Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed

Journal of Clinical Sleep Medicine, Vol. 13, No. 8, 2017 Insomnia is likely the most common sleep disorder, with population estimates generally showing that approximately 10% of the United States population meets criteria for an insomnia disorder.1 This prevalence is even higher in the Veteran population with an estimate of 26%.2 Insomnia is a major risk factor for neuropsychiatric disorders,3 suicide,4 cardiometabolic disease risk,5 and all-cause mortality.6 It is frequently comorbid with psychiatric, chronic medical and addictive disorders, conditions commonly reported in the Veteran population. Fortunately, efficacious and effective treatments exist, most notably cognitive behavioral therapy for insomnia (CBT-I),7 which is the recommended first-line treatment for the disorder,8 even in the context of comorbidities.9 Efficacious medication regimens also exist when CBT-I is not available.10 Although other sleep disorders such as sleep apnea and narcolepsy are typically referred for treatment by sleep medicine specialists, insomnia is often neglected or dealt with in the context of primary care. This can potentially lead to problems, because primary care clinicians often lack training regarding importance, screening, assessment, and management of insomnia. The Veterans Affairs (VA) network is an especially salient context to examine the diagnosis and treatment of insomnia in the context of primary care. As an organization, the VA has made efforts and allocated resources to recognize the importance of mental health in the context of primary care, including those for insomnia. In addition, the VA has engaged a nationwide training and education program focused on insomnia diagnosis and treatment.11 It is with this information in mind that the paper by Ulmer and colleagues in this issue of Journal of Clinical Sleep Medicine explores the beliefs, attitudes, and behaviors of VA primary care clinicians regarding insomnia.12 Overall, the results of this study show that insomnia is frequently misreported or not reported in the medical record, on many occasions mishandled through provision of suboptimal care, and often just plain missed—not discussed or brought up at all. Ulmer and colleagues report that the plurality of clinicians surveyed believed that insomnia symptoms were experienced by 20% to 39% of their patients. Prior work by this group has shown that the prevalence of poor sleep quality may COMMENTARY