Sleep insufficiency, insomnia, and related sleep disorders are concerns that affect millions of US adults. The disorders also contribute to significant cognitive, emotional, and physical health challenges. Insomnia affects approximately 30% of the US population. It is characterized by difficulty falling asleep, difficulty staying asleep, and early-morning waking and is linked to daytime distress and impairment. Common sleep disruptors include environmental factors such as noise, light, and air pollution and also personal habits such as excessive screen use before bedtime. Evaluating patients with insomnia in primary care requires integrating sleep health assessments into routine visits and use of insomnia screening tools and sleep diaries for accurate diagnosis. Nonpharmacologic therapies such as sleep hygiene and cognitive behavior therapy for insomnia are the preferred treatments. Pharmacotherapy or combination therapy (with cognitive behavior therapy for insomnia and pharmacotherapy) may be considered when these interventions are ineffective. Family physicians should weigh the risks and benefits of insomnia medication use carefully for all patients but especially for older adults because of potential adverse effects. Managing insomnia effectively in primary care involves a comprehensive approach, prioritizing nonpharmacologic strategies, regular monitoring, and patient-centered care.
Case 2. PM is a 52-year-old woman who comes to your office because of difficulty sleeping through the night for the past 6 months. She reports falling asleep easily by 10 pm but routinely wakes at approximately 3 am and is unable to fall asleep again. Melatonin has not helped. She takes escitalopram for anxiety and is otherwise healthy. She exercises regularly, drinks two cups of coffee per day, and consumes alcohol once per week.
Definitions and Prevalence
Sleep loss can be classified on the basis of features and severity. Sleep insufficiency affects about 35% of US adults and involves inadequate sleep duration (less than 7 hours) or fragmented sleep due to frequent awakening. It can be acute (resulting from factors such as jet lag or stress) or chronic (resulting from ongoing inadequate sleep) and is associated with cognitive impairment, mood disturbances, increased risk of unintentional injuries, and chronic health conditions.1,2 Sleep deprivation is a more severe condition in which individuals get less than 5 hours of uninterrupted sleep. It affects approximately 25% of US adults, particularly those with irregular work schedules.3
Insomnia, which affects an estimated 30% of the US population, is defined by significant dissatisfaction with sleep quality or quantity, leading to daytime distress and impairment. It includes difficulty falling asleep; difficulty maintaining sleep, with frequent awakenings; and early-morning waking without the ability to return to sleep.4 Although these symptoms alone describe the experience of insomnia, the formal diagnosis of insomnia disorder further requires the symptoms to be frequent and persistent over time, causing significant daytime impairment and not explained by another medical, psychiatric, or environmental cause.5
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision, insomnia disorder involves dissatisfaction with sleep quantity or quality accompanied by one or more symptoms such as difficulty initiating sleep, difficulty maintaining sleep, or early-morning awakenings.6 To meet the diagnostic criteria, these symptoms must cause significant distress or impairment in functioning, occur at least three times per week, persist for at least 3 months, and occur despite adequate opportunity for sleep.5 Insomnia is further classified by its duration as acute (occurring at least three times per week for 1 week to 3 months) or chronic (involving persistent difficulties occurring at least three times per week for 3 months or longer, resulting in significant daytime impairment).7,8
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