Re: Sleep and the Family Doctor: Time to Lead

To the Editor: We have read with interest Dr. Sorscher's¹ commentary in the March-April 2011 issue of the Journal of the American Board of Family Medicine. We concur strongly with his assertions that sleep and sleep disorders are an important and under-recognized primary care domain. He provides an excellent and succinct summary of the prevalence and consequences of disordered sleep as well as the challenges of translating evidence-based assessment and management into clinical practice. He calls for family physicians to seek certification in sleep medicine as a means of assuming a leadership role in the care of patients with sleep-related problems. This is indeed an important direction toward improving care of sleep related issues. However, we wish to offer additional recommendations with a focus on insomnia as the most prevalent sleep disorder in primary care.

Insomnia merits an interdisciplinary approach.¹ Medical input is needed to differentiate insomnia from other primary sleep disorders, to identify and address medical and medication contributors, and to judiciously prescribe hypnotic medications in a time-limited fashion. In addition to input from medical professionals, the expertise of behavioral clinicians is needed to deliver preferred, evidence-based cognitive behavioral therapy for insomnia and to participate in the identification of depression, anxiety, substance abuse, and other psychiatric comorbidities that can impact sleep. Our work concerning self-efficacy for sleep suggests a role for nursing professionals to assess and foster readiness for behavioral change.^2,3

These considerations argue for interprofessional care teams that address not only other multifaceted chronic conditions, such as depression and diabetes, but also insomnia as a biopsychosocial chronic illness rather than simply a medical or a behavioral symptom. Such teams are central to further development of the patient-centered medical home.⁴ The teams are, potentially, a “win-win” for the professions involved and, more importantly, for our patients who suffer the consequences of poor sleep. We urge that future family medicine research and innovation on insomnia and sleep problems examine the utility of team-based care in improving outcomes.