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Assessment and Management of Insomnia 6-8 Carlos H CONTEMPO UPDATES LINKING EVIDENCE AND EXPERIENCE Assessment and Management of Insomnia 6-8 Carlos H. Schenck, MD pression, and suicidality. Insomnia is plored. The bedpartner’s input can pro- associated with enormous direct and in- vide important information regarding Mark W. Mahowald, MD direct costs, as much as $14 billion in snoring and breathing patterns, un- Robert L. Sack, MD the United States in 1995.7 Physicians usual sleep motor activity, and day- should therefore establish an effective time consequences from suboptimal NSOMNIA IS A COMMON TREATABLE clinical strategy for eliciting and man- sleep. Use of caffeine, alcohol, and drugs disorder of insufficient or poor- aging insomnia complaints.9-11 Use of a (prescription, over-the-counter, herbal quality sleep, with adverse daytime I 1 sleep-trained nurse, psychologist, or products, illicit agents) should also be consequences. Insomnia presents as both on a consultation basis or as a mem- discussed. Reliving a typical day with the trouble falling asleep (long-sleep ber of the physician’s medical practice patient can be helpful. latency), trouble staying asleep (exces- should be considered. One study has re- A sleep log (diary), completed for at sive or prolonged awakenings), or feel- ported on the benefit of behavioral treat- least 7 consecutive days, is important for ing nonrestored from sleep. Insomnia ment of insomnia provided by a trained evaluating an insomnia complaint11 and can be a primary disorder emerging in clinic nurse in a general medical prac- is especially useful in identifying circa- childhood or later, a conditioned (psy- tice.12 However, the cost-effectiveness of dian rhythm disorders as a cause of in- chophysiological) disorder, or comor- incorporating a sleep-trained nurse or somnia. A sleep questionnaire is also use- bid with a psychiatric, medical, or other psychologist into a medical practice has ful; a commonly used one is the sleep disorder.1 Insomnia can be tran- yet to be reported. Pittsburgh Sleep Quality Index13 that has sient (related to stress, illness, travel) 19 items yielding data on the severity of or chronic (occurring nightly for Ͼ6 Assessment insomnia. Urine toxicology screening months). Persistent untreated insom- may be needed in selected cases to de- nia is a strong risk factor for major de- Assessment of insomnia complaints tect use of stimulant drugs (ephedrine, pression.2 Insomnia must be distin- should begin with a history obtained cocaine, amphetamines). guished from sleep-state misperception from the patient and bedpartner, then Psychological screening should as- and short sleep states without symp- continue with a physical examination. sess the presence and severity of depres- toms.1 The primary focus should be on the sion and anxiety, which are the most More than 50 epidemiological stud- functional impact and severity, and chro- common psychiatric conditions associ- ies have shown that one third of vari- nicity of the complaints, with rapid iden- ated with insomnia. The Beck Depres- ous general populations have insom- tification of target symptoms for use in sion and Beck Anxiety Inventories are nia symptoms and that 9% to 21% have formulating a management strategy. simple, validated, self-administered tests insomnia with serious daytime conse- Questioning should be directed at de- with easy guidelines for physician in- quences, such as bodily fatigue, dimin- termining age of onset, predisposing fac- terpretation.11 Such tests should be ad- ished energy, difficulty concentrating, tors and traits (family history, habitual ministered to insomnia patients with memory impairment, low motivation, light sleeper, sensitivity to noise and suspected depression and anxiety or to loss of productivity, irritability, inter- other stimuli, deviant circadian sleep and patients with no identified cause of in- personal difficulties (with family, friends, wake rhythm), precipitating events somnia. Formal psychological or psy- coworkers), increased worrying, anxi- (stress, illness, medication, or bedpart- chiatric referral can be considered on a ety, and depression.3-5 Chronic sleep loss, ner’s sleep problem), duration and spe- case-by-case basis. Patients with a past which occurs in untreated insomnia, is cific characteristics (nightly, intermit- a major risk factor for fatigue-related au- tent, or situation-specific: weekday vs weekend, with vs without bedpartner, tomobile crashes and industrial acci- Author Affiliations: Departments of Psychiatry (Dr dents, loss of jobs, marital and social sleep at home vs away, time-of-night pat- Schenck) and Neurology (Dr Mahowald), Minnesota tern, and daytime consequences). Life- Regional Sleep Disorders Center, Hennepin County problems, poor health, metabolic and Medical Center and University of Minnesota Medical endocrine dysregulation with im- style, daily activity patterns, and mal- School, Minneapolis; and Department of Psychiatry, adaptive behaviors must be addressed, Oregon Health Sciences University, Portland (Dr Sack). paired ability to maintain weight con- Corresponding Author and Reprints: Carlos H. trol, coronary heart disease, major de- including the frequency, timing, and Schenck, MD, Department of Psychiatry (844), Hen- type of meals consumed. Timing of nepin County Medical Center, 701 Park Ave S, Min- sexual activity and exercise, and any neapolis, MN 55415. See also Patient Page. Contempo Updates Section Editor: Sarah Pressman other effect on sleep, should also be ex- Lovinger, MD, Fishbein Fellow. ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 21, 2003—Vol 289, No. 19 2475 Downloaded from www.jama.com at Sanofi-Aventis, on September 11, 2007 ASSESSMENT AND MANAGEMENT OF INSOMNIA or current history of psychiatric disor- commonly associated with insomnia adults who must care for spouses or der who present with an insomnia com- include asthma, chronic obstructive pul- family members with medical disor- plaint should most likely be referred to monary disease, congestive heart fail- ders associated with sleep disruption of- a psychiatrist to assess whether a psy- ure, ischemic heart disease, gastro- ten complain of insomnia with day- chiatric disorder is contributing to the esophageal reflux, rheumatologic or time consequences. The physician must insomnia complaint. other pain-related disorders, hyperthy- assess the value of various treatment Actigraphy is an objective test that is roidism, end-stage renal disease, and modalities for a particular patient: a useful in identifying sleep-state mis- neurodegenerative disorders.7,14,15 Noc- low-dose sedative (0.125/0.25 mg of al- perception, sleep-interruption insom- turnal gastroesophageal reflux can be an prazolam; 0.5 mg of lorazepam) at bed- nia, and circadian rhythm disorders. Ac- epiphenomenon of obstructive sleep ap- time may facilitate the prompt resump- tigraphy uses a wrist monitor that nea, improving with treatment of the lat- tion of sleep throughout multiple records movement during successive ter condition.16 caretaking-related awakenings; zale- 1-minute time bins on a microcom- The most common sleep disorder as- plon (5-10 mg) as occasion requires can puter chip. The movement and non- sociated with sleep-onset and sleep- help control any tendency for pro- movement pattern can correlate closely maintenance insomnia is restless legs longed awakenings; strategic daytime with wakefulness and sleep.11 Never- syndrome, which at times is linked with naps (15-45 minutes), depending on the theless, there can be substantial error disruptive periodic limb movements of napping capabilities of the individual in some insomniacs who lie quietly in sleep, obstructive sleep apnea, and para- and the schedule of daily activities; and bed for prolonged periods of time.11 somnias (sleep behavior disorders).17,18 judicious use of caffeine in the morn- Polysomnography (formal physiologi- Restless legs syndrome affects up to 10% ing or early afternoon to increase alert- cal monitoring of sleep) should be re- of the general population and more than ness. However, prolonged naps or naps served for cases of insomnia with a sus- 25% of pregnant women and often re- taken late in the day could aggravate in- pected organic sleep disorder. The use sults in severe insomnia.17 Restless legs somnia, as could excessive amounts or of actigraphy and polysomnography syndrome manifests as peculiar, dis- ill-timed use of caffeine. Regular exer- should be decided during a consulta- tressing, and painful leg sensations cise should also be encouraged, pro- tion with a sleep specialist. during drowsiness that are relieved by vided that the timing of the exercise walking or other measures that are in- does not interfere with sleep. Conditioned Insomnia compatible with falling asleep. Dopa- A common cause of persistent insom- minergic or opiate therapy, or both (and Management Guidelines nia is conditioned (learned or psycho- at times use of benzodiazepines, par- The diagnostic and management strat- physiological) insomnia. This disor- ticularly clonazepam) at bedtime is usu- egies of insomnia are linked. The phy- der usually arises from an episode of ally effective, safe, and well-tolerated sician should promptly place an insom- acute situational insomnia (triggered by during long-term nightly use.17-20 The nia complaint into 1 of 4 categories (not pain, illness, medication, stress, travel, common and quite treatable parasom- mutually exclusive): related to stress, bereavement). The patient soon asso- nias include abnormal behaviors asso-
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