Clinical decision-making in the evaluation and treatment of insomnia

doi:10.1016/0002-9343(90)90349-I

The American Journal of Medicine

Volume 89, Issue 3, September 1990, Pages 357-362

https://doi.org/10.1016/0002-9343(90)90349-I Get rights and content

Abstract

We interviewed a representative random sample of 501 office-based general physicians and 298 nurse practitioners to evaluate their approach to the symptoms of insomnia. Clinicians were presented with a standard case of a patient complaining of difficulty sleeping, with the age of the patient depicted as either 37 years or 77 years. Historical information was provided in response to practitioners' questions. In evaluating the history, physicians asked an average of 2.5 questions and were most likely to ask about psychologic problems. Only 47% of the physicians who were presented with the elderly case vignette elicited a sleep history. By contrast, nurse practitioners asked an average of 3.2 questions, and 60% of them took a sleep history. Despite many possible non-pharmacologic therapies for the patients presented, 46% of physicians identified a prescription medication as the single most effective therapy for the older patient, compared with 17% of nurse practitioners. These findings suggest that physicians place inadequate emphasis on history-taking in the evaluation of insomnia and resort to the use of psychoactive drugs even when non-pharmacologic approaches might be more effective.

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Impact of psychological disorders
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
In this article, we discuss the nature and treatment of insomnia in the context of common psychological comorbidities, including mood disorders, anxiety-related disorders, chronic pain, and substance-use disorders. We first review issues related to the diagnosis of insomnia when other psychological problems are present, and recent progression toward a more accurate understanding of the relation between sleep and psychological disorders. For each patient group discussed, we then provide a review of common sleep problems in the respective psychological problem, and discuss the current literature on insomnia treatment targets, insomnia treatment strategies, and insomnia treatment outcome data. We also discuss noteworthy insomnia treatment considerations for each patient population.
Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study
2017, HPB
Citation Excerpt :
As we know the clinical presentation (i.e. pain), pancreatic function of patients with CP often does not match the degree of morphological abnormalities seen on imaging.40–47 Furthermore, one can debate the extent to which case vignettes reflect actual clinical practice or only physician competence.48–51 In conclusion, this survey showed that the current opinion and clinical decision-making process of international pancreatologists differ vastly in various aspects in the diagnosis and treatment of CP.
The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research.
An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG.
A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment.
Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.
Knowledge and attitudes of primary care nurses about the management of patients with insomnia
2017, Enfermeria Clinica
Describir los conocimientos, actitudes y actuación de las enfermeras en un área de Atención Primaria sobre la atención al paciente con insomnio.
Estudio descriptivo. Se envió cuestionario online a todas las enfermeras de centros de salud del área sanitaria de Mallorca entre junio-julio de 2014. Variables: sociodemográficas, del profesional, formación, preferencias de manejo clínico del insomnio.
Respondieron 138 enfermeras (47%). La mayoría mujeres (92,8%), media de edad 50,42 años (DE = 8,9). La mayoría lo considera un problema importante de salud. Solo un 11% ha realizado alguna actividad formativa sobre trastornos del sueño en los últimos 5 años. Casi la mitad declara interrogar habitualmente sobre las repercusiones del insomnio en la vida laboral y sobre los hábitos que pueden alterar el sueño. El 79,7% valora posibles reacciones adversas de los medicamentos que toma el paciente para el insomnio y valora de forma diferente a los ancianos el 80,4%. Los tratamientos que declaran realizar habitualmente son medidas higiénicas (76%), fitoterapia (44,9%) y 22,4% terapia cognitivo-conductual. La terapia cognitivo-conductual es considerada efectiva y aplicable por las enfermeras (63,7%) y médicos (58%). Los profesionales que más se forman son los que practican de forma significativa terapia cognitivo-conductual con mayor frecuencia.
Las enfermeras realizan una correcta anamnesis y evaluación del insomnio, sin embargo algunas terapias de demostrada efectividad son todavía escasamente utilizadas.
To describe the knowledge, attitudes, and performance of primary care nurses in the management of patients with insomnia.
Descriptive study. An online questionnaire was sent to all primary care nurses of the Majorca Primary Care Department between June-July 2014. Measurements: sociodemographic variables, professional characteristics, tuition, usual clinical practice in the management of patients with insomnia.
138 nurses answered the questionnaire (47%). Most of them were women (92.8%), 50.42 years old (DE = 8.9). The majority considered insomnia an important health problem. Only 11% had received some formative activity on insomnia in the last 5 years. Nearly half declares to ask patients about consequences of insomnia in their jobs and about habits that alter their sleep quality. 79.7% considered the possible adverse effects of insomnia drugs and take into consideration the age of patient (80.4%). The usual treatments were sleep hygiene (76%), phytotherapy (44.9%) and 22.4% cognitive behavioral therapy (CBT). This therapy is considered effective and applicable by nurses (63.7%) and doctors (58%). Those nurses who attended courses in the last 5 years apply CBT more frequently.
Nurses conduct a correct anamnesis and evaluation of patients with insomnia. However some therapies of known effectiveness, such as CBT, are still scarcely applied.
Decision rules for GHB (gamma-hydroxybutyric acid) detoxification: A vignette study
2014, Drug and Alcohol Dependence
Citation Excerpt :
Vignettes are brief descriptions of hypothetical situations, designed and constructed in most studies by researchers, to be evaluated by respondents and to elicit comment or opinion as to these typical scenarios (Barter and Renold, 1999; Zwaanswijk et al., 2011) and are used as an instrument in qualitative research. We decided to perform a vignette study because vignettes accurately capture actual practice, represent real-life responses, reflect clinical complexity (Kalf and Spruijt-Metz, 1996) and research has documented that they can be a measure of knowledge (Everitt et al., 1990). Vignettes are a valid tool in situations where case-mix variation is a concern (Englund et al., 2000; Peabody et al., 2000), and should contain evidence-based scoring criteria to express improved health outcomes.
GHB dependent patients can suffer from a severe and sometimes life-threatening withdrawal syndrome. Therefore, most of the patients are treated within inpatient settings. However, some prefers an outpatient approach to treatment. The aim of this study was to develop decision rules for addiction physicians to determine whether an outpatient or inpatient setting should be chosen for a safe GHB detoxification.
A prospective vignette study was performed. Forty addiction medicine specialists from various treatment settings and residents of the Addiction Medicine postgraduate Master training were asked to contribute vignettes of GHB dependent patients. A focus group of 15 psychiatrists and addiction medicine specialists was asked to recommend an outpatient or inpatient setting for GHB detoxification treatment per vignette. Finally, five addiction medicine specialists, experts in GHB dependence treatment in the Netherlands, assessed the bio-psychosocial reasons for the choices of the focus group and formulated the recommended criteria.
Based on the bio-psychosocial state of twenty vignette patients, addiction physicians and psychiatrists established the criteria and conditions recommended for the indication of an outpatient GHB detoxification. Intensity of addiction (GHB dose ≤32 g/d and frequency of abuse ≤2 h) was stated as the primary criterion in determining the setting as well as the complexity of the psychiatric comorbid disorders. The importance of a stable support system was emphasised.
The vignette study resulted in a set of criteria with which addiction medicine specialists can make a weighted decision as to an outpatient or inpatient setting for GHB detoxification.
Assessment Techniques for Insomnia
2010, Principles and Practice of Sleep Medicine: Fifth Edition
Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD)
2009, Sleep Medicine
Citation Excerpt :
This indicates that if patients do not take the initiative to let their physician know about their sleep disturbances, there is little chance that the physician will explore sleep disturbances or mental disorders in the patient. Studies conducted with general practitioners have documented this phenomenon on many occasions [19–21]. The latter point and the findings of this study emphasize that educational efforts are needed to increase the recognition of sleep disorders.
Although the epidemiology of insomnia in the general population has received considerable attention in the past 20 years, few studies have investigated the prevalence of insomnia using operational definitions such as those set forth in the ICSD and DSM-IV, specifying what proportion of respondents satisfied the criteria to reach a diagnosis of insomnia disorder.
This is a cross-sectional study involving 25,579 individuals aged 15 years and over representative of the general population of France, the United Kingdom, Germany, Italy, Portugal, Spain and Finland. The participants were interviewed on sleep habits and disorders managed by the Sleep-EVAL expert system using DSM-IV and ICSD classifications.
At the complaint level, too short sleep (20.2%), light sleep (16.6%), and global sleep dissatisfaction (8.2%) were reported by 37% of the subjects. At the symptom level (difficulty initiating or maintaining sleep and non-restorative sleep at least 3 nights per week), 34.5% of the sample reported at least one of them. At the criterion level, (symptoms + daytime consequences), 9.8% of the total sample reported having them. At the diagnostic level, 6.6% satisfied the DSM-IV requirement for positive and differential diagnosis. However, many respondents failed to meet diagnostic criteria for duration, frequency and severity in the two classifications, suggesting that multidimensional measures are needed.
A significant proportion of the population with sleep complaints do not fit into DSM-IV and ICSD classifications. Further efforts are needed to identify diagnostic criteria and dimensional measures that will lead to insomnia diagnoses and thus provide a more reliable, valid and clinically relevant classification.

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^☆: This research was made possible by a grant from the John A. Hartford Foundation.

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Special articleClinical decision-making in the evaluation and treatment of insomnia☆

Abstract

Communication skills of house officers

Ann Intern Med

Clinical hypocompetence: the interview

Ann Intern Med

Research in medical interviewing

Ann Intern Med

The medical interview: a core curriculum for residencies in internal medicine

Ann Intern Med

A study of general practice in Massachusetts

JAMA

Teaching history-taking: where are we?

Yale J Bio Med

Sleeping pills, insomnia and medical practice

N Engl J Med

“White paper” on sleep and aging

J Am Geriat Soc

Insomnia and its treatment

Arch Gen Psychiatry

Drug use and expenditures in 1982

JAMA

Taking a sleep history

Am Fam Physician

Sleep disorders

Hosp Pract

Special article
Clinical decision-making in the evaluation and treatment of insomnia☆