomnia must be distinguished from sleep-state misperception and short sleep states without symptoms. More than 50 epidemiological studies have shown that one third of various general populations have insomnia symptoms and that 9% to 21% have insomnia with serious daytime consequences, such as bodily fatigue, diminished energy, difficulty concentrating, memory impairment, low motivation, loss of productivity, irritability, interpersonal difficulties (with family, friends, coworkers), increased worrying, anxiety, and depression. Chronic sleep loss, which occurs in untreated insomnia, is a major risk factor for fatigue-related automobile crashes and industrial accidents, loss of jobs, marital and social problems, poor health, metabolic and endocrine dysregulation with impaired ability to maintain weight control, coronary heart disease, major depression, and suicidality. Insomnia is associated with enormous direct and indirect costs, as much as $14 billion in the United States in 1995. Physicians should therefore establish an effective clinical strategy for eliciting and managing insomnia complaints. Use of a sleep-trained nurse, psychologist, or both on a consultation basis or as a member of the physician’s medical practice should be considered. One study has reported on the benefit of behavioral treatment of insomnia provided by a trained clinic nurse in a general medical practice. However, the cost-effectiveness of incorporating a sleep-trained nurse or psychologist into a medical practice has yet to be reported.