Israel Andrew G, Lieberman Joseph A
University of California, San Diego, School of Medicine, USA.
Postgrad Med. 2004 Dec;116(6 Suppl Insomnia):7-13. doi: 10.3810/pgm.12.2004.suppl38.257.
Primary care physicians are often the first healthcare providers to encounter insomnia in their patients. However, they face many obstacles to diagnosis and treatment of insomnia that stem from patient- and physician-related factors. During consultations, most patients do not mention their sleep difficulties because they believe that insomnia is a trivial concern that does not have serious health consequences. Physicians also face diagnostic obstacles related to conflicting or vague diagnostic definitions, office-based time constraints, and a lack of training in sleep medicine in medical school and residency programs. Once a diagnosis is made, initiating appropriate treatment is also complicated because of outdated treatment guidelines and US Food and Drug Administration prescribing constraints. These factors may have contributed to the perception that there are no good treatment options for insomnia and that all available medications have a poor risk-benefit ratio. For example, benzodiazepines are known to carry a risk of tolerance and abuse. Until recently, few long-term data were available on the safety and efficacy of current agents, which may have contributed to reticence to treat chronic insomnia. Furthermore, there is limited evidence that treating insomnia is associated with improved patient outcomes, and this may have discouraged active treatment programs for insomnia. Increased awareness that insomnia can precede and exacerbate coexisting illnesses, including depression and chronic pain syndromes, is needed. As data emerge from recent clinical trials with newer, promising nonbenzodiazepine medications, it should become easier for primary care physicians to take a proactive role in diagnosing and treating insomnia and thus improve patient functioning.
初级保健医生往往是其患者中最早遇到失眠问题的医疗服务提供者。然而，他们在失眠的诊断和治疗上面临许多源于患者和医生相关因素的障碍。在会诊期间，大多数患者不会提及他们的睡眠困难，因为他们认为失眠是一个微不足道的问题，不会产生严重的健康后果。医生还面临与相互矛盾或模糊的诊断定义、基于办公室的时间限制以及医学院校和住院医师培训项目中睡眠医学培训不足相关的诊断障碍。一旦做出诊断，由于过时的治疗指南和美国食品药品监督管理局的处方限制，启动适当的治疗也很复杂。这些因素可能导致了这样一种看法，即没有好的失眠治疗选择，所有可用药物的风险效益比都很差。例如，苯二氮䓬类药物已知存在耐受性和滥用风险。直到最近，关于当前药物安全性和有效性的长期数据很少，这可能导致对治疗慢性失眠有所顾虑。此外，治疗失眠与改善患者预后相关的证据有限，这可能阻碍了积极的失眠治疗项目。需要提高对失眠可先于并加重包括抑郁症和慢性疼痛综合征在内的共存疾病的认识。随着来自近期使用更新的、有前景的非苯二氮䓬类药物的临床试验的数据出现，初级保健医生在诊断和治疗失眠方面发挥积极作用并从而改善患者功能应该会变得更容易。
