Clinical decision-making in the evaluation and treatment of insomnia.

We interviewed a representative random sample of 501 office-based general physicians and 298 nurse practitioners to evaluate their approach to the symptoms of insomnia. Clinicians were presented with a standard case of a patient complaining of difficulty sleeping, with the age of the patient depicted as either 37 years or 77 years. Historical information was provided in response to practitioners' questions. In evaluating the history, physicians asked an average of 2.5 questions and were most likely to ask about psychologic problems. Only 47% of the physicians who were presented with the elderly case vignette elicited a sleep history. By contrast, nurse practitioners asked an average of 3.2 questions, and 60% of them took a sleep history. Despite many possible non-pharmacologic therapies for the patients presented, 46% of physicians identified a prescription medication as the single most effective therapy for the older patient, compared with 17% of nurse practitioners. These findings suggest that physicians place inadequate emphasis on history-taking in the evaluation of insomnia and resort to the use of psychoactive drugs even when non-pharmacologic approaches might be more effective.