Four steps to sleep

Professor Malcolm Lader discusses a stepwise approach to the clinical management of insomnia

Insomnia is a common subjective complaint estimated to affect one in three people in the UK¹. The inability to obtain a sufficient amount and quality of sleep can impact on both the physical and psychological well-being of an individual, their friends and family². Indeed a chronic lack of sleep is associated with significant morbidity and mortality^3,4_for example, road traffic accidents are more common in those suffering from lack of sleep-emphasizing the clinical case for effectively treating and managing patients with insomnia. Despite the prevalence of insomnia, the condition is significantly under represented in GP surgeries, only 21 per cent of individuals with insomnia actually consult their GP about sleep problems¹. This highlights the need to improve awareness that insomnia is a serious condition that warrants treatment and that effective medications are available. Diagnosis Accurate diagnosis of patients suffering with insomnia is often difficult in general practice because the condition has a diverse aetiology. It is important at the onset for the GP to clarify whether the patient is suffering a primary condition or whether it is a symptom of an underlying condition. At least ten causes of sleep disorders are likely to be encountered by the GP in the community⁵ (see Table 1); and five 'P' causes of insomnia are recognised (see Table 2). To determine whether the patient is suffering with an acute or chronic form of the condition, it is important to take a detailed sleep history. It may also be pertinent to ask the patient (and partner) to complete a sleep diary documenting information on sleep latency (time it takes to fall asleep), sleep duration and quality of sleep because this may also aid diagnosis⁵ (see Figure 1).

Treatment

The type of therapy (behavioural and/or pharmacological) offered to the patient will depend on the aetiology of the condition and the severity of the symptoms. There are a number of different hypnotics currently available (see Table 3) but some are out-dated. The most commonly prescribed are the benzodiazepines which have raised safety concerns in general practice as a result of their potential for physical and psychological dependence and drug abuse. Nevertheless, they remain an important and effective category of hypnotics for the short-term treatment of certain types of insomnia. Management The stepwise plan is a clinical management strategy for the treatment of insomnia (see Figure 2). It is a recommended protocol designed to tailor the patient's treatment to the nature and severity of their sleep disorder to improve the way in which the condition is managed and treated.

. Step 1: At each step of the stepwise sleep plan it is important to encourage and reinforce sleep hygiene and education (see Table 4). In some cases, restoration of a regular sleeping pattern can restore the patient's quality of sleep without the need for medical intervention.
. Step 2: Where medication is deemed necessary the sedating antihistamines should be considered because they have a low incidence of mild side-effects⁶ and are not reported to cause chemical dependence⁷. GPs can either recommend an OTC antihistamine-based sleep aid (for example Nytol) or prescribe a sedating antihistamine for patients who receive free prescriptions. A range of OTC herbal sleep aids (for example Nytol herbal) is also available.
. Step 3: A sedating antihistamine can be given for a further 14 days if the patient's insomnia is improving. Beyond this, undue reliance on medication may supervene. However, when the insomnia is severe, disabling or causing extreme stress and the patient has not responded to a sedating antihistamine, the prescription of a short-acting hypnotic is recommended. Current guidelines on their use (see BNF) recommend they are prescribed at the lowest effective dose for a maximum of 14 days to minimise the potential for dependence and severe adverse reactions.
. Step 4: All patients, whether taking an OTC remedy or prescribed medication, must agree to a review date. This is particularly important for patients receiving long-term hypnotic therapy. Patients can be given information and advice on how to discontinue treatment (structured drug withdrawal program). Some patients may benefit from referral to a sleep specialist for specific advice, if for example, previous advice/medication has proven unsuccessful or they do not respond to a withdrawal program.

Conclusion

The stepwise management plan is a good clinical approach to the treatment of insomnia because it allows the GP to tailor patient drug therapy to the severity of the condition and may help to reduce costs. However, GPs need to exercise caution with their use of hypnotics, particularly the benzodiazepines, not only to guard against the potential side- effects of medication but also to avoid creating long-term users. As with any therapeutic decision, it is important at each stage of treatment to weigh up the clinical benefits versus the risk of serious adverse effects and dependence on the medication.

Malcolm Lader is Professor of Clinical Psychopharmacology at the Institute of Psychiatry in London

References
1 Taylor Nelson research February 1996 - data on file
2 Lechky O. Questions about sleep should be a routine part of patient visits, physician says. Can Med Assoc J. 1993; 149: 1296-8
3 Silva J et al. Special report from a symposium held by the World Health Organisation and the World Federation of Sleep Research Societies: An Overview of insomnias and related disorders-recognition epidemiology, and rational management. Sleep 1996; 19: 412-6
4 Wingard D L & Berkman LF. Mortality risk associated with sleeping patterns amongst adults. Sleep 1983; 6: 102-107
5 Royal Society of Medicine. The medical management of insomnia in general practice. Round table series 28 lader M, ed. 1992
6 Kudo Y & Kurihara M. Clinical evaluation of diphenhydramine hydrochloride for the treatment of insomnia in psychiatric patients : a double-blind study. J Clin Pharmacol, 1990; 11: 1041-8
7 'System to retrieve information for drug evidence' (STRIDE) and drug abuse warning network (DAWN) reports for federal register. 1989, 54:8814-8827