Comprehensive Workup for Insomnia

Initial Screening

The American Academy of Sleep Medicine recommends screening for sleep problems using two key questions: (1) "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" and (2) "Does the problem with your sleep negatively affect your daytime functioning?" 1, 2
If the patient answers yes to both questions, proceed with a more focused assessment 1
Consider using validated screening tools such as the Insomnia Severity Index to identify cases of insomnia and assess treatment effects 2
The Epworth Sleepiness Scale can help rule out comorbid sleep disorders 1, 2

Obtain a detailed sleep history including specific insomnia complaints, sleep-wake patterns, and daytime consequences 3
Request completion of a 2-week sleep diary/log documenting bedtime and wake times, sleep onset latency, number and duration of awakenings, total sleep time, and nap frequency and duration 2, 3
Consider actigraphy for at least 7 days to objectively measure sleep-wake patterns, particularly when circadian rhythm disorders are suspected 3

Assess for medical conditions that commonly cause insomnia, such as cardiovascular diseases, pulmonary conditions, neurological disorders, pain conditions, gastrointestinal disorders, and endocrine disorders 4, 1
Screen for psychiatric conditions commonly associated with insomnia, including depression, anxiety disorders, bipolar disorder, and post-traumatic stress disorder 4, 5

Conduct a thorough review of all medications that may contribute to insomnia, such as beta-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 4
Assess use of substances that can disrupt sleep, including caffeine, alcohol, nicotine, over-the-counter sleep aids, and recreational drugs 4, 6

Distinguish between primary insomnia and comorbid (secondary) insomnia 7, 4
Consider other sleep disorders in the differential diagnosis, including obstructive sleep apnea, restless legs syndrome, and circadian rhythm sleep disorders 4, 3

The American Academy of Sleep Medicine recommends Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment for chronic insomnia 7
Pharmacological options should be considered when non-pharmacological approaches are insufficient, including short-intermediate acting benzodiazepine receptor agonists or ramelteon as first-line pharmacotherapy 7, 6
Combined therapy (CBT-I plus medication) may be appropriate based on symptom pattern, treatment goals, and patient factors 6