Abstract
Insomnia is one of the more common complaints patients present to their physicians. Sleep problems affect up to one-third of all Americans, and the loss of workplace productivity and increased healthcare utilization result in costs approaching $100 billion a year. Patients with acute insomnia generally respond well to various sedative hypnotic medications, but chronic insomnia is a different challenge. Physicians and patients may raise concerns about the long-term use of sedative hypnotic medications. Even in light of these concerns, however, the chronic insomnia remains, ostensibly leaving the physician few choices. A number of promising nonpharmacologic strategies are available that physicians can easily implement. Through the use of self-rating instruments and a sleep log, physicians can bring the sleep problem into better focus and monitor the efficacy of clinical interventions. Certain behavioral techniques, such as sleep hygiene, stimulus control, and sleep restriction, can be effective remedies for chronic insomnia. The use of cranial electric stimulation for insomnia is also showing promising results. Through careful assessment and the adoption of simple nonpharmacologic strategies, the physician's interventions may result in a good night's sleep.
Doctor, I can't get to sleep!” sleep problems represent one of the most common complaints heard by primary care providers. Providers' responses tend to vary broadly depending on the acuity of the complaint. On one hand, a sleep problem with an acute onset and little in the way of antecedents will typically prompt the prescription of some sleep aid. On the other hand, a patient with a chronic sleep problem probably presents with an extensive past history of ineffective, or at best partially effective, pharmacologic management. As the physician quickly lists the patient's prior medications and in return learns of the patient's poor response, a sense of gloom may descend on the interview. At this point, many healthcare providers may feel boxed in. Typical interventions at this juncture might include a consultative referral to a psychiatrist or a sleep medicine specialist. The former can search for contributing emotional problems, while the latter can recommend more sophisticated diagnostic procedures—perhaps, for example, a test for obstructive sleep apnea.
Of course, medical consultation is the bedrock of good clinical practice, but another, complementary pathway exists. This alternate approach involves the consideration of and, when appropriate, the use of nonpharmacologic treatment strategies for the management of sleep disorders. We conducted this review of published literature on the nonpharmacologic treatment of patients with insomnia by querying the cochrane Database of systematic reviews, pubmed, and psycinfo. The following search terms were used with each database: insomnia, sleep problems, and sleep disorders.