Behavioral Treatments for Insomnia in Primary Care Settings

Joshua Fogel, PhD


Topics in Advanced Practice Nursing eJournal. 2003;3(4) 

In This Article


The reported prevalence of insomnia ranges from 4% to 33% in the general population, depending upon how insomnia is classified.[3,4] One way to classify insomnia involves asking a few yes/no questions regarding insomnia symptoms, such as: (1) Do you have any difficulty falling asleep?, (2) Are you waking up during the night or waking up too early in the morning?, and (3) Are you unable to fall back to sleep? Practitioners may also ask about the frequency and/or severity of these insomnia symptoms.[4]

A second way to classify insomnia is to ask about insomnia symptoms (as above) along with questions about the daytime consequences of these insomnia symptoms (eg, daytime sleepiness, irritability, depressed or anxious mood). A third way to classify insomnia is to measure dissatisfaction with sleep quantity or quality.[4]

A fourth way to classify insomnia is with a formal DSM-IV diagnosis of primary insomnia.[4] This includes the 5 criteria:

  1. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep for at least 1 month;

  2. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning;

  3. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia;

  4. The disturbance does not occur exclusively during the course of another mental disorder, and

  5. The disturbance is not due to the direct physiologic effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.[2]

Although not a formal DSM-IV diagnosis, sleep research also describes the category of secondary insomnia. As indicated in the criteria enumerated above, primary insomnia has no identifiable factors causing the insomnia. Secondary insomnia is the all-inclusive term used where a medical condition, mental condition, substance (illegal or prescribed), or another sleep disorder causes the insomnia.[4]

Using any of the 4 classification systems above, women are consistently more likely than men to have insomnia. Generally, increased age is a risk factor for insomnia, although there are mixed results for age in studies classifying insomnia as insomnia symptoms along with daytime consequences or as dissatisfaction with sleep quantity or quality. Marital status is a risk factor: those who are separated, divorced, or widowed are more likely to have insomnia.[4]

Mixed results exist concerning the association of lower income and lower education with a higher risk of insomnia, possibly because of confounding higher age. Occupational status is a risk factor; those who do not work are more likely to have insomnia than those who do work. However, a number of studies show retirees have the highest risk, followed by homemakers. Students do not appear to be at risk for insomnia. This suggests that the occupational status risk factor could be partially due to older age and female gender, as there are a greater number of individuals in these categories not working.[4] Although stress is a risk factor for insomnia, it is not the number of stressful events, but rather the way one evaluates the stressors and the lack of control over stressful events that increases the risk for insomnia.[5]

It is estimated that 50% to 69% of primary care patients have insomnia and only about 33% discuss it with their primary care physicians.[6,7] Even with this high number of individuals with insomnia, it is estimated that only about 5% of primary care patients seek treatment for their insomnia.[6] Overall, in a variety of healthcare settings, between 27% and 45% of those with insomnia discuss their sleep problems with a healthcare professional.[4] In a general practice setting, healthcare practitioners are not aware of those with insomnia in more than 50% of cases.[7]

Among those with insomnia symptoms, 50% have recurrent, persistent, or multiple health problems. Among those with depression, 80% have insomnia symptoms. If anxiety is present, the percentage of patients with insomnia increases to 90%. Thirty-three percent of insomnia symptoms are associated with a mental disorder.[4]

Chronic insomnia is associated with a greater risk of automobile accidents, greater healthcare utilization, increased alcohol use, increased daytime sleepiness, and increased depression.[8] It has been suggested that sleeping difficulty among the elderly is a predictor of increased mortality.[9]


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