Insomnia can be very distressing and affects 10–30% of the population. It is more common in women and increases with age. Most adults require 7–9 hours sleep a night, although some people say they function on as little as 4 or as much as 10 hours. Key roles for the GP are to establish any underlying reasons for the insomnia such as depression, anxiety, medication side effects, lifestyle choices, sleep apnoea or chronic disease (see Box 64.1), and advise on sleep hygiene (see Figure 64).
Insomnia is either primary (no other contributing cause) or secondary (caused or affected by an underlying condition).
History
The following questions should help you to define the nature of the sleep problem:
- Describe your sleeping difficulty. Identify secondary causes of insomnia: look specifically for symptoms of anxiety and depression.
- Describe your bedtime routine. What time do you go to bed? How long does it take getting to sleep? How long do you stay asleep? If the time spent in bed is more than a few hours longer than the time spent sleeping the cause may be primary insomnia. Restricting the time in bed can improve sleep quality. Computer screen exposure may also delay sleep.
- Any associated symptoms with awakenings? Look for signs of a secondary cause (e.g. sleep apnoea). Physical problems may account for around 40% of cases of insomnia.
- What time do you wake up? Early morning awakening may be a symptom of depression.
- When did problems start? Have you had any other problems or difficulties during this time? Do symptoms correlate with other events (e.g. relationship breakdown or bereavement)? This may indicate anxiety, low mood or depression.
- What is your usual or desired sleep duration? Some patients may feel that they do not get enough sleep but are still able to function well during the day: this is not insomnia.
- Do you sleep during the day?
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