Q&A: PCPs on ‘front lines’ in insomnia recognition, care

In the United States, 30% to 35% of adults experience brief symptoms of insomnia and 10% of adults have a chronic insomnia disorder, according to the American Academy of Sleep Medicine.

Studies have shown that insomnia is linked to a variety of adverse health outcomes, including type 2 diabetes, CVD, kidney disfunction, depression and anxiety.

In recognition of Insomnia Awareness Night on Monday, June 22, Healio Primary Care spoke with Jennifer L. Martin, PhD, FAASM, professor of medicine at the David Geffen School of Medicine at UCLA and a member of the board of directors of the American Academy of Sleep Medicine, to learn more about what primary care physicians can do for patients with insomnia.

Q: What role do PCPs play in insomnia care?

A: Primary care providers are on the front lines in recognition of insomnia in their patients. They play an important role in helping their patients obtain good overall sleep health. In the case of insomnia, one of the most important steps that primary care physicians can take is to simply ask their patients how they’re sleeping. We know from research studies that, oftentimes, patients don’t tell their primary care physicians if they’re struggling with sleep until their sleep problems are severe, and at that point they tend to be desperate for treatment. The main role of a primary care provider in insomnia care is to just ask questions about sleep. The second important role for primary care providers is to encourage patients to seek treatment in the form of cognitive behavioral therapy for insomnia if they do, in fact, have sleep issues that could be insomnia.

Q: What treatments should PCPs consider for patients with chronic insomnia?

A: In 2016, the American College of Physicians made some very specific recommendations about the best first-line treatments for insomnia and cognitive behavioral therapy for insomnia was recommended as the first-line treatment for most patients. Unfortunately, a lot of patients don’t talk to their doctor about sleep problems until they’re suffering, and then there’s a perception that the only thing that a primary care doctor has to offer is a prescription for a sleeping pill. But what the clinical practice guidelines suggest is that sleeping pills should be reserved for people who don’t get sufficient benefits from non-medication approaches. That shouldn’t be our first attempt, that should be something that we use to supplement treatment down the road.

Q: When should PCPs refer patients with insomnia to a sleep specialist?

A: Insomnia disorder is different from having a bad night of sleep. A primary care physician should feel free, and within the scope of their practice, make recommendations about health sleep habits in general. So things like having a consistent routine, making sure that people aren’t using a lot of caffeine late in the day, watching alcohol consumption because we know that that can affect sleep — those are the kinds of healthy sleep habits that a primary care provider might make for someone who just occasionally struggles with sleep. But insomnia disorder is not typically improved with those recommendations. Insomnia disorder is a sleep problem that is severe enough to affect how someone functions during the day, and we would diagnose this as a sleep disorder if it happens at least three times a week and lasts for at least 3 months. Once an insomnia problem hits that threshold, that’s the time to send someone for specialty care. Most insomnia treatment is offered by psychologists or other mental health providers who are trained in cognitive behavioral therapy. But a lot of times, an accredited sleep disorder center — if they don’t have someone like that on staff — has a connection to providers like that in the community. There also are some self-guided treatments that patients can use. Some of them are available through insurance companies, but some of them are actually available to patients free online. A primary care provider might also encourage patients, especially patients that they know tend to be very motivated and self-directed, to try one of these programs themselves.

While insomnia is the most common sleep disorder, a lot of times people with insomnia also have a condition called obstructive sleep apnea. As a primary care provider is thinking about a patient who is struggling with sleep, they need to be aware not only of difficulties with sleep at night, but also with how sleepy people feel during the day, whether they snore or whether they have other symptoms of obstructive sleep apnea. And particularly in the case of a patient who has both insomnia and sleep apnea, those are patients who are best managed by a sleep specialist.  The simple insomnia or the simple sleep-apnea may not require intervention by a sleep specialist, but once a person has two different sleep disorders, that’s a great time to make a referral.

Q: Once patients are diagnosed with insomnia, what other conditions should PCPs watch for?

A: Insomnia almost always goes along with another problem. We used to think that insomnia was caused by other things, and it turns out that there’s a bidirectional relationship. An example might be that someone with insomnia may also have depression and a lot of time, the depression makes the insomnia worse and the insomnia makes the depression worse. When someone is struggling with sleep, it’s important to think about other mental health considerations, particularly depression. Not because we think of it as a cause of insomnia, but because we know the two things make each other worse — they exacerbate each other. The other thing that comes up frequently is anxiety; people with insomnia sometimes have a co-occurring problem with anxiety. The approach is not to pick one over the other, but to try to address both at the same time. We also know that a number of physical health conditions are associated with insomnia, things like chronic pain conditions. And again we see that bidirectional relationship, that having problems with chronic pain makes it harder to sleep but having sleep problems makes it harder to cope with chronic pain. In the context of conditions that primary care doctors see frequently, sometimes insomnia plays a role in making it difficult to manage those comorbid conditions.

Q: How has the COVID-19 pandemic impacted insomnia in the U.S.?

A: What we know from many years of studying the evolution of chronic insomnia is that a lot of times, there’s some life event that gets people’s sleep off track. And this is considered pretty normal. If someone had a disruption to their routine —  for a lot of people, transitioning to work from home and becoming a homeschool teacher for your kids and maybe not having the help in your household that you’re used to —  because of all those routine disruptions, people’s sleep isn’t as good as it used to be. For many people, as they start to develop new routines, their sleep will just get better. For a portion of people, and maybe for one out of five or one out of 10 people, their insomnia problem will actually start to take on a life of its own. If it persists for more than 3 months, we consider it its own independent problem. What’s happened now, we would call a stress reaction or acute insomnia and we wouldn’t necessarily be too aggressive about treating it, other than encouraging people to have good sleep habits. But what we’re seeing — not in the United States yet, but in countries that were hit earlier in the pandemic — is that rates of persistent sleep problems like insomnia are higher. We’re especially seeing this in health care workers who are dealing directly with COVID-19 patients — not because of contracting COVID-19, but because of all the stress that goes with their jobs. I would anticipate that we’ll see the same pattern in the U.S. in coming months, that for a number of people, a chronic insomnia problem was triggered by increased stress or changes in habits and routine that occurred during the COVID-19 pandemic.