Diagnosis and Management of Sleep Problems in Primary Care:
A Challenge for Public Health
by T. Bedirhan Üstün


INTRODUCTION
    Sleep problems are a frequent complaint in primary care (general practice) and often a main reason for visiting a doctor. They can be caused by physical symptoms or diseases, but much evidence from previous studies suggests that sleep disturbances are often associated with psycholgical distress and mental disorders. Little is known about the global impact of sleep problems, their influence on the identification by GP of psychological disorders, or their outcomes.

    TABLE 1

    Epidemiology of Sleep Disorders: FACTS


    95 % of general population have sleep problem in their lifetime (Gallup, 1979)
    Difficulty with sleep ranges from about 10% to 49%
    50% Treatment seeking (Gallup 1991, WHO 1995)
    24% have "insomnia" in primary care (WHO, 1995)
    36% report insomnia complaints (Gallup, 1991)
    Recognition is poor (<50%) (WHO,1995)
    50% still insomniac after 12 months (WHO, 1995)
    10 % report chronicity (>4 M) (Gallup, 1991, Schram 1995)


    WHO International Collaborative Study on Psychological Problems in General Health Care assessed the form and frequency of sleep problems in general health care attenders at 15 primary care settings world-wide screening 26,000 primary care attenders and interviewing 5,400. The results (Üstün et al 1995) showed that the sleep problems are frequent in primary care, they were associated with significant disability, and were not adequately recognized or treated by GPs:

    • Sleep problems were common in primary care settings at all sites (estimated prevalence: 26.8%).
    • The main types of sleep problems were trouble falling or staying asleep.
    • Of those with sleep problems, 51.5% had a well-defined ICD-10 mental disorder, 14.9% were subthreshold cases.
    • All persons with sleep problems had a significant degree of disability in their daily activities and social roles.
    • Among patients with well-defined ICD-10 diagnoses, the concordance between the research instrument and the GPs was higher in those with sleep problems.
    • Presence of a sleep disorder was not related to prescription of psychotropic drugs.
    • Among patients with sleep problems who were followed up, a substantial proportion still had sleep problems and/or social disability.


    These findings support the need to emphasize to GPs the importance of sleep problems. Indeed, sleep problems themselves cause disability, and are highly associated with psychological disorders. They may persist for months, even when not associated with psychological disorders. Hence the need to develop educational programs for GPs.


    FIGURE 1

    Epidemiology of Diagnosis and Management of Sleep Problems in Primary Care



BACKGROUND
    World Health Organization EDUCATIONAL PACKAGE For PSYHOLOGICAL PROBLEMS In GENERAL HEALTH CARE, therefore included sleep problems as a main part of the basic educational focus in training general practitioners, and other primary care providers. The major objectives of this project are to:

  • Develop training and resource materials for GPs to improve the rates of identification and management of common mental health problems in primary health care settings, specifically, depression, anxiety, somatoform disorders, alcohol use and other common complaints such as sleep problems (insomnia) and fatigue.

  • Develop and implement training and other strategies to diffuse the training and resource packages to primary health care workers.

  • To evaluate the effectiveness of the training and resource materials.

    Currently WHO has produced education and resource materials (Educational materials for GPs on Sleep Problems are provided in Appendix). These include:

    • i. to improve the knowledge, skills and behaviours of PCPs.
    • ii. Development of self-instruction materials for patients (and their families) to improve their understanding of mental health problems and their management.


FUTURE NEEDS
    1. Development of training programs for GPs to enhance their knowledge of diagnostic criteria and management techniques and also their skills in patient education including strategies to enhance compliance with treatment recommendations.

    2. Implementation of training programs and other strategies to enhance the dissemination and diffusion of the training & education kits. The essential components of this phase are to:

    • Ensure that persons from key organizations are integrally involved in the development of the training package and materials and also the development and implementation of the dissemination strategy. An advisory group (s) will be set-up for this purpose and will include key stake-holders as well as persons with expertise in the relevant areas.
    • Identify the major structures and systems that would enhance the dissemination of the training programs and resource materials e.g. colleges of general practitioners, continuing education programs.
    • Identify cost-effective marketing strategies to promote the concept of mental health management in primary health care and to promote the associated training packages and resource materials.
    • Implement training programs. A variety of options may be considered including group training workshops, academic detailing and correspondence courses.

    3. Evaluation of the materials and the effect of training. This will occur at three levels:

    • i. Process evaluation. Issues related to clarity, ease of understanding, content and presentation of the resource materials and of the training program will be assessed.
    • ii. Impact evaluation. This will examine the immediate effects of the training on the knowledge, attitude, beliefs and skills of GPs.
    • iii. Outcome evaluation. Longer term changes related to the identification and management of mental health problems will be examined. The outcomes will include detection rates and appropriate use of medication, referral rates and functioning measures (disability and productivity) as well as other indices of costs of illness (direct and indirect costs) to indicate the cost-effectiveness of measures.


RECOMMENDATIONS
    1. Educational Programs for Sleep Problems in Primary Care should be given priority in view of the great public health importance of the sleep problems, their impact on lives of the people and the society. Primary care doctors are in the best position to treat patients with sleep problems. An International Advisory Board should study the relevance of the Educational Efforts in WHO package regarding the diagnosis and management of Sleep Problems. WHO's Educational Package should be considered as a standard tool, which can be expanded and utilized as necessary

    2. Educational Issues should focus on the Management Guidelines to deal with the questions below:

    • who has a sleep problem?
    • what is sleep problem related to?
    • how the insomniac should be approached?
    • who is evaluated/treated by whom and how?
    • what are the consequences of sleep problems?
    • what treatment for whom?

    3. An International Epidemiological Study of Sleep Problems should be conducted in different cultures. This study should utilize culturally sensitive methodology and assess multiple dimensions related to sleep such as diagnostic features, functioning at body level (e.g. difficulty concentrating, memory problems) person level (Daily activities disabled by sleep problems such as work productivity, accidents), and social level . The study should explore the recognition and management of these problems

    4. Diagnostic Classification systems and Assessment Tools (e.g., questionnaires) should be revised to incorporate the needs for-

    • standardization of clinical diagnoses
    • standardization of research criteria
    • collection of public health statistics
    • education of health professionals

    5. PUBLIC AWARENESS on INSOMNIA should be raised by systematic programs. This will help to clarify misconceptions on treatment. Awareness of public and doctors go hand in hand.

    6. Consensus needed among Sleep Experts and Primary Care Doctors

    • Areas of agreement: e.g., Definition of sleep problem complaint of unsatisfactory sleep either quantity or quality quantity: frequency or duration above a certain threshold distress and/or interference with functioning caused by the complaint
    • establishment of need for education
    • data based concepts
    • further scientific studies to evaluate the effectiveness of educational programs




Appendix

WHO Educational Package on Mental Disorders in Primary Care: Sections dealing with Sleep Problems in Primary Care



T. Bedirhan Üstün, Division of Mental Health and Prevention of Substance Abuse, World Health Organization Geneva, Switzerland


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