When Should Insomnia Be Treated?

We suspect a patient fulfills insomnia disorder when they report three or more nights per week where it takes more than 30 minutes to fall asleep and/or return to sleep for at least three months. To reach diagnostic criteria, they then must also report that this is a problem for them, meaning, it is impacting functioning in some way (e.g., at work, school, or socially), or it is causing significant distress.

How Do Doctors Diagnose Insomnia?

Insomnia is based on the patient's report. While in the sleep field, we generally have a sophisticated set-up for conducting overnight sleep studies called, polysomnography, this is not appropriate to diagnose insomnia alone. An overnight sleep study is most often ordered when sleep apnea is suspected. The reason that a sleep study is not used for diagnosing insomnia is because one night of sleep does not provide an accurate picture of an insomnia patient's experience. It's biased data. The average patient does not sleep well with the wires and hook-up process done at the sleep lab. Those with insomnia sometimes actually sleep better at the sleep lab compared to their bed at home because of "classical conditioning." This means that their bed at home is associated with negativity, frustration, and anxiety, but other beds do not cue this response.

Insomnia specialists often require patients to complete sleep logs. Their perception of their sleep tracked each morning. This can provide more color to their presenting complaints. That said, a diagnosis of insomnia can be made during the first session with your clinician based on your report of symptoms when reflecting on the past few months.

When Is Treatment Warranted?

We recommend that patients complete cognitive behavioral treatment for insomnia (CBT-I) when they have the symptoms described above. CBT-I is the first-line treatment recommended for insomnia. In fact, research shows that those with insomnia should first try CBT-I and only consider a sleeping pill if CBT-I does not work. Unfortunately, it typically happens that patients do not get treated in this order due to insufficient access to care. There are still only a few hundred of us to treat the 33-50% of the population suffering from insomnia.

Who Does Not Need Insomnia Treatment?

While sleep specialists are happy to help those suffering from insomnia, it's important not to overpathologize your symptoms. I have had patients tell me, "I'm waking up every night, two to three times per night." This is not necessarily pathological. We all wake two to three times per night. We sleep in cycles that last about 90-120 minutes, then wake briefly (sometimes so brief we don't recall it the next day) before starting another cycle. This in itself does not warrant treatment. If it's taking more than 30 minutes to return to sleep when waking, that means treatment would be warranted. If there are frequent awakenings and loud snoring, this might mean that your primary care might want to send you to a sleep medicine specialist to order a sleep study.

It's also important not to worry just because your sleep tracker or wearable says you are waking up a lot or not sleeping deeply. My team works really closely with sleep tracking and wearable data, and we absolutely love seeing the enthusiasm about sleep that such use indicates. That said, waking up a lot or not sleeping deeply by itself does not necessarily cause concern for a clinician. We'd also need to hear that other symptoms are present (e.g., excessive daytime sleepiness, loud snoring, insomnia, etc.).