A stepped‑care approach to insomnia in primary care may be appropriate given the high prevalence of insomnia and limited numbers of specialist sleep medicine and sleep psychology practitioners. Education about sleep is an important component, addressing unrealistic or misinformed expectations about sleep which often perpetuate symptoms of insomnia. The key principles in the management of insomnia include reducing sleep‑related anxiety and maladaptive behaviours around sleep, in addition to addressing comorbidities and precipitating factors. Given the poorer prognosis with chronic insomnia, longer term management strategies are required to improve outcomes. This may involve strategies to reduce acute distress and possibly a short course of a hypnotic drug.
In patients with acute insomnia, a short‑term approach to improve sleep quality is appropriate. Other sleep disorders such as restless legs syndrome and circadian rhythm disorders can also present as insomnia. 13 While tiredness and fatigue are common symptoms of insomnia, excessive daytime sleepiness is uncommon and warrants further investigation and exclusion of sleep disordered breathing. Up to 50% of people with obstructive sleep apnoea will report symptoms of insomnia and may have difficulty in adhering to continuous positive airway pressure (CPAP) therapy. Insomnia may also present in conjunction with a comorbid sleep disorder. 12 As insomnia and comorbidities can impact on each other, comprehensive assessment and management of all contributing conditions is essential. 11 ComorbiditiesĬomorbid disorders such as depression, anxiety and chronic medical conditions are common. 10 In a longitudinal study of 388 patients with chronic insomnia, 46% of patients had persistent symptoms at three years and 14% had a relapse following remission of their insomnia. There is a high rate of recurrence so a previous history of insomnia is a significant predictor of the future development of insomnia disorder. Chronic insomniaĬhronic insomnia or insomnia disorder is defined as a sleep disturbance occurring on three or more nights per week, over a three‑month period, which results in significant distress or impacts on daytime functioning. People can also start using countermeasures like caffeine to reduce tiredness during the day, which can negatively impact on sleep on subsequent nights. 9 For example, if people are not sleeping well, it is common for them to retire to bed earlier wishing to get to sleep, which leads to spending longer in bed getting frustrated about not sleeping. 1 Acute insomnia is at risk of evolving into chronic insomnia if individuals develop changed thinking and maladaptive behaviours around sleep. Short‑term insomnia with sleep disturbance and daytime impacts for less than three months will often occur in response to a precipitating stressor which results in a predictable change in sleep quality. This belief is often perpetuated by society’s emphasis on the importance of obtaining perfect sleep for optimal health and well‑being. 1 Presentations with sleep disturbance stem from a belief that sleep is failing to meet expectations rather than having any true negative consequences. In contrast, insomnia has an impact on daytime functioning. While sleep disturbance, with difficulty initiating and maintaining sleep, is a common complaint, many people continue to function well throughout the day.
It is important to take a thorough history to distinguish between insomnia and sleep disturbance.
Insomnia is not attributable to the physiological effects of a substance (e.g. narcolepsy, breathing‑related sleep disorder, a circadian rhythm sleep–wake disorder, parasomnia).Ĭoexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia. Is not better explained by, and does not occur exclusively during, the course of another sleep–wake disorder (e.g. Occurs despite adequate opportunity for sleep. early morning awakening with inability to return to sleep.ĭisturbance causes clinically significant distress or impairment (social, occupational, educational, academic, behavioural or other important areas of functioning).įrequency of at least three nights per week.difficulty maintaining sleep (frequent awakenings or problems returning to sleep after awakening).Dissatisfaction with sleep quality or quantity associated with one or more of the following:
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