Clinical Review

The assessment and management of insomnia in primary care

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2899 (Published 27 May 2011) Cite this as: BMJ 2011;342:d2899
  1. Karen Falloon, PhD candidate1,
  2. Bruce Arroll, professor and head of department1,
  3. C Raina Elley, associate professor1,
  4. Antonio Fernando III, senior lecturer2
  1. 1Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92109, Auckland 1142, New Zealand
  2. 2Department of Psychological Medicine, University of Auckland
  1. Correspondence to: B Arroll b.arroll{at}auckland.ac.nz
  • Accepted 19 April 2011

Summary points

  • Insomnia affects a third of people and is a common cause of consultation in primary care

  • History is the main diagnostic tool

  • There are many causes of secondary insomnia, which should be ruled out and treated first

  • Excessive daytime sleepiness should raise questions about obstructive sleep apnoea

  • Primary insomnia is diagnosed after excluding other causes of insomnia. It can be treated effectively by sleep hygiene techniques, by restricting time in bed, or with behavioural interventions

  • Sedatives should be used as a last resort when other approaches have failed because of risks of tolerance and adverse effects

Insomnia affects about a third of the general population according to a recent longitudinal study in the UK1 and cross sectional studies estimate the prevalence in patients attending primary care to be between 10% and 50%.2 3 According to the American Sleep Disorders Association International Classification of Sleep Disorders coding manual, insomnia refers to “a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment and lasting for at least one month.”4 Although some patients who have this problem may not report it as such, inadequate sleep has been associated with reduced physical health3 4 5 6 and mental health.7 8 9 The continued widespread use of sedative medication to treat insomnia raises concern about the potential for long term tolerance and addiction, particularly where insomnia is the presenting complaint of missed diagnoses such as depression, or when adverse effects might be a problem—for example, falls in older adults.10 11 12 The normal range of sleep is seven to nine hours per night,13 although some individuals claim they can function on as little as four hours, whereas others need up to …

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