Key Feature 4: In appropriate patients with insomnia, use hypnotic medication judiciously (ex: prescribe it when there is a severe impact on function, but do not prescribe it without a clear indication).
Skill: Clinical Reasoning
So many patients have difficulty with sleep, and understandably, so many of them want a prescription for a quick fix. This makes sense: by the time they've come to see the doctor they are typically run-down, exhausted, and the idea of putting extra energy into working at sleep hygiene is utterly heinous. But it's the only thing that fixes the problem and is far better at improving outcomes in the long-term. The risk of harm is also astronomically in favour of nonpharmocological therapy.
That being said, there are times when a short-term course of pharmacotherapy may be appropriate. A patient may be having an acutely difficult moment in their life and need a sleep aid to get through a time-limited stressor. Generally no more than a week's worth of sleeping pills would be warranted for this. What should one prescribe to balance the risk of benefit and harm in such a circumstance?
Choices (with some general reasons for or against) include:
Key Feature 3: In all patients with insomnia, provide advice about sleep hygiene (ex: limiting caffeine, limiting naps, restricting bedroom activities to sleep and sex, using an alarm clock to get up at the same time each day).
Skill: Clinical Reasoning, Patient Centered
The Foundation for Medical Practice Education (aka McMaster Module) on Insomnia provides a clear and succinct breakdown of the evidence-based approached to behavioural and cognitive strategies that can be used to decrease insomnia. They state, "Non-pharmacologic treatment is first-line therapy for insomnia. There is high evidence that behavioural and cognitive techniques are effective forms of therapy for long-term results, especially when used in combination with other therapies."
The Insomnia McMaster Module provides some background information on the utility of CBT-I
See attached files for a sleep diary format, a more detailed approach to CBT-I, a patient handout on strategies to improve sleep:
Key Feature 1: In patients presenting with sleep complaints, take a careful history to:
Phase: History, Diagnosis
Key Feature 2: When assessing patients with sleep complaints, obtain a collateral history from the bed partner, if possible.
Skill: Clinical Reasoning
Later this week I'll be leading a teaching session with my resident peers on insomnia, so I need to do my due diligence and actually know a little bit about it beforehand. This is changing gears from my string of posts regarding pediatric issues lately, as this is not as common of a pediatric as adult complaint.
Like with all presentations, for any complaint of sleep disturbance for whatever reason, I need to have a list of possible differential diagnoses. The DDx for sleep-wake disorders per the LMCC, which I find to be very logical, is broken down as follows:
I like this differential because it provides a general framework, rather than listing off a series of specific causes, because there are SO MANY specific causes that may lead to sleep disturbance. Notice one of the skills for this Key Feature (#1) is "Selectivity." The clinician really needs to employ selective questioning as the patient interview unfolds to get at what truly is the disturbance and what could be causing it. That being said, general things to inquire about include
Based on clinical assessment, if a medical (including psychiatric) disease is suspected, it is important to investigate, diagnose, and treat this as indicated. Like with any psychiatric illness, insomnia cannot be diagnosed until medical illness, medication effects or substance use, or other psychiatric illness is ruled out. If this is the case, the patient may meet the DSM-5 diagnosis of Insomnia Disorder:
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (ex: narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G. The insomnia is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
An overview of the other DSM-5 sleep-wake disorder conditions:
That's just the DDx for a primary sleep-wake disorder. Now you may better appreciate my appreciation for the simplified DDx as listed by the LMCC approach to sleep-wake disturbance! At least this is a great starting point to frame one's clinical approach.