Chronic Insomnia Treatment

Insomnia is not only an important public health issue but the most common sleep complaint seen in the general or specialty physician practice.  Insomnia is defined as

  • difficulty initiating sleep (sleep onset)
  • staying asleep (sleep maintenance)
  • early morning awakening or
  • fragmented, non-restorative sleep, lasting more than three months
  • Daytime sequelae of fatigue, decreased alertness or energy, or reduced cognitive function are integral to the diagnosis.

So-called short sleep is not itself a good measure of insomnia since documented sleep needs vary, even in a good-sleeping population. Insomnia should be part of a routine health examination (Practice Parameters, American Academy of Sleep Medicine, 2000).  Despite the widespread prevalence of insomnia, it is often underreported by patients and underdiagnosed by physicians.

Once thought to be a secondary disorder, compelling research evidence has emerged that even when the “primary” disorder has been successfully treated, whether medical or psychiatric, insomnia remains in about 80 – 85% of cases. A small percentage of insomnia cases are seen in which no co-morbid medical or psychiatric problem is present, and these are called primary insomnia.  These data led the Academy to conclude that insomnia is not only a primary disorder, but actually a co-morbid disorder requiring its own separate treatment.

Methods for evaluating insomnia in current diagnostic practice include obtaining a good medical and sleep history (see attached articles), self-report data (including sleep logs, questionnaires, structured interviews), and bed partner interviews when possible.  Polysomnography is not recommended for evaluation of insomnia unless symptoms of sleep apnea are a consideration.  Two good screening instruments for the physician are the Epworth Sleepiness Scale and the Insomnia Severity Index (click here for resources).  If additional screening is needed, the Pittsburgh Sleep Quality Index may be used, but is most often used in research settings and more complex to score.

The American Academy of Sleep Medicine identifies the following areas for diagnostic evaluation by a sleep specialist in addition to the medical examination:

  • a detailed, skilled sleep history
  • evaluation for symptoms of heightened arousal or hyperreactivity
  • symptoms of  common psychiatric disorders, especially anxiety, depression, bipolar disorder, obsessive compulsive disorder
  • symptoms of Restless Leg Syndrome (RLS) or Periodic Limb Movement Disorder (PLMD)
  • knowledge of the patient’s sleep/wake cycle for circadian disorders
  • snoring, sleep apnea or other breathing-disordered symptoms
  • symptoms of or a history of drug or alcohol abuse, which can have long-term effects on the sleep cycle
  • history of prescribed and over the counter medication use.

Treatment of chronic insomnia involves both medical and psychological or psychiatric intervention, especially with the presence of identified medical disorders.  The use of sleep medications has declined in recent years as both patients and physicians learn the habit-forming potential in their long-term use.  The treatment of choice, from an evidence-based perspective, for many insomnia patients is cognitive behavioral therapy for insomnia (CBT-I).  CBT-I involves a series of techniques designed to restore sleep efficiency over time, including stimulus control and sleep restriction where appropriate.  Results of CBT-I have been found to be more effective than medication in several studies, particularly in terms of its success over the long term.  It also augments medication for sleep.

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