1 APRIL 2022 ausdoc . com . au

Figure 1 . Prevalence of acute ( less than three months duration ) and chronic ( three months or longer duration ) insomnia in Australian adults . Source : Reynolds A et al 2019 ²

Table 1 . Diagnostic criteria for insomnia Table 2 . The ‘ 3P model ’ of chronic insomnia

Daytime symptoms At least one associated daytime symptom , including :

• Fatigue , malaise

• Lethargy , reduced energy / motivation

• Poor mood , irritability

• Concentration , memory , attention difficulties

• Impaired social , family , academic or workplace functioning

• Dissatisfaction , worry or concerns about sleep

• Daytime sleepiness

Chronicity Insomnia may be defined as an acute or chronic condition :

• Acute insomnia is defined if nocturnal and daytime symptoms have been present for less than three months

• Chronic insomnia disorder is defined by the presence of nocturnal and daytime symptoms for at least three months

overwhelmingly suggests that insomnia and depression share a bidirectional relationship and that the insomnia and depression should be conceptualised as two comorbid conditions when they co-occur . ^{5 , 20} Insomnia is a risk factor for the onset of future depression . ²¹ CBTi is an effective treatment for insomnia in

the presence of moderate and severe comorbid symptoms of depression , and randomised controlled trials have shown that CBTi improves the symptoms of depression and anxiety . ^{22 , 23} A recent randomised controlled trial reported that digital CBTi resulted in greater rates of remission of depression at one-year follow-up ( 56 % remission ) compared with controls ( 37 % remission ) on the 16-item self-report Quick Inventory of Depressive Symptomatology . ²⁴

Assess patients presenting with symptoms of depression for comorbid insomnia and those presenting with insomnia for comorbid depression .

There is a growing trend for the

Evidence overwhelmingly suggests that insomnia and depression share a bidirectional relationship .

prescription of ‘ off-label ’ antidepressants and antipsychotics ( for example , mirtazapine and quetiapine ) to manage insomnia . ^{10 , 25} However , as there is insufficient evidence regarding the long-term efficacy or safety of these medicines for insomnia , antidepressants and antipsychotics are not recommended for the management of

. 6 , 7 , 26 , 27 insomnia

DIAGNOSIS AND ASSESSMENT

PATIENTS with insomnia may present to GPs complaining of poor sleep , dissatisfaction with sleep or sleep-related daytime impairments ( daytime fatigue , lethargy , sleepiness and malaise ). The Sleep Condition Indicator is an eight-item self-report measure of insomnia that maps onto DSM-5 . ^{16 , 28} Scores range from 0 to 32 , with lower scores indicating worse sleep . Scores of 0-16 indicate insomnia . This simple tool can be used to assess for insomnia before conducting further assessment .

Diagnostic criteria for insomnia appear in table 1 .

Further assessment

In patients with a positive sleep condition indicator score ( score of 0-16 ), discuss the following : current nocturnal and daytime insomnia symptoms ; the onset of insomnia ; any known precipitants ; bedtime habits and routines ; timing of exercise ,

Perpetuating Psychological , behavioural and physiological processes / factors that allow the insomnia to become a self-maintaining condition ( even after the initial precipitant has subsided ) Examples of perpetuating factors :

• Repeated association of the bedroom environment with time spent awake in bed , frustration , cognitive arousal and anxiety , resulting in a conditioned relationship between the bedroom environment and a state of arousal / alertness ; the bedroom environment , time of night and intention to sleep will then trigger an arousal response that prolongs the bedtime wakefulness — This conditioned or learned component of insomnia is one of the main targets of CBTi

• Dysfunctional beliefs about sleep can heighten the threat of sleep loss and catastrophising over the anticipated negative effects of sleep loss on health — Maladaptive behavioural responses to sleep loss and daytime impairments ( eg , absenteeism ) tend to reinforce the threat of sleep loss and the insomnia condition

• People with insomnia characteristically spend more time in bed than is necessary in an attempt to ‘ catch up ’ on lost sleep ; this , however , means more time spent awake in bed , night-time worry and cognitive arousal . In turn , this reinforces the conditioned ‘ arousal response ’ to the bedroom routine or environment

• Cancelling daytime tasks and / or napping during the day reduces energy expenditure , reduces sleep pressure in the late evening and increases sleeping difficulties

• An irregular sleep – wake schedule ( eg , staying up much later and sleeping in for several hours longer on the weekend ) can exacerbate sleeping difficulties during the week ( eg , difficulties falling asleep at the desired time on Sunday night and getting out of bed early on Monday morning )

meals and caffeine ; lifestyle and workplace factors associated with exacerbation or reduction of insomnia severity ; history of sleeping pill use ; and other treatments / devices / approaches that have previously been used to reduce the symptoms of insomnia .

If the symptoms of insomnia have been present for longer than a month and there is evidence of frustration or anxiety while attempting sleep ,