Behavioral Treatments for Insomnia

Abstract and Introduction

Insomnia is a common problem among individuals in the general population, with reports indicating prevalence as high as 33%. Advanced practice nurses (APNs) have the opportunity to make a positive impact on the sleep experience of patients experiencing insomnia who are seen in primary care settings. This paper reviews the epidemiology of insomnia, including its definition and classification. Guidelines for assessment, including sample screening questions and formal tools based on scientific evidence, are described. Behavioral treatment options for insomnia include stimulus control, a number of different relaxation techniques, sleep restriction, cognitive behavioral treatments, and sleep hygiene. The scientific evidence for these treatments, as advocated by the American Academy of Sleep Medicine and the American Psychological Association, are reviewed, and a sample 2-session treatment plan for use with primary care patients with insomnia is presented.

Sleep difficulty, termed "insomnia," can occur for short or long periods of time. Some people may have infrequent and isolated insomnia symptoms, while others may have insomnia symptoms that are bothersome enough to be classified as either a disturbing burden or even a formal disorder.^[1]

Epidemiologic studies have described insomnia in different ways that can be grouped into 4 categories: (1) insomnia symptoms, (2) insomnia symptoms plus daytime consequences, (3) dissatisfaction with sleep quantity or quality, and (4) insomnia diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV).^[2] This article briefly discusses the different approaches used in the scientific literature to classify insomnia, followed by clinical assessment and treatment approaches that an APN can use to identify and treat insomnia in primary care settings. This article does not focus on those individuals experiencing an occasional night or two of sleeping difficulty.

Cite this: Behavioral Treatments for Insomnia in Primary Care Settings - Medscape - Oct 29, 2003.

Table. Brief Behavioral Treatment Plan for Insomnia ^[16]
Session	Intervention
Initial Visit	(1) Screen positive for possible insomnia.
	(2) Assign sleep log and teach how to complete it on daily basis.
	(3) Teach how to calculate a daily sleep efficiency score.^*
First Treatment Session (2 weeks later)	(1) Review of sleep log, including sleep efficiency score, especially to see the amount of time napping.
	(2) Discussion of bedtime habits (eg, television watching, reading, worrying, etc.).
	(3) Brief sleep education consisting of individual differences in sleep needs, the effects of aging on sleep, and the influence of sleep drive and circadian rhythms on sleep.
	(4) Teach stimulus control techniques including: (a) eliminating nonsleep-related activities from bed and bedroom, (b) following a consistent sleep-wake schedule, and (c) avoiding daytime napping.
Second Treatment Session (4 weeks after initial visit)	(1) Review of first treatment session instructions.
	(2) Problem-solving of any potential treatment adherence problems.
	(3) Possible modification of patient's sleep strategy and instructions to encourage future independent trouble-shooting.

^*Sleep efficiency is calculated by taking the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep efficiency).

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