Patient Factors in Treatment Selection

Some sleep disorders, such as narcolepsy, are best treated pharmacologically, whereas others, such as chronic and primary insomnia, are more amenable to behavioral interventions. The management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions. Beyond these general principles, several patient factors should guide the clinician in selecting and designing a treatment plan.

As a first step, the clinician must gauge the patient's acceptance of various treatment modalities. Regardless of how efficacious a particular treatment may be, it will be of little clinical usefulness if it is unacceptable to prospective patients (Morin et al. 1993b). Patients with negative attitudes toward drugs are unlikely to comply with prescribed medications, whereas those who are unwilling to invest time and effort are poor candidates for behavioral interventions. Individuals who are less educated or insightful may be better candidates for concrete behavioral recommendations and for pharmacotherapy, whereas more educated and psychologically minded patients may be more receptive to cognitive and psychotherapeutic interventions.

There are few reliable predictors of treatment outcome for insomnia patients treated with psychological interventions (Bliwise et al. 1995; Lacks and Powlishta 1989; Morin et al. 1994a). Age and gender are unrelated to outcome. In fact, when older adults are carefully screened for underlying sleep disorders such as sleep apnea and periodic limb movements, their response to insomnia treatment is as favorable as that of younger patients (Morin et al. 1993a; Pallesen et al. 1998). The nature (i.e., onset, maintenance, mixed), the severity, and the duration of insomnia are not consistently related to outcome. In general, patients who are not using hypnotic medications and who have no concurrent psychiatric disorders have a better treatment response than do medicated patients or those with psychiatric disorders. Nonetheless, the presence of psychiatric disorders or prolonged use of hypnotic medications should not preclude treatment specifically targeting the sleep complaint because some emerging evidence suggests that these patients, often those most in need of treatment, may also benefit from a sleep-focused intervention (Dashevsky and Kramer 1998; Morin et al. 1994b; Riedel et al. 1998).