Insomnia in primary care settings: Still overlooked and undertreated?

Aljohara S Almeneessier; Bader N Alamri; Faisal R Alzahrani; Munir M Sharif; Seithikurippu R Pandi-Perumal; Ahmed S BaHammam

doi:10.4103/JNSM.JNSM_30_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 1 | Issue : 2 | Page : 64-68

Insomnia in primary care settings: Still overlooked and undertreated?

Aljohara S Almeneessier¹, Bader N Alamri², Faisal R Alzahrani³, Munir M Sharif⁴, Seithikurippu R Pandi-Perumal⁵, Ahmed S BaHammam⁴
¹ Department of Family Medicine, College of Medicine; Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
² Department of Medicine, Dalhousie University, Halifax, Canada
³ Department of Otolaryngology Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
⁴ Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
⁵ Somnogen Inc, Toronto, Canada

Date of Web Publication

6-Jun-2018

Correspondence Address:
Aljohara S Almeneessier
Department of Family Medicine, College of Medicine, King Saud University, Riyadh
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_30_18

Abstract

Background: Insomnia is a major medical problem that is often associated with low health status and increased health-care utilization. Therefore, we conducted this study to determine the frequency of insomnia in a population presenting to the primary healthcare (PHC) clinics for health problems other than sleep disorders. Methods: We interviewed 336 consecutive patients attending PHC face-to-face by trained medical students. Validated questionnaires were used to evaluate insomnia, sleep quality, and daytime sleepiness. The insomnia questionnaire classifies patients into three categories: (1) no insomnia, (2) Level I insomnia with the absence of daytime dysfunction, and (3) Level II insomnia with the presence of daytime dysfunction. Results: Level I insomnia was reported by 19.3% and Level II by 57.1%. Patients with insomnia were older and had worse sleep quality. Apart from a higher prevalence of hypertension among patients with insomnia, there was no difference in other comorbidities between those with insomnia and no insomnia. None of the included patients has reported his/her complaint of insomnia to the treating general practitioner (GP), and none of them was diagnosed with insomnia by the GP. Conclusion: Insomnia and daytime dysfunction are very common in primary care population. Despite the frequent visits of these patients to PHC, none of them has reported that he/she complains to his/her GP, and therefore, did not receive any treatment for insomnia. Education of GPs is necessary to improve recognition, diagnosis, and treatment of insomnia.

Keywords: Daytime dysfunction, family physician, general practitioner, sleep, sleepiness

How to cite this article:
Almeneessier AS, Alamri BN, Alzahrani FR, Sharif MM, Pandi-Perumal SR, BaHammam AS. Insomnia in primary care settings: Still overlooked and undertreated?. J Nat Sci Med 2018;1:64-8

How to cite this URL:
Almeneessier AS, Alamri BN, Alzahrani FR, Sharif MM, Pandi-Perumal SR, BaHammam AS. Insomnia in primary care settings: Still overlooked and undertreated?. J Nat Sci Med [serial online] 2018 [cited 2023 Mar 27];1:64-8. Available from: https://www.jnsmonline.org/text.asp?2018/1/2/64/233816

Introduction

Insomnia is a common distressing sleep disorder. In fact, insomnia is the most common sleep disorder in the general population.^[1] It is usually defined as difficulty in initiating or maintaining sleep, waking up earlier than desired, or nonrestorative sleep that results in significant distress or impairment in daytime function.^[2] Some look to insomnia as a symptom of an underlying disorder rather than a disease on its own. Previously, chronic insomnia was viewed in some cases as secondary to underlying medical, psychiatric, neurological, or substance abuse disorders.^[1] However, the recent approach to chronic insomnia best views the disorder as a comorbid disorder that warrants separate treatment attention.^[3] Insomnia has been shown to be associated with serious medical complications. Several meta-analyses demonstrate that insomnia is a significant risk factor for cardiovascular diseases, arterial hypertension, myocardial infarction, chronic heart failure, and Type 2 diabetes.^[3] Moreover, insomnia has been shown to be independently associated with significantly elevated use of health-care services, medications, and alcohol use.^[4],[5]

Several assessment tools have been used in epidemiological studies to assess the prevalence of insomnia, which results in a wide variance in the reported prevalence of the disorder.^[6]

Primary care physicians are in a unique position to diagnose and to provide medical treatment for most patients with insomnia; nevertheless, insomnia, likewise most sleep disorders, is underrecognized and underdiagnosed.^[7] Despite that, insomnia is underrecognized, and many sufferers do not receive adequate treatment. Although insomnia is a distinct disorder, patients usually do not report insomnia symptoms to physicians, and physicians do not explore or assess sleep disorders in their patients.^[8]

Therefore, we designed this study to determine the frequency of insomnia in a representative population presenting to the primary healthcare (PHC) clinics for health problems other than sleep disorders using a validated assessment questionnaire that has been validated in the primary care setting.

Methods

Sample

We conducted the study in six randomly selected (simple random) PHC centers in Riyadh city, Saudi Arabia in the period from October to December 2012. We targeted consecutive Saudi adult (>18 year) male and female patients attending the clinics with various medical problems. We excluded pregnant women and all shift workers, and workers forced to wake up early (before dawn (Fajr)) for professional duties. In addition, short sleepers, as defined in the 3^rd edition of the International Classification of Sleep Disorders-3, were also excluded from the study.^[2]

Medical records of the participants were checked to document the chronic illnesses of the participants and to verify whether the participants with insomnia have been diagnosed or treated for insomnia by their primary care physician.

Medical students explained the study protocol and objectives to the participants and interviewed the participants face-to-face. To minimize errors in data collection and diagnoses, medical students attended an educational session on insomnia and the used questionnaires, and received training on data collection.

Informed consent was obtained, and the institutional review board approved the study.

Questionnaires

Demographic data and comorbidities were collected. In addition, sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and daytime sleepiness (Epworth Sleepiness Scale [ESS]). The ESS is a validated questionnaire that assesses the likelihood that the subject will fall asleep during certain activities.^[9] A score of ≥10 indicates daytime sleepiness. The PSQI is a validated and reliable questionnaire that is widely used as one of the most important sleep health assessment tools to assess sleep quality.^[10] It is a self-report questionnaire that assesses sleep quality over a 1-month time interval. The measure consists of 19 individual items, creating seven components that produce one global score. The PSQI measures different aspects of sleep, including seven component scores and one composite score. The component scores consist of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency (i.e., the percentage of time in bed that one is asleep), sleep disturbances, use of sleeping medication, and daytime dysfunction. Each item is scored on a 0–3 interval scale. The total PSQI score is then calculated by adding the seven component scores, to provide an overall score ranging from 0 to 21. A global score of ≥5 is associated with poor sleep. An Arabic version of the PSQI has been validated previously.^[11]

To evaluate insomnia, a previously validated questionnaire to assess insomnia in the primary care setting was used.^[12] The questionnaire is composed of five questions:

Do you often have difficulty falling asleep?
Do you wake up too early in the morning?
If you frequently wake up during the night, do you have difficulty going back to sleep?
Do you often feel tired when you awaken in the morning?
Does sleep loss affect your mood during the day, making you feel tense, irritable, or depressed?

Questions number 1, 2, and 3 aims to assess insomnia symptoms,^[12] where participants were asked to report sleep difficulties persisting for at least 1 month.^[2] For questions number 1, 3, 4, and 5, the frequency of symptom was considered on a weekly basis. Answers were considered positive if the complaint occurred three times or more per week. In question number 2, “too early in the morning” meant awakening before the patient's usual waking time, associated with an inability to return to sleep.

The clinical condition of the participants was classified according to the responses to the five questions. The clinical condition was classified as:

No insomnia, if the answer was “no” to questions 1, 2, and 3
Level 1 insomnia-an absence of daytime dysfunction, if the answer was “yes” to any of questions 1–3 and “no” to questions 4 and 5
Level 2 insomnia-the presence of daytime dysfunction, if the answer was “yes” to any of questions 1–3 and “yes” to questions 4 or 5.

Validation of the Arabic versions of the questionnaires

Two bilingual physicians independently translated the three used questionnaires from the original English versions into Arabic. Two other bilingual physicians, who had no knowledge of the original version of the questionnaire, back-translated the Arabic drafts into English. The translations were reviewed in collaboration with the translators, and the back-translation was assessed for equivalence to the original English versions. Discrepancies between the forward- and back-translation versions were discussed and resolved to produce the final Arabic versions. To maintain the psychometric properties of the original questionnaires, the questionnaires were at first administered to 10 bilingual subjects, who completed both the Arabic versions and the English versions to determine the test–retest reliability. Questionnaires results were independent of version. Afterward, we conducted a pilot study with a sample of 30 individuals to assess the legibility, practicality, and accuracy of the Arabic versions of the three questionnaires and the associated data gathering process before beginning the study.

Statistical analysis

We chose a sample size that would allow us to detect an insomnia prevalence of 50% with an alpha (α) of 0.05 and a precision of 1%. The estimated minimum sample size was 291.^[12],[13]

Data are expressed as means ± standard deviation; a Chi-square test was used to compare dichotomous data. For continuous variables, Student's t-test was used. We considered results significant if P ≤ 0.05. We used SPSS 16.0 (Chicago, IL, USA) to analyze the data.

Results

We recruited 336 participants, where males comprised 212 (63%), and the mean age of the participants was 33.2 ± 14.2 years with a mean body mass index of 26.9 ± 5.6. Criteria for Level I insomnia were met in 19.3% and Level II in 57.1%. [Table 1] presents the demographics, educational levels, and social data of the total group, patients without insomnia, Level I insomnia and Level II insomnia.

Table 1: Demographics, educational levels, and social data of the total group, patients without insomnia, Level I insomnia, and Level II insomnia

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Among patients with Level I insomnia, early morning awakening was reported in 78.5%, while difficulty in initiating sleep (36.9%) and maintaining sleep (29.2%) was less frequent. Among patients with Level II insomnia, difficulty falling asleep, difficulty in maintaining sleep, and early morning awakenings had high frequencies (58.3, 51.6, and 69.8%, respectively). Approximately 83% of patients with Level II insomnia exhibited a mood disturbance due to sleep loss, while 66.1% of patients with Level II insomnia complained of tiredness on awakening [Table 2].

Table 2: Insomnia symptoms

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[Table 3] presents a comparison of comorbidities, the ESS and PSQI score of patients without insomnia, Level I insomnia and Level II insomnia. Patients with insomnia were older and had worse sleep quality. Apart from a higher prevalence of hypertension among insomniacs, there was no difference in other comorbidities between those with insomnia and no insomnia. Interestingly, participants had not been previously diagnosed or treated for insomnia, and none of them has reported his complaints of insomnia to the general practitioner.

Table 3: A comparison of comorbidities, the Epworth Sleepiness Score and the Pittsburgh Sleep Quality Index score of patients without insomnia, Level I insomnia and Level II insomnia

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Discussion

This is the first observational investigation on the distribution of insomnia in the primary care setting in Saudi Arabia. The study demonstrated that insomnia is extremely common in the primary care population and revealed a high prevalence of insomnia (76.4%), and most insomniacs (57.1%) complained of daytime disturbances as a result of their insomnia.

Our findings concur with an Italian study that used the same questionnaire and reported the presence of insomnia in 64% of primary care population, with 20% classified as Level I and 44% as Level II.^[12]

The reported prevalence in both studies (the current study and the Italian study) is relatively high, which could be related to the fact that the used sleep questionnaire is based on a binary response (yes/no). This may have contributed to inflated estimates. In a previous review by Ohayon, the presence of symptoms of insomnia for at least three nights per week (similar to the definition of Level I insomnia in the current study) was reported in 16%–21% of the general population, while insomnia symptoms associated with daytime consequences (similar to a level II insomnia) was reported in 9%–15%.^[13] However, in patients attending primary care with several comorbidities, the prevalence of insomnia is expected to be higher.

In a multisite survey of five American Medical Group Association, Level I and Level II insomnia were reported by 13.5 and 32.5% of the respondents, respectively.^[14] In our study and the Italian study,^[12] where the survey was performed on patients attending PHC clinics, the percentage of patients who reported insomnia symptoms was high (76.4% and 64%, respectively), with a prevalence of Level II insomnia (57.1% and 44%, respectively) twice to three times that of Level I insomnia (20%). These results indicate that the effect of daytime dysfunction is an important factor that differentiates between subjects with insomnia in the general population and patients with insomnia in the primary care setting.

In developed countries, insomnia represents a heavy burden for primary care physicians. A previous study in the USA revealed that patients with insomnia ask for a clinical consultancy on average 12.87 times per year compared to 5.25 times per year for the patients without insomnia.^[5] Previous studies in primary care settings in Saudi Arabia revealed that the majority of primary care physicians think that sleep disorders are related to psychiatric disorders.^[7],[15] However, psychiatric disorders are not the only risk factors for recurrent insomnia. In a survey carried out on a large sample of an adult population, multiple types of concomitant health problems were associated with increased difficulty in initiating and maintaining sleep.^[16] Most patients attending primary care clinics have multiple health problems, which increase the risk for insomnia. Another major risk factor for the occurrence of insomnia was a previous complaint of insomnia.^[16] Therefore, recurrent insomnia is not unusual in patients with treated insomnia. This requires proper follow-up and early treatment of recurrent insomnia in its early stages before becoming established and chronic, which stresses the importance of the role that primary care physicians can play in this perspective.

Although this study was conducted in a primary care setting, none of the interviewed participants with insomnia had been diagnosed or treated for insomnia; in addition, none of the patients has conveyed his complaint about poor sleep to the treating doctor suggesting that this disorder is underrecognized and undertreated. A previously published international survey examined the characteristics of insomnia in the general population in four developed countries (France, Italy, Japan, and the USA) to better understand why insomnia is underrecognized and undertreated.^[17] The study showed that among those with a history of insomnia, the rate of reporting insomnia symptoms to their treating physicians was generally low, and among those who did consult a physician, few were prescribed any medication.^[17] Not reporting symptoms of insomnia to the treating physicians needs further research. Different factors, such as culture and beliefs, may play a part in this. In addition, fear of the consequences and adverse effects of treatment including the possible risks of dependence on medications may be another factor. Underrecognition and undertreatment of insomnia in the primary care setting in this paper concur with a recent study in Saudi Arabia that revealed poor knowledge of sleep medicine and its disorders, and underrecognition of the importance and impact of sleep disorders among primary care physicians.^[7] In addition, previous studies in the primary care settings in Saudi Arabia revealed that obstructive sleep apnea and restless legs syndrome are common among patients attending primary care services; however, these disorders are underrecognized by primary care physicians.^{[8],[18],[19]} Therefore, educating primary care physicians on sleep disorders will allow the early detection of sleep disorders and the provision of proper treatment or referral to a sleep medicine specialist.

A limitation of this study is the fact that the study was conducted in a primary care setting, which limits our ability to generalize the results to a general Saudi population; however, this sample helped us to confirm the high prevalence of insomnia in the primary care settings and the underdiagnosis of this disorder by the treating physicians.

Conclusion

This study reveals that insomnia and daytime dysfunction are very common in patients attending primary care clinics. Insomnia is a daily challenge for primary care physicians, who often miss and underdiagnose this disorder. Despite the high prevalence of insomnia among patients visiting primary care physicians, surveyed patients did not report their complaints to their treating physicians and therefore were unlikely to receive treatment or referrals to a specialty clinic. Focused and targeted education of primary care physicians on insomnia and other sleep disorders will allow the early detection of sleep disorders and hence the provision of early treatment and the prevention of complications.

Financial support and sponsorship

This work was financially supported by the Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (MED511-02-08). The study sponsors played no role in the study design, the collection, analysis or interpretation of data, writing the manuscript, or the decision to submit the manuscript.

Conflicts of interest

There are no conflicts of interest.

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