- Email: [email protected]
Wake up to insomnia diagnosis: Asking the right questions of who, where, when, and what
Sleep Medicine 10 (2009) 941–942
Contents lists available at ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Editorial
Wake up to insomnia diagnosis: Asking the right questions of who, where, when, and what
Assessment of insomnia often proves a challenge in research and clinical practice. The studies of populations by Ohayon and various colleagues over the last 15 years have expanded understanding and raised questions about insomnia and other sleep disorders in the community [1–13]. In this issue of Sleep Medicine [14], Ohayon and Reynolds offer valuable information to researchers and clinicians of insomnia that includes diagnostic algorithms to characterize insomnia through the systematic telephone survey of over 25,500 individuals from seven industrialized European countries. This paper and its predecessors indicate how epidemiology can improve conceptualization of the complaint of insomnia and its clinical relevance. The authors conclude that a significant proportion of the populations with sleep complaints or insomnia symptoms do not fit into DSM-IV and ICSD classifications. Their analysis leads to a recommendation for more reliable, valid, and clinically relevant classification of insomnia complaints. The findings highlight again that it is the observer’s questions and methodology that determine the significance of sleep disturbance. Ohayon has produced a comprehensive body of work that explores multiple sleep disorders and sleep complaints in the community as well as the interaction of sleep and psychiatric disorders. In this new publication, Dr. Ohayon joins with Dr. Reynolds, a leader in the study group defining sleep disorders in the next revision of the diagnostic manual for psychiatry, to analyze the differences in responses among very large populations in their complaints of sleep disturbance and daytime consequence. The authors state their intention: ‘‘The differential diagnosis evaluation could be essential to recognize the true prevalence of insomnia and to improve clinical utility of insomnia diagnoses.” This paper moves towards such recognition while also demonstrating that the who, where, when and what of the evaluation process will influence the results. The who and where of insomnia. This attempt at representative sampling of 255 million European residents who were 15 years or older used the structured phone survey, Sleep-EVAL, to interview over 30,000 randomly selected individuals. A most impressive 25,579 completed the survey. Participation rates varied from a low of 68% in Germany to a high of 89% of individuals from Italy. The unwillingness of the Germans to participate could have potential relevance as Germany has 20 million more residents than Italy, the next most populous European country. The study otherwise appears to appropriately sample gender, age, marital status, occupation, and educational status across the industrialized European population. Ohayon and Zulley [15] previously reported that 7% of adult Germans experienced global sleep dissatisfaction and that this was a better indicator of underlying pathology than insomnia 1389-9457/$ - see front matter Ó 2009 Published by Elsevier B.V. doi:10.1016/j.sleep.2009.08.009
symptoms without sleep dissatisfaction. Germans who reported sleep dissatisfaction reported twice the rate of excessive daytime sleepiness, eight times higher frequency of sleep or mental disorders, 10 times higher rates of seeking help for their sleep problems, and use of sleep medication that was five times more likely [15]. In Italy, 27.6% of the sample reported insomnia symptoms, 10.1% complained of sleep dissatisfaction, 7% had diagnoses of insomnia disorder, and 5.7% reported use of sleep-enhancing medication [16]. The when of insomnia. Although treatment was not a focus of this paper, the presentation over the night and duration of insomnia will have relevance to therapeutic intervention. The level of distress will determine whether a health care provider initiates treatment for acute or short-term insomnia, while the definition of long-term insomnia can be for one month up to decades. Both behavioral and pharmacologic intervention will vary based upon the time of night when the patient is most actively describing wakefulness. The reader’s attention is directed to Tables 4–6 and Figs. 1 and 2 offered by Ohayon and Reynolds. These summaries of this large sample provide perspectives about complaints and potential disorders that will help individual patients and the treating clinician in their quest for objective information about the nature of sleep complaints. What to use to characterize the relevance of insomnia as a disorder. Sleep-EVAL uses lay interviewers trained to complete the structured phone survey. Sleep-EVAL categorizes responses into six classes of variables identified as potential factors associated with sleep dissatisfaction: sociodemographic descriptors, environmental factors, life habits, health status, psychological factors, and sleep/wake factors. Additionally, the survey has grown to include the diagnostic categories for the Diagnostic and Statistical Manual for Mental Disorders, fourth ed. (DSM-IV) [17] and the International Classification of Sleep Disorders, second ed. [18]. It has proved a robust tool to investigate sleep complaints in large populations and symptomatic groups. Ohayon and Reynolds highlight the importance of dissatisfaction by (1) quantity (sleep that is too short or too light along with duration on 3 or more nights per week); (2) quality (sleep latency, return to sleep after awakening, inability to resume sleep once awake, non-restorative sleep); and (3) daytime consequences that impact function – cognition (memory, concentration, and efficacy), affective tone (irritability, anxiety, and depression), sensory irritability, and difficulty completing daily tasks (work, study, or household). The authors also emphasize the importance of measuring the dimensions of severity, distress, or impairment to enhance the quality, reliability and validity of the insomnia diagnosis in clinical and research settings.
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Editorial / Sleep Medicine 10 (2009) 941–942
To understand the authors’ call for better diagnostic and dimensional criteria for insomnia, the reader must understand Figs. 1 and 2 and Diagrams 1 and 2. Only half the complainants (about 15% of the entire population with insomnia) received diagnosis by DSMIV. For the elderly only a third qualified for an insomnia diagnosis. Although the diagnostic label in DSM-IV, ‘‘dyssomnia not otherwise specified,” can be used to characterize the complaint, the authors emphasize that any system of diagnosis that includes 50% or more of complainants as an ‘‘other” is a poor system of assessment. With more than one-third of adults in developed countries complaining of poor quality sleep or offering insomnia symptoms, physicians, nurses, mental health professionals and technologists will regularly encounter someone who is sleeping poorly, which is why it is important for all students in clinical health care to study Diagrams 1 and 2. These diagrams effectively demonstrate that who, where, when and what influence the outcome of report and potential diagnosis. As the importance of healthy sleep grows in the eyes of the public, so will the request for assistance. To manage the 9.8% of the population who report symptoms and daytime consequences and/or the 6.6% who meet DSM-IV diagnostic criteria, education becomes key. Ohayon and Reynolds, however, demonstrate that many respondents reported poor sleep but failed to meet diagnostic criteria for duration, frequency and severity in the two current classification systems. Research and future therapeutic strategies require better measures of severity, distress, and impairment. The field of sleep medicine should offer thanks to Ohayon and Reynolds for this large-scale study of sleep complaints across nations and broad populations. References [1] Ohayon MM. Difficulty in resuming or inability to resume sleep and the links to daytime impairment: definition, prevalence and comorbidity. J Psychiatr Res 2009;43(10):934–40. [2] Ohayon MM. From wakefulness to excessive sleepiness: what we know and still need to know. Sleep Med Rev 2008;12(2):129–41. [3] Ohayon MM. Interlacing sleep, pain, mental disorders and organic diseases. J Psychiatr Res 2006;40(8):677–9.
[4] Ohayon MM, Okun ML. Occurrence of sleep disorders in the families of narcoleptic patients. Neurology 2006;67(4):703–5. [5] Ohayon MM, Vecchierini MF. Normative sleep data, cognitive function and daily living activities in older adults in the community. Sleep 2005;28(8):981–9. [6] Ohayon MM. Prevalence and correlates of nonrestorative sleep complaints. Arch Intern Med 2005;165(1):35–41. [7] Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 2004;27(7):1255–73. [8] Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002;6(2):97–111. [9] Ohayon MM, Lader MH. Use of psychotropic medication in the general population of France, Germany, Italy, and the United Kingdom. J Clin Psychiatry 2002;63(9):817–25. [10] Ohayon MM, Roberts RE. Comparability of sleep disorders diagnoses using DSM-IV and ICSD classifications with adolescents. Sleep; 2001. [11] Ohayon MM, Guilleminault C, Zulley J, Palombini L, Raab H. Validation of the sleep-EVAL system against clinical assessments of sleep disorders and polysomnographic data. Sleep 1999;22(7):925–30. [12] Ohayon MM, Shapiro CM. Sleep and fatigue. Semin Clin Neuropsychiatry 2000;5(1):56–7. [13] Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res 1997;31(3):333–46. [14] Ohayon MM, Reynolds CF. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the international classification of sleep disorders (ICSD). Sleep Med 2009;10(9):952–60. [16] Ohayon MM, Smirne S. Prevalence and consequences of insomnia disorders in the general population of Italy. Sleep Med 2002;3(2):115–20. [17] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth ed., text revised (DSM-IV-TR). Washington, DC; 2000. [18] American Academy of Sleep Medicine. International classification of sleep disorders, second ed.: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine; 2005.
Philip M. Becker * Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 8140 Walnut Hill Lane, Suite 100, Dallas, TX 75231, USA * Tel.: +1 214 750 7776; fax: +1 214 750 4621. E-mail address: [email protected]
Contents lists available at ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Editorial
Wake up to insomnia diagnosis: Asking the right questions of who, where, when, and what
Assessment of insomnia often proves a challenge in research and clinical practice. The studies of populations by Ohayon and various colleagues over the last 15 years have expanded understanding and raised questions about insomnia and other sleep disorders in the community [1–13]. In this issue of Sleep Medicine [14], Ohayon and Reynolds offer valuable information to researchers and clinicians of insomnia that includes diagnostic algorithms to characterize insomnia through the systematic telephone survey of over 25,500 individuals from seven industrialized European countries. This paper and its predecessors indicate how epidemiology can improve conceptualization of the complaint of insomnia and its clinical relevance. The authors conclude that a significant proportion of the populations with sleep complaints or insomnia symptoms do not fit into DSM-IV and ICSD classifications. Their analysis leads to a recommendation for more reliable, valid, and clinically relevant classification of insomnia complaints. The findings highlight again that it is the observer’s questions and methodology that determine the significance of sleep disturbance. Ohayon has produced a comprehensive body of work that explores multiple sleep disorders and sleep complaints in the community as well as the interaction of sleep and psychiatric disorders. In this new publication, Dr. Ohayon joins with Dr. Reynolds, a leader in the study group defining sleep disorders in the next revision of the diagnostic manual for psychiatry, to analyze the differences in responses among very large populations in their complaints of sleep disturbance and daytime consequence. The authors state their intention: ‘‘The differential diagnosis evaluation could be essential to recognize the true prevalence of insomnia and to improve clinical utility of insomnia diagnoses.” This paper moves towards such recognition while also demonstrating that the who, where, when and what of the evaluation process will influence the results. The who and where of insomnia. This attempt at representative sampling of 255 million European residents who were 15 years or older used the structured phone survey, Sleep-EVAL, to interview over 30,000 randomly selected individuals. A most impressive 25,579 completed the survey. Participation rates varied from a low of 68% in Germany to a high of 89% of individuals from Italy. The unwillingness of the Germans to participate could have potential relevance as Germany has 20 million more residents than Italy, the next most populous European country. The study otherwise appears to appropriately sample gender, age, marital status, occupation, and educational status across the industrialized European population. Ohayon and Zulley [15] previously reported that 7% of adult Germans experienced global sleep dissatisfaction and that this was a better indicator of underlying pathology than insomnia 1389-9457/$ - see front matter Ó 2009 Published by Elsevier B.V. doi:10.1016/j.sleep.2009.08.009
symptoms without sleep dissatisfaction. Germans who reported sleep dissatisfaction reported twice the rate of excessive daytime sleepiness, eight times higher frequency of sleep or mental disorders, 10 times higher rates of seeking help for their sleep problems, and use of sleep medication that was five times more likely [15]. In Italy, 27.6% of the sample reported insomnia symptoms, 10.1% complained of sleep dissatisfaction, 7% had diagnoses of insomnia disorder, and 5.7% reported use of sleep-enhancing medication [16]. The when of insomnia. Although treatment was not a focus of this paper, the presentation over the night and duration of insomnia will have relevance to therapeutic intervention. The level of distress will determine whether a health care provider initiates treatment for acute or short-term insomnia, while the definition of long-term insomnia can be for one month up to decades. Both behavioral and pharmacologic intervention will vary based upon the time of night when the patient is most actively describing wakefulness. The reader’s attention is directed to Tables 4–6 and Figs. 1 and 2 offered by Ohayon and Reynolds. These summaries of this large sample provide perspectives about complaints and potential disorders that will help individual patients and the treating clinician in their quest for objective information about the nature of sleep complaints. What to use to characterize the relevance of insomnia as a disorder. Sleep-EVAL uses lay interviewers trained to complete the structured phone survey. Sleep-EVAL categorizes responses into six classes of variables identified as potential factors associated with sleep dissatisfaction: sociodemographic descriptors, environmental factors, life habits, health status, psychological factors, and sleep/wake factors. Additionally, the survey has grown to include the diagnostic categories for the Diagnostic and Statistical Manual for Mental Disorders, fourth ed. (DSM-IV) [17] and the International Classification of Sleep Disorders, second ed. [18]. It has proved a robust tool to investigate sleep complaints in large populations and symptomatic groups. Ohayon and Reynolds highlight the importance of dissatisfaction by (1) quantity (sleep that is too short or too light along with duration on 3 or more nights per week); (2) quality (sleep latency, return to sleep after awakening, inability to resume sleep once awake, non-restorative sleep); and (3) daytime consequences that impact function – cognition (memory, concentration, and efficacy), affective tone (irritability, anxiety, and depression), sensory irritability, and difficulty completing daily tasks (work, study, or household). The authors also emphasize the importance of measuring the dimensions of severity, distress, or impairment to enhance the quality, reliability and validity of the insomnia diagnosis in clinical and research settings.
942
Editorial / Sleep Medicine 10 (2009) 941–942
To understand the authors’ call for better diagnostic and dimensional criteria for insomnia, the reader must understand Figs. 1 and 2 and Diagrams 1 and 2. Only half the complainants (about 15% of the entire population with insomnia) received diagnosis by DSMIV. For the elderly only a third qualified for an insomnia diagnosis. Although the diagnostic label in DSM-IV, ‘‘dyssomnia not otherwise specified,” can be used to characterize the complaint, the authors emphasize that any system of diagnosis that includes 50% or more of complainants as an ‘‘other” is a poor system of assessment. With more than one-third of adults in developed countries complaining of poor quality sleep or offering insomnia symptoms, physicians, nurses, mental health professionals and technologists will regularly encounter someone who is sleeping poorly, which is why it is important for all students in clinical health care to study Diagrams 1 and 2. These diagrams effectively demonstrate that who, where, when and what influence the outcome of report and potential diagnosis. As the importance of healthy sleep grows in the eyes of the public, so will the request for assistance. To manage the 9.8% of the population who report symptoms and daytime consequences and/or the 6.6% who meet DSM-IV diagnostic criteria, education becomes key. Ohayon and Reynolds, however, demonstrate that many respondents reported poor sleep but failed to meet diagnostic criteria for duration, frequency and severity in the two current classification systems. Research and future therapeutic strategies require better measures of severity, distress, and impairment. The field of sleep medicine should offer thanks to Ohayon and Reynolds for this large-scale study of sleep complaints across nations and broad populations. References [1] Ohayon MM. Difficulty in resuming or inability to resume sleep and the links to daytime impairment: definition, prevalence and comorbidity. J Psychiatr Res 2009;43(10):934–40. [2] Ohayon MM. From wakefulness to excessive sleepiness: what we know and still need to know. Sleep Med Rev 2008;12(2):129–41. [3] Ohayon MM. Interlacing sleep, pain, mental disorders and organic diseases. J Psychiatr Res 2006;40(8):677–9.
[4] Ohayon MM, Okun ML. Occurrence of sleep disorders in the families of narcoleptic patients. Neurology 2006;67(4):703–5. [5] Ohayon MM, Vecchierini MF. Normative sleep data, cognitive function and daily living activities in older adults in the community. Sleep 2005;28(8):981–9. [6] Ohayon MM. Prevalence and correlates of nonrestorative sleep complaints. Arch Intern Med 2005;165(1):35–41. [7] Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 2004;27(7):1255–73. [8] Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002;6(2):97–111. [9] Ohayon MM, Lader MH. Use of psychotropic medication in the general population of France, Germany, Italy, and the United Kingdom. J Clin Psychiatry 2002;63(9):817–25. [10] Ohayon MM, Roberts RE. Comparability of sleep disorders diagnoses using DSM-IV and ICSD classifications with adolescents. Sleep; 2001. [11] Ohayon MM, Guilleminault C, Zulley J, Palombini L, Raab H. Validation of the sleep-EVAL system against clinical assessments of sleep disorders and polysomnographic data. Sleep 1999;22(7):925–30. [12] Ohayon MM, Shapiro CM. Sleep and fatigue. Semin Clin Neuropsychiatry 2000;5(1):56–7. [13] Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res 1997;31(3):333–46. [14] Ohayon MM, Reynolds CF. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the international classification of sleep disorders (ICSD). Sleep Med 2009;10(9):952–60. [16] Ohayon MM, Smirne S. Prevalence and consequences of insomnia disorders in the general population of Italy. Sleep Med 2002;3(2):115–20. [17] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth ed., text revised (DSM-IV-TR). Washington, DC; 2000. [18] American Academy of Sleep Medicine. International classification of sleep disorders, second ed.: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine; 2005.
Philip M. Becker * Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 8140 Walnut Hill Lane, Suite 100, Dallas, TX 75231, USA * Tel.: +1 214 750 7776; fax: +1 214 750 4621. E-mail address: [email protected]