Here are some ideas for family physicians on how to treat patients with insomnia, from psychiatrist Dr. Rachel Morehouse, head of the departments of psychiatry at Dalhousie University in Halifax and Memorial University in St. John’s, N.L. She is also medical director of the Atlantic Health Sciences Sleep Centre in Saint John, N.B.
1. If you know the patient—and many FPs have that advantage of continuity of care—think about what it might be about their life (medical or psychiatric issues, work or family issues) that could be causing insomnia. Develop a theory.
2. Ask “Why now?” and clarify if this really is an acute problem (or not), and what might be the trigger.
3. Follow the leads that answer(s) to the above question generate.
4. Be aware that anything that causes a person discomfort (or inhibits relaxation) is a potential cause of insomnia. Common things include pain (such as arthritic pain), anxiety, shortness of breath (asthma, COPD), anger (job, family), sadness (depression), or itch (psoriasis or dry skin).
5. Sleeping environment: too much light, noise or activity, pets on the bed, etc., can be an important factor.
6. The bed is for the three “S”es—sleeping, sickness and sex—not surfing the Internet, texting, watching television, arguing with a spouse and other “awake” activities.
7. What is the patient ingesting? Medication (prescription, OTC or illegal), caffeine in all its various forms (e.g., cola, tea, coffee, chocolate, energy drinks, herbal teas), alcohol or even large meals at bedtime can be factors.
8. What is the patient’s sleep schedule? Is he or she going to bed too early (because their work shift starts at 4 a.m.) or too late (because they are playing hockey in the late evening when ice time is available at the rink)?
9. Shift work: Some people just can’t sleep in the daytime. They just can’t. Also, as people age, their ability to shift their sleep schedule deteriorates.
10. What is the effect on daytime functioning? If there is absolutely no effect, the problem may not be insomnia. Is the patient safe to drive a car if he or she is truly sleep-deprived?
If you still can’t figure out a patient’s sleep issues, perhaps instead of reaching for your prescription pad re-book the patient for another appointment so you can explore more. It also gives the patient a chance to think about his or her problem.