Insomnia: Principles and Management

Considering how important sleep is in general, and insomnia is as a chief complaint in the primary care setting, good texts on the subject are sorely needed. Medical school curricula mostly ignore sleep, and insomnia is unmentioned even in many residency settings. Insomnia: Principles and Management fills a need for the practicing physician covering a broad range of topics within the umbrella of insomnia. In 5 sections, 14 chapters, 8 appendices, and 285 pages, this book covers many topics. Some are a bit obscure, such as “Amygdalar Modulation of Sleep Regulation,” whereas others are more clinical, e.g., “Long-Term Use of Hypnotic Medications.” Overall, 21 authors provide a broad look at insomnia and information for the beginner looking for basic information as well as the scholar looking for research topics. If you are looking for an easy cover-to-cover read, this book might not be the best selection; however, if you desire a single book to act as both primer and reference, this should do the trick. Part I, Characterization of Insomnia, reviews the diagnosis of insomnia, certain clinical aspects, and psychiatric comorbidities. Depending on which group of experts you ask, there are anywhere from 18 to 84 different sleep disorders of which insomnia is a subset. The complexities of accurate diagnosis are detailed and organized into groups. Some conclusions are implied, such as the importance of mood disorders associated with insomnia—which will surprise nobody. Other conclusions are less obvious, such as “ … the majority of insomniacs do not appear to have significantly disrupted sleep” (p. 31) and “improvement of nighttime sleep does not directly result in improved daytime functioning” (p. 31). While a bit dense in parts, this section succeeds in its goal of description and characterization. Part II, Treatment of Insomnia, disappointed me by its lack of cases and a relatively abstract approach. As a family physician, I need some straightforward concepts illustrated by examples. Fortunately, Dr. Peter Hauri does include several case studies in chapter 14, but other authors did not. The treatment part of the book is more directed toward a sleep clinic or comprehensive program and is less useful for a single practitioner alone with a tired patient looking for a 15-minute solution. Chapter 6 is about melatonin—fact and fiction—but does provide some useful conclusions such as “Melatonin is more likely to promote sleep when given during the day in the context of accumulated homeostatic sleep drive. It is less likely to promote sleep directly when given at night” (p. 108). Chapter 7, “Long-Term Use of Hypnotic Medications,” is only 6 pages long and is not a comprehensive discussion on pharmacotherapy. This section is the one I found most lacking. I would have liked an additional chapter devoted to general treatment focused on medications and including other modalities. Part III, Special Topics in Insomnia, is more helpful than the title suggests. For example, chapter 9, “Insomnia in Older Adults,” is specific and useful. Using tables and charts as well as text, the principles and conclusions here apply to most adults, not just geriatric individuals. Geriatric-specific topics address nursing-home issues and self-medication with over-the-counter products. The chapter on circadian rhythms has over 300 references and is packed with studies and data. I struggled with these 35 pages, but I can see how it might engross researchers, industrial hygienists, and insomnia aficionados. Part IV, which includes Neuroanatomical Mechanisms of Insomnia, is basic science and research oriented. Although seemingly obscure, these 2 chapters held my attention better than expected. A solid understanding of pharmacotherapy requires a biochemical foundation, and that is what chapter 11 provides. Even if one understands little of the detail and remembers even less, the casual reader will come away with an appreciation of the complexity of sleep neurophysiology, biochemistry, and control mechanisms. Who would have thought that tumor necrosis factor alpha has a role in promoting sleep? The final chapter, on conclusions and future directions, summarizes the book and suggests areas of research from a scientific as well as a public health perspective. I suggest reading it first as an introduction to and guide for the preceding chapters. Overall, Insomnia: Principles and Management is a good book for practitioners interested in sleep disorders and researchers looking for a well-referenced book covering a broad reach of topics. It is not for everybody and not for most medical students, but it would fit well on the shelf of a residency library or sleep scholar. I know more about insomnia than I did before and am glad for it. However, I don't think my clinical practice will change much as a result. So if you are not sure, just buy the book. You can always keep it on your nightstand.