Current Issues In The Diagnosis And Treatment Of Insomnia

By Dr. Gregg D. Jacobs
March 29, 2005

A recent review article on insomnia in the journal Lancet (364, 2004, 1959-73) highlights numerous important issues in the diagnosis and treatment of insomnia. These include the following:

A diagnosis of insomnia must include a complaint of impaired daytime functioning. Although the subjective complaints can include fatigue, mood impairment, and reduced performance or productivity, objective evidence for deficits in neurobehavioral functioning (reduced vigilance, memory disturbance, etc.) is mixed, and the degree of dysfunction is generally mild. Indeed, it may not only be sleep loss but also the hyperarousal that characterizes insomnia that produce these daytime impairments.
Fatigue and sleepiness in insomnia patients should not be confused. Sleepiness is defined by episodes of drowsiness or involuntary dozing in sedentary situations. As a group, insomnia patients report elevated levels of fatigue yet do not exhibit elevated levels of sleepiness. Those who do should be assessed for underlying sleep disorder such as sleep apnea.
Cognitive-behavioral therapy (CBT) is more effective than sleep medications for sleep-onset insomnia while both treatments are equally effective for sleep-maintenance insomnia. However, CBT maintains its effects long-term while sleeping pills do not and CBT has no side effects compared to sleeping pills. Also, benefits from sleeping pills often disappear when the pills are stopped, which suggests that sleeping pills don't treat the causes of insomnia. As a result, hypnotics are primarily indicated for the short-term treatment of insomnia or cases of insomnia that are not responsive or treatable with CBT.
The challenge that arises with respect to CBT is to make it more widely available. Although studies indicate that treatment by a clinician is most effective, recent studies suggest that books, internet-based treatment, and telephone treatment all produce improvements in sleep.