Behavioral Treatments for Insomnia in Primary Care Settings

Joshua Fogel, PhD


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

In This Article


Practice guidelines and tools have been developed for insomnia assessment. A systematic approach to insomnia assessment is recommended so that the APN will be ready to intervene by treating the insomnia via behavioral methods or by referring the patient elsewhere for treatment.

The American Academy of Sleep Medicine offers practice parameters for the assessment of chronic insomnia.[10] Standard assessment includes screening for insomnia symptoms. An in-depth sleep history will help identify the cause and type of insomnia. A physical examination is important for evaluation of related medical symptoms or conditions.

According to the American Academy of Sleep Medicine, self-administered questionnaires, at-home sleep logs, symptom checklists, psychological screening tests, and bed-partner interviews are helpful for insomnia screening and assessment but do not replace an interview by a healthcare professional. While there is little evidence that these tools can indicate the cause of insomnia, they are often useful for measuring treatment effectiveness.[10]

A number of instruments or devices are marketed for insomnia assessment, but they are not necessary for diagnosing primary insomnia. For example, polysomnography is not required for standard insomnia assessment due to its high cost, unless there is a medical indication such as symptoms of sleep apnea. Multiple sleep latency tests are also not routinely indicated for insomnia evaluation, and there is little evidence of the routine need for portable sleep studies, actigraphy, or static charge-sensitive beds to evaluate insomnia.[10]

There are a number of insomnia questionnaires, one of the more popular of which is the Insomnia Severity Index.[11] It is reliable and valid and has 7 items that use a 5-point Likert-style scale. Scores can range from 0 to 28, with a cutoff score of 8 suggesting the presence of clinical insomnia. The questionnaire has 3 questions assessing the severity of insomnia and 1 question each assessing satisfaction with current sleep pattern, sleep interference, "noticeability" of sleeping problem to others, and concern about sleeping problems.

Another popular questionnaire is the Epworth Sleepiness Scale. It assesses for excessive daytime sleepiness suggestive of insomnia.[12] It can be taken and scored free of charge at, although users should be aware that this measure can have false positive results for insomnia.

Symptom history. The APN in the primary care setting can start with questions recommended by the National Institute of Health (NIH) publication[13] titled Insomnia: Assessment and Management in Primary Care to screen for insomnia. These questions include, "How have you been sleeping recently?" "When did the problem begin?" "What daytime consequences do you report?" "Do you experience dozing off or difficulty staying awake during routine tasks, especially while driving?" If responses to these answers suggest the presence of insomnia, the APN may choose to ask other questions listed in the publication to further probe for the cause of insomnia.

If insomnia is suspected, questions should be asked regarding: (1) symptoms or a history of depression, anxiety, obsessive compulsive disorder, or any other psychological symptomatology; (2) restless leg syndrome or periodic limb movement disorder; (3) sleep/awake schedule disorders such as narcolepsy; (4) snoring and other symptoms of sleep apnea; (5) history of drug or alcohol use; and (6) current medication use, particularly those with sympathomimetic or stimulant action such as bronchodilators, decongestants, weight loss products, attention deficit products, and pain relievers containing caffeine that may be causing the side effect of insomnia.[10] These are important questions to help in the differential diagnosis of primary insomnia from another sleep disorder, psychiatric disorder, substance use, or medical condition. Review of systems may be necessary to detect chronic pain, cardiac or respiratory compromise, or metabolic disorders that may be interfering with sleep.

Tools and rating scales. It is very important to give the patient a sleep diary and ask that it be completed daily after awakening in the morning for 2 weeks. For an individual with the desired goal of sleeping at night, sleep diaries typically allow for the recording of bedtime, total sleep time, time it took to fall asleep, the number of times awakening at night, use of sleep medications, time out of bed in the morning, and a rating of subjective sleep quality and daytime symptoms. A sample sleep diary is also available in Insomnia: Assessment and Management in Primary Care . Recommending to the patient that they complete a diary entry each morning and record estimates instead of exact times will allow for ease in completing the task and not cause more stress that may disrupt sleep.[13]

The sleep diary is very useful for calculating sleep efficiency. Sleep efficiency is defined as the ratio of actual time spent asleep to time spent in bed (expressed as a percentage, with higher numbers indicating better sleep continuity).[2] This information can be calculated daily from the patient's sleep diary. The American Academy of Sleep Medicine suggests that the sleep efficiency ratio is usually < 85% for those experiencing insomnia.[14]

Although not an essential part of the assessment, the APN may also choose to ask the patient to complete the Insomnia Severity Index and/or the Epworth Sleepiness Scale. These self-report scales may help in the insomnia assessment. They also can be very useful in monitoring treatment effectiveness if completed at first assessment and after treatment has been initiated.

Physical examination. A general physical examination based on patient history and review of systems is appropriate to rule out any underlying medical disorder or condition that is associated with insomnia. Attention should be focused on looking for sources of chronic pain, signs of respiratory compromise such as chronic obstructive pulmonary disease, signs of heart failure, signs of hyperthyroidism or hypothyroidism, neurologic disorders such as peripheral neuropathy and Parkinson's disease, and signs of uremia. Neurologic examination should include mental status examination to screen for dementia if warranted. Elevated heart rate and blood pressure may indicate sympathetic stimulation from caffeine or other substances.

Differential diagnosis and referral. Information obtained from the patient history and physical examination may help in the differential diagnosis of insomnia from other medical conditions that may have associated insomnia symptoms. If other sleep disorders besides insomnia are present, a referral to a sleep specialist is indicated.[7] To locate sleep specialists practicing in the United States, the American Academy of Sleep Medicine lists accredited member sleep disorder centers on their Web site, and the National Sleep Foundation has a list of healthcare professionals with an interest in sleep disorders.

If psychological symptoms or psychiatric disorders are present and the APN believes it is outside of his or her scope of practice, appropriate referral to psychologists, psychiatrists, psychiatric APNs, social workers, and/or counselors is indicated. If the APN believes that medication interactions are present and they are causing the insomnia, a change may be warranted. Consultation with either physicians or pharmacists may be necessary.


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