Sleep Spotlight: Who Needs to Ask About Sleep?

A recent large survey of physicians and individuals with sleep difficulties demonstrates a gap between a highly shared knowledge that sleep is critical to health and a low frequency of discussions about sleep during clinical care. The Wake Up America study¹ was conducted by The Harris Poll online within the US in September and October 2021. Responses were received from 300 primary care physicians, 152 psychiatrists, and 1,001 people who either reported a physician-made diagnosis of insomnia or self-reported significant problems with sleep at least 3 nights per week for at least 3 months. A unique aspect of this survey is that the health care professionals and people with sleep problems were both asked the same questions.

The Importance of Talking About Sleep

The majority of both groups (98% of physicians and 91% of those with sleep difficulties) agreed that sleep is an essential pillar of health. Despite that shared knowledge, however, only 66% of physicians reported speaking about sleep at routine clinical visits, and only 27% of people with trouble sleeping reported their physicians asked them about sleep at every visit. Furthermore, a full sleep history was routinely taken by only 12% of the physicians who answered the survey.

Among the people with sleep problems who did not report a physician-made diagnosis of insomnia, only 57% said that they had spoken with their physician about their sleep difficulties. Although 70% of all people with sleep trouble said they were desperate for better sleep and improved daytime function, only half of those individuals (53%) said they had talked with their doctor about that specific need. Stigma regarding the use of medications to aid sleep was reported by 66% of participants who had used or were using prescription medications for sleep difficulties. Additionally, despite knowing sleep was important, approximately two-thirds of people who had trouble sleeping believed at least 1 myth about sleep.

Together these findings suggest a need for physicians to have more consistent, meaningful (ie, memorable) and educational conversations about sleep with their patients, recognizing that more than half of people with sleep difficulties are not raising the issue on their own. Although the survey was done among primary care physicians and psychiatrists, it is relevant to neurologists considering the increasing evidence that sleep plays a vital role in brain health and can impact the course of several neurologic conditions both directly and indirectly.^2-7

Treatment Beliefs

Although both people with difficulty sleeping and physicians alike endorse that sleep is an essential pillar of health, there are barriers to seeking treatment for sleep problems. As noted, many with sleep difficulties do not raise the issue with their physicians and stigma exists about having sleep difficulties and taking medications for sleep.

The majority of physicians (83%) and people with difficulty sleeping (78%) endorsed the statement that insomnia is a distinct medical condition that calls for treatment. However, approximately two-thirds of people with sleep problems believed that available treatments were not likely to help them. Almost half (44%) shared the incorrect belief that all prescription medications for sleep difficulties have the same mechanism of action (ie, work the same way). Physicians also had concerns about sleep medications, with 31% agreeing that there are no “good” treatments and 50% believing their patients are unsatisfied with the treatments they are receiving for sleep difficulties.

Considering these beliefs about treatment and the desperation for better sleep and daytime function people with sleep problems express, it is perhaps not surprising that the survey findings estimate that people with sleep problems spend an average of $285 annually on products advertised to help them sleep better.^1,2 With an estimated prevalence for insomnia of 25 million people, in the US alone, this potentially could add up to approximately $7.125 billion annually spent on remedies people feel are not helping.

These findings raise questions about what treatments are being used most often as well as the real-world efficacy of those treatments and emphasize the importance of continuing to discuss sleep at every health care visit.

Effects of Poor Sleep

The American Heart Association has recently added sleep as one of the 8 essential cardiovascular health factors,⁷ in recognition of evidence that poor sleep is associated with higher rates of diabetes, vascular diseases, stroke, and dementia.^3,4,6 Poor sleep also affects mood, and in addition to 70% of people with sleep difficulties saying they were desperate for improvement, 54% reported feeling frustration, 52% reported irritability, and 51% reported stress. Increases in anxiety (39%), being emotional (28%), loneliness (19%), and feeling out of control (17%) were also reported.

Daily function is affected by sleep with 29% and 27% of people with sleep difficulties reporting struggles at work or with finances, respectively; 10% reported job loss related to their sleep issues. People with insomnia and other sleep difficulties reported that lack of sleep affected their mood (59%), leaving them frustrated, irritated, and stressed. Many (19%) had relationships with friends and family end because of their sleep problems and 13% said romantic relationships had ended over sleep difficulties.

Sleep Facts and Myths

It is essential to ask about sleep and perform a thorough clinical evaluation of any sleep problems that are reported because there is a great deal of misinformation about sleep and its role in health. In the Wake Up America survey, 74% of people with sleep problems felt they had good knowledge about sleep. However, 63% erroneously believed that it is possible to get used to functioning on less sleep; 61% thought daytime naps could be used to make up for lost sleep at night, and 43% thought lost sleep could be regained on another night. None of these beliefs reflects what we know about sleep deficits and the need for regular sleep.⁸ Conversations about sleep and health should reflect our knowledge that regularity of sleep is as important as having 7 to 9 consecutive hours of sleep per 24-hour period for adults. It can also be pointed out that a minimum of 2 nights of 7 to 9 consecutive hours of sleep is needed to restore function after 1 night of sleep deprivation.^8,9

Limitations of the Survey

Those invited to take the poll were people already registered with The Harris Poll as being willing to take surveys, so this was not a truly random sampling. Patients and physicians were separate samples, rather than dyads of patients and their specific treating physicians.¹

Improving Communication About Sleep

Improving communication about sleep requires dispelling some commonly held misconceptions about sleep, reinforcing the importance of sleep, and educating people that sleep disorders are medical problems that can be treated. Recognizing that stigma and misinformation may prevent patients from raising the topic of sleep, all physicians must ask about sleep in ways that invite patients to openly discuss any sleep difficulty they are having (Box).⁹

Summary

Sleep matters and yet, it seems to be easy for us somehow not to talk about it either as patients or physicians. Future studies are needed to understand why people who report being desperate for relief do not bring it up with their doctors, and education is needed to dispel common myths about sleep. Research on real-world efficacy and education about behavior therapies as well as new pharmacologic treatments with different mechanisms of action and side-effect profiles are also needed. Most importantly, sleep is essential to cardiovascular and neurologic health and neurologists can help to improve clinical care by asking open-ended questions about sleep and taking a sleep history or referring patients to sleep medicine when sleep difficulties are endorsed.