Shared insight on how daytime functioning has become part of the insomnia treatment paradigm.
Michael J. Thorpy, MD: Vikas, insomnia is often regarded by people as just being a nighttime problem. But it’s more than that, isn’t it? It’s a 24-hour-a-day problem; it’s a night-and-day problem. Why do we think of it more as a 24-hour-a-day problem rather than a nighttime problem?
Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE: There are several reasons. One is that generally if you don’t sleep well at night, if you’re having difficulty falling asleep and staying asleep, if you’re waking up too early, then a poor night of sleep is going to translate into decreased performance during the day. Patients with insomnia are 3 times more likely to lack concentration during the day compared with people who sleep well at night. They’re twice as likely to suffer from poor energy levels, and there’s a higher degree of mood disorders in patients who have insomnia. In general, especially with patients who have chronic insomnia, if you don’t get good sleep night after night, then you start worrying about your sleep all day. “Is tonight going to be the night that I’m going to get some sleep?” That itself lends itself to another night of poor sleep. It can perpetuate beyond that.
Michael J. Thorpy, MD: You’re so right. There are many people who wake up in the morning and think, “If I don’t get a good night sleep tonight, I’m not going to be able to do the things I want to do the next day.” They start worrying about it in the morning. They have symptoms related to it all day because of it.
Karl Doghramji, MD: Michael, if I could just amplify that as well. Clinically, I find that some patients who seem to have some trivial difficulties with sleep itself, waking up just a few times or maybe having a very short sleep latency, complain of insomnia. When I ask them why they’re so concerned about a few awakenings, they say, “It’s because I feel miserable during the day.” That seems to be the common complaint with insomniacs. It’s not what happens at night; it’s how they feel during the day.
Michael J. Thorpy, MD: Tiredness, fatigue, and difficulty getting things done during the day are often the major complaints, not the nighttime complaints.
Nathaniel Fletcher Watson, MD: If we take that into consideration, it’s interesting that so many clinical trials looking at insomnia medications and treatments don’t address daytime functioning almost. That’s changing with some of the newer medications coming out and some clinical trial activity out there, but it’s remarkable how myopic we’ve been as a field focusing on the nighttime, sleep latency and wake after sleep onset, sleep efficiency, and the number of awakenings but not daytime-functioning issues such as sleepiness, mood-related issues, or cognition. Hopefully this will change as we move forward.
Erinn E. Beagin, MD: It’s something I ask my patients. They’ll come in and say, “I’m not getting 8 hours’ sleep.” I’ll say, “How many are you getting?” “I’m getting 5 hours’ sleep. But when I was in the military, I used to go to bed at 11 PM and be up at 4 AM.” The No. 1 question I ask is, “Are you tired during the day? How do you feel during the day?” And they say, “I power through. I’ve got no problems.” For that patient, it’s reassurance, but you’re absolutely right. It’s the people who come in and say they can’t function the next day that I’m much more concerned about.
Transcript edited for clarity.