Magazine article Clinical Psychiatry News

Don't Be Too Quick to Prescribe for Insomnia

Magazine article Clinical Psychiatry News

Don't Be Too Quick to Prescribe for Insomnia

Article excerpt

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.

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 such as 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. …

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