Insomnia occurs in 50 percent of us at some point during our lives. It is a large class of conditions in which patients have difficulty initiating sleep and/or difficulty maintaining sleep. Patients with these symptoms are usually referred to a sleep clinic when the symptoms have continued for more than a few weeks. Acute forms of this are often dealt with by the primary care physician particularly if obvious stressors were the cause.
“Primary” insomnia refers to a condition in which the symptoms have been lifelong, and usually will require long-term pharmacologic therapy (sleeping medications) of some type. If this is necessary, choosing the right medication is very important.
When insomnia develops later in life, it may be “secondary” to a variety of causes, and as such there may be a variety of treatment options. Patients who have difficulty initiating sleep may have a psychological cause such as depression or anxiety that may offset the body’s ability to “turn on sleep”. Difficulty initiating sleep may also be caused by a variety of medical conditions including pain syndromes, fibromyalgia, and thyroid disease. Additionally sleep initiation insomnia may be caused by many medications including steroids, beta-blockers, stimulants, and many antidepressant medication such as SSRIs. This type of insomnia also can lead to dependence on hypnotic medications (sleeping pills) that may be undesirable, such that eventual elimination of the medication may be difficult as “rebound insomnia” may develop.
Conditions that cause difficulty “maintaining” sleep are snoring, sleep apnea, limb movement disorders, and other medical conditions similar to those noted above. Very often such patients may not have trouble initially falling asleep initially, yet may have difficulty reinitiating sleep.
The workup and treatment for insomnia generally includes a very thorough review of medical conditions, medications, consideration of schedule changes and circadian influences, as well as possible coexisting conditions such as anxiety or depression (in which case the treatment plan should be done in coordination with physician or therapist following these conditions.) The treatment approaches may include pharmacologic and nonpharmacologic strategies depending on the pattern of the insomnia. While sleep studies are generally not helpful for patients who have difficulty initiating sleep, in patients who have trouble staying asleep, a sleep study/polysomnogram may be considered at some point as well.