Insomnia.

What is it?
- Insomnia is an inability to gain adequate sleep (WHO, 1993). This is subjective, however, as 'adequate' sleep varies from person to person.

Classification
- Insomnia can be classified by its duration, as transient (lasting two to three days); short-term (less than three weeks); and chronic (most nights for three weeks or more).

- It can be subdivided into sleep-onset insomnia (difficulty in falling asleep); frequent nocturnal awakening (difficulty in maintaining sleep); and early morning awakening.

- It can also be classified by underlying cause.

Incidence
- Between 9 and 31 per cent of all people have sleep problems in any given year (WHO, 1993).

- Prevalence seems to be greater in women, older people, and those who are socio-economically disadvantaged (WHO, 1993).

- Insomnia typically develops at times of increased life stress (WHO, 1993).

Common causes
- Lifestyle factors such as alcohol or caffeine consumption.

- Environmental factors such as noise or an uncomfortable bed.

- Physical health problems such as sleep apnoea or pain.

- Psychological factors such as stress or grief.

- Mental health problems such as depression or anxiety.

- Medication side-effects.

- Primary insomnia if no other cause is apparent.

Management
- Assessment should be made of the underlying cause of insomnia and appropriate action taken as this is more likely to be successful as a long-term cure, though it is more time-consuming than giving a prescription for a hypnotic.

- Non-drug strategies include behavioural therapy, anxiety management, self-monitoring and counselling.

- Problem-solving approaches can enable the person to manage the problem, and take control of the condition.

- Treatment with hypnotics is only indicated in anticipated transient or short-term insomnia (Mehta, D.K. et al, 2005).

Complications
- Chronic insomnia may lead to psychiatric problems or abuse of alcohol and/or other drugs.

- Misdiagnosis of insomnia can lead to a failure to treat potentially curable conditions such as depression.

- The use of hypnotics to treat insomnia can lead to drug tolerance and dependence and/or adverse effects from drug withdrawal following dependence, including acute rebound insomnia.

- The irritability that results from insomnia can have an effect on relationships with partners, families and work colleagues.

- Accident statistics have shown that daytime sleepiness can double the risk of having an accident while operating machinery or driving a car.

Patient teaching
- Health education should include lifestyle advice such as reducing caffeine and how to promote a healthy sleep pattern.

- Teaching relaxation techniques can be useful for some patients.

- Sleep diaries can be useful for assessment and monitoring.

- In more difficult cases patients may benefit from referral to a clinical psychologist or trained counsellor.

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