Michael A. Grandner|Subhajit Chakravorty
Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed
University of Arizona|Banner - University Medical Center Tucson|University of Pennsylvania|Philadelphia VA Medical Center
free accesssleep hygieneinsomnia primary care misreported mishandled plain missed michael grandner phd mtr cbsm faasm subhajit chakravorty md michael grandner phd mtr cbsm faasm address correspondence michael grandner phd cbsm department psychiatry university arizona tucson az 85724520 6266346 email address email protected sleep health research program department psychiatry university arizona tucson arizona behavioral sleep medicine clinic banneruniversity medical center tucson arizona search papers author subhajit chakravorty md corporal michael j crescenz va medical center philadelphia pennsylvania division sleep medicine department medicine perelman school medicine university pennsylvania philadelphia pennsylvania search papers author published onlineaugust 15 2017httpsdoiorg105664jcsm6688cited by36sectionspdf shareshare onfacebooktwitterlinkedinredditemail toolsadd favoritesdownload citationstrack citations aboutintroductioninsomnia likely common sleep disorder population estimates generally showing approximately 10 united states population meets criteria insomnia disorder1 prevalence even higher veteran population estimate 262 insomnia major risk factor neuropsychiatric disorders3 suicide4 cardiometabolic disease risk5 allcause mortality6 frequently comorbid psychiatric chronic medical addictive disorders conditions commonly reported veteran population fortunately efficacious effective treatments exist notably cognitive behavioral therapy insomnia cbti7 recommended firstline treatment disorder8 even context comorbidities9 efficacious medication regimens also exist cbti available10although sleep disorders sleep apnea narcolepsy typically referred treatment sleep medicine specialists insomnia often neglected dealt context primary care potentially lead problems primary care clinicians often lack training regarding importance screening assessment management insomnia veterans affairs va network especially salient context examine diagnosis treatment insomnia context primary care organization va made efforts allocated resources recognize importance mental health context primary care including insomnia addition va engaged nationwide training education program focused insomnia diagnosis treatment11 information mind paper ulmer colleagues issue journal clinical sleep medicine explores beliefs attitudes behaviors va primary care clinicians regarding insomnia12overall results study show insomnia frequently misreported reported medical record many occasions mishandled provision suboptimal care often plain missednot discussed brought ulmer colleagues report plurality clinicians surveyed believed insomnia symptoms experienced 20 39 patients prior work group shown prevalence poor sleep quality may greater 70 among without mental health diagnosis even higher among mental health diagnosis13 discrepancy troublingwhat also disturbing ulmer colleagues report even within va system recommended firstline treatments used12 clinicians asked responded insomnia common response counseling healthy sleep hygiene known ineffective treating insomnia14 also common prescription hypnotic medication adjusting medications may contribute insomnia also suboptimal strategies may also increase risk complications falls patients many elderly health care recipients within veterans health system10 although 82 primary care clinicians heard cbti 43 indicated know whether even offered facility surprising veterans health administration invested national rollout cbti well telehealthbased treatment programs assessment sleep disorders conduct cbtiwhen insomnia encountered slightly half 53 indicated routinely document fewer half 39 routinely include problem list routinely include many seemed still consider insomnia symptom secondary condition rather comorbid diagnosis reflecting attitude inconsistent current nosologies1516 unsupported scientific evidence17 particular concern belief reported 100 respondents sleep difficulties expected remit following successful treatment conditions depression posttraumatic stress disorder belief contradictory available scientific evidence1819 neglecting insomnia may worsen prognosis comorbid conditions20interestingly providers often supportive importance insomnia another important finding investigation providers 80 thought insomnia important health concerns two thirds 67 believed treating insomnia important treating sleep apneathe results study show although insomnia considered important concern primary care prevalence may underestimated documentation unreliable treatment suboptimal despite access standard treatment interventions also appears primary care clinicians beliefs insomnia treatment reflect outdated nosologies misunderstandings sleep hygiene represents important opportunity sleep medicine field develop strategies improved screening management protocols insomnia primary care settings although sleep apnea sleep disorders usually require referral sleep specialist insomnia treatment still often remains primary care leading underdiagnosis well perpetuation disorder addition recommending referral need better educate primary care clinicians recognize treat insomnia refer specialized carerecently national institutes health sleep research society jointly held workshop focused dissemination implementation science sleep research report meeting highlights major goal field increase sleep health literacy among patients providers well21 goal also part healthy people 2020 program article ulmer colleagues issue focuses problem specifically level primary care providers several strategies help ameliorate problemfirst health care systems va need continue develop comprehensive insomnia screening treatment protocols consistent published guidelines devising standard protocols assessment management insomnia important goal several major obstacles exist including lack knowledge among providers lack screening resources lack access cbti unclear guidelines hypnotic prescriptions health services research context insomnia care critically needed better understand overcome obstacles deliver optimal care patientssecond increased recognition difference cbti sleep hygiene clearly needed provider level intramural basis although approaches behavioral cbti demonstrated efficacy treatment insomnia disorder sleep hygiene considered adjuvant intervention sometimes allocated control condition insomnia clinical trials even worse many patients may spend time effort sleep hygiene end bias trying cbti belief lack possible efficacythird urgent need access efficacious insomnia treatment options although va cbti rollout resulted many individuals trained provide services still large unmet demand addressing need may include broadening existing training programs include cbti addition brief behavioral treatments insomnia based cbti proven effective22 goal may also include developing training programs nondoctorallevel providers nurses masterslevel therapists social workers may able see patients larger numbers online cbti programs rapidly growing number may effective especially less complex casesinsomnia prevalent important sleep disorder especially within veterans health care system patients insomnia routinely present primary care providers article issue ulmer colleagues highlights despite providers generally supportive importance insomnia many problems hamper effective identification management given current dissemination implementation priorities within sleep medicine field imperative field address unmet need access care sleep health literacy among providers models care implemented within health systemsdisclosure statementthis work supported k23hl110216 ik2cx000855 authors report conflicts interests dr chakravorty received research support teva pharmaceuticals pi michael perlis studyrelated medication astrazeneca dr grandner received consulting fees fitbit curaegis technologies research support kemin industriescitationgrandner chakravorty insomnia primary care misreported mishandled plain missed 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