Insomnia: Are Primary Care Doctors Still Getting It Wrong?

It’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia is not always treatable by primary care providersIt’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia Addressed in Primary Care

Investigators surveyed 51 primary care providers (PCPs) in the VA system as to their perceptions and treatment of insomnia. About 80% of the respondents said they felt insomnia was as important as other health problems. Yet they tended to underestimate its prevalence and often failed to document its presence.

Other research has shown that the prevalence of poor sleep quality among veterans is extremely high: over 70% in veterans without mental illness and even higher in veterans with a mental health diagnosis. Yet most PCPs surveyed estimated that only 20% to 39% of their patients experienced insomnia symptoms. When insomnia emerged as a problem, only 53% said they regularly entered it into their patients’ medical records.

Insomnia Conceived Of as Secondary Problem

Scientists now have plenty of evidence that insomnia is a disorder in its own right—regardless of whether it occurs alone or together with another disorder. Yet many PCPs seemed to view it as merely a symptom or a condition secondary to another disorder.

All of the PCPs endorsed the belief that when insomnia occurs together with a health problem such as depression and PTSD, successful treatment of the depression or PTSD will eradicate the trouble sleeping. Current scientific evidence does not support this belief.

Insomnia Treated With Sleep Hygiene

The first-line insomnia treatment recommended by the American Academy of Sleep Medicine and other professional organizations is cognitive behavioral therapy for insomnia (CBT-I). CBT-I is available at VA facilities.

Even so, the insomnia treatment PCPs most often recommended to their patients was counseling on good sleep hygiene. But sleep hygiene doesn’t work as a stand-alone treatment for insomnia. What’s more, it may make the prospect of CBT-I less palatable, given that some CBT guidelines call for behavioral changes that resemble the rules of good sleep hygiene.

Still Getting It Wrong

It seems like primary care doctors are just as outdated in their conception and treatment of insomnia as they were 10 and 20 years ago. I’m not alone in voicing this concern. Here’s how Michael Grandner and Subhajit Chakravorty titled their commentary on the survey results: “Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed.”

There’s no ambiguity here.

Help You Deserve From Your Doctor

Your PCP may be responsive to your complaint of insomnia and current in his or her knowledge of how to diagnose and treat the condition. If so, well and good.

But your doctor may not be quite so on the ball when it comes to dealing with trouble sleeping. Don’t let that deter you from seeking help for insomnia elsewhere. A good doctor will:

  1. Respond to concerns about insomnia as attentively as he or she would to concerns about double vision or shortness of breath. Insomnia can be debilitating, and chronic insomnia can result in changes that compromise health and quality of life. A doctor who dismisses it as trivial or hands you the rules for good sleep hygiene before waving you out the door is not the right doctor.
  2. Ask questions about the duration, frequency, and severity of your problem, and possible underlying conditions. This type of inquiry is crucial to arriving at an accurate diagnosis and appropriate treatment. Doctors who don’t have the time or knowledge to ask these questions should refer you to someone who does.
  3. Discuss treatment options that are research based and individualized. CBT-I may require referral to a specialist, yet there may be no specialist certified in behavioral sleep medicine practicing in the area. Likewise, a prescription for sleeping pills is useless to a patient who has no intention of filling it. Treatment discussions should be dialogs, and doctors should encourage patient participation.

This is the kind of response we deserve when we bring up the topic of insomnia with PCPs.

But it may not be the kind of response we get. How has your doctor reacted when you’ve mentioned trouble sleeping? (If you found this post helpful, please like and share on social media. Thanks!)

Sleep Problems Following a Stressful Childhood

Only a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

insomnia can occur following a stressful childhoodOnly a minority of the insomnia sufferers I interviewed for The Savvy Insomniac said their insomnia began in childhood. But regardless of when their sleep problem began, a number reported having had stressful and/or abusive experiences in childhood.

Is there a relationship between adverse childhood experiences and insomnia later in life? Anecdotal and scientific evidence suggests there is.

Difficult Childhoods

Liz’s insomnia started in adulthood, worsening around the time of menopause. But she remembered being “a very, very nervous, anxious child”:

I have my suspicions that my trouble sleeping goes back a long, long way. My mother and father had difficulties and they fought a lot, and that made me anxious. I don’t think I feared for myself so much as I felt a general anxiousness about the disruption. Then I had a brother who was 6 years older than me and was always getting into trouble. He grew up with his father away in Egypt during the war. All of sudden he was 6 years old and he had a father and there were major problems between them. That was another disruption, another source of anxiety for me.

Keith thought it was the pattern of abuse he experienced at the hands of a family member that set him up for trouble sleeping:

I experienced severe childhood abuse—physical, emotional, and sexual abuse. It started when I was young and continued a long, long time. It happened early in the morning. When I wake up early now, and I often do, there’s frustration that I’m not able to sleep because I’m vigilant, I’m unable to relax. I’m pretty sure the childhood abuse is the source of my sleep difficulties.

What the Research Shows

Adverse childhood experiences (ACEs) increase people’s susceptibility to health problems later in life. The relationship between ACEs and mental illness, substance abuse, and heart disease is well documented. A recent literature review conducted by Harvard researchers shows that children who experience trauma are also more vulnerable to sleep disorders as adults.

In a majority of studies documenting this relationship, sleep problems were assessed subjectively, by the patients or participants themselves:

  • In a retrospective study of data collected from 17,337 HMO members, trouble falling and staying asleep was significantly associated with several types of childhood trauma: (1) physical abuse, (2) sexual abuse, (3) emotional abuse, (4) witnessing domestic violence, (5) household substance abuse, (6) household mental illness, (7)parental separation or divorce, and (8) household member imprisonment.
  • In a subsequent study, the authors found these same ACEs to be associated with frequent insufficient sleep.
  • In a longitudinal study, children who experienced family conflict between the ages of 7 and 15 were more likely to report insomnia at age 18.
  • Among women overall, there was a strong association between childhood sexual abuse and sleep disturbances reported in adulthood.

In two studies, sleep problems were assessed objectively using a wristwatch-type device:

  • Among 39 insomnia patients, a history of abuse and neglect explained a moderate amount of variance in sleep onset latency (39%), sleep efficiency (37%), number of body movements (40%) and moving time in bed (36%).
  • Among 48 psychiatric outpatients, childhood stress load was a correlate of total sleep time, sleep latency, sleep efficiency, and number of body movements.

Finally, the more traumatic childhood events people reported, the poorer was their quality of sleep:

  • People who experienced 1 to 2 ACEs were twice as likely to report poor sleep quality as people with no ACEs. People who experienced 3 to 6 ACEs were 3.5 times as likely to experience poor quality sleep as people with no ACEs.
  • As the number of ACEs went up, so did the prevalence of insufficient sleep.

Clearly adverse childhood experiences make it more likely that people will develop chronic insomnia or insomnia symptoms in adulthood. I did not experience familial abuse or neglect. I’m guessing, though, that the bullying I experienced one year at school increased my susceptibility to insomnia . . . but that’s a topic for another blog post.

How about you? Do you think there’s a link between your trouble sleeping and adversity you experienced in your youth?