From new knowledge regarding the neuronal and neurotransmitter regulation of arousal and sleep through new strategies for managing insomnia and, most importantly, daytime sleepiness, the sleep field is making rapid and fundamental advances. This supplement brings together cutting-edge information in a clinically useful manner.
Hypocretin, a recently discovered neurotransmitter peculiar to a small group of cells in the hypothalamus (the ventrolateral preoptic nucleus), appears to be the kingpin overseeing both the arousal and sleep centers of the hypothalamus. Through these centers, norepinephrine, serotonin, histamine, and GABA systems are modulated to produce wake and sleep states or pathological states. The characteristics and interactions of these systems are clearly presented by Jerome M. Siegel, Ph.D., in the leadoff article. Next, Thomas Roth, Ph.D., provides an enlightening overview of the normal (and abnormal) sleep cycle, the ultradian and circadian cycles affecting sleep, sleep homeostasis, and key determinants of sleep. The insights from these 2 provide the basis for understanding the mechanisms by which primary care physicians can improve the sleep and wakefulness of patients with sleep problems.
Terry B. Young, Ph.D., discusses the prevalence and complexity of measuring and understanding the various abnormalities of sleep, and particularly their reflection in daytime sleepiness and its consequences. Discussion of the language of sleep and tiredness, the cultural filters by which these might be perceived by patients, the different conceptual frameworks by which "sleepiness," "tiredness," and "fatigue" are viewed by patients, and the impact of these on patients are helpful to clinicians in understanding their patients' interpretations of their experiences of insomnia.
Karl Doghramji, M.D., and Paul P. Doghramji, M.D. (brothers, one a sleep specialist and the other a family physician), in their complementary articles, structure an approach to recognizing and evaluating insomnia, excessive sleepiness, and their sequelae. The review of brief self-assessment instruments that are easily used in the primary care setting provides important tools to the clinician to rapidly confirm the presence of a sleep problem requiring a therapeutic response, and then to measure treatment response. Karl Doghramji, M.D., also provides a useful overview of the disorders of circadian rhythm and their consequences, while Paul P. Doghramji, M.D., provides insight into how they can present during acute problem, chronic care, and health maintenance visits.
Depression is possibly precipitated by insomnia, although it is not clear if insomnia is a true risk factor or only an early marker of the development and recurrence of depression. Similarly, residual insomnia may differentiate a group of patients at high risk for relapse. Complicating these relationships is the impact of medications used to treat depression. Maurizio Fava, M.D., provides an excellent clinical overview of what we know about these relationships and the impact of the various categories of antidepressants on sleep processes and insomnia, and articulates clinical options for augmenting antidepressant therapy to respond to patients' sleep and wake problems. Dr. Fava's review leads into a useful compendium of treatment options in primary care in the following 3 articles.
Charles M. Morin, Ph.D., provides an overview of nonpharmacologic treatments for insomnia, including data on the effectiveness of such strategies as sleep restriction, stimulus reduction, and relaxation techniques. He also provides a very practical discussion of the clinical approach to evaluating and educating the patient with an insomnia problem and presents insight into cognitive behavioral therapy techniques specifically for insomnia and the efficacy of these measures alone and in combination with pharmacotherapy. James K. Walsh, Ph.D., balances this with a presentation of the pharmacologic options for the management of insomnia, both the newer "nonbenzodiazepine" benzodiazepine receptor agents and the sedating hypnotics. Of interest is the discussion of the evolving evidence that these are of value in long-term use, with little or no development of tolerance or rebound (which, if it does occur is generally limited to the first night off medication). Also briefly reviewed are the rather dour, although scant, data on the use of trazodone to treat insomnia in both depressed and nondepressed patients.
Managing daytime sleepiness directly, rather than only by trying to improve sleep, is the exciting forefront of helping our patients with insomnia-related problems. Daytime sleepiness can arise from a number of conditions affecting our patients, including idiopathic insomnia, posttraumatic hypersomnia, shift work, narcolepsy, and obstructive sleep apnea, as well as the temporary overloads of life. Improving alertness and safety (e.g., related to driving and other critical tasks) is a primary goal in these conditions. The development of modafinil, FDA approved for use in narcolepsy and shift work—related insomnia and as adjunctive therapy for obstructive sleep apnea, provides an important new option for clinicians, one that also benefits other patient groups affected by severe daytime sleepiness and fatigue (e.g., patients with multiple sclerosis). Jonathan R. L. Schwartz, M.D., concludes this supplement with an overview of this agent and the other agents that have been historically used.
Together, the articles in this supplement arm the primary care physician with the knowledge of basic sleep and wake control mechanisms, clinical assessment tools and strategies, and understanding of treatment options available to help patients with insomnia and excessive daytime sleepiness. Insomnia affects a large portion of adults, with 16% reporting that it impairs daytime function1; each year it is involved in over 100,000 auto accidents with more than 40,000 injuries and 1550 deaths.2 It's not just a nuisance problem in primary care—rather, it is a serious problem for which we now have the means to dramatically improve the lives of our patients and their families.
Larry Culpepper, MD, MPH
Editor in Chief
The Primary Care Companion to the Journal of Clinical Psychiatry