Join Sleep Review’s Sree Roy in conversation with sleep expert Russell P. Rosenberg, PhD, and primary care physician Paul Doghramji, MD, FAAFP about managing insomnia in primary care. They share insights from an expert consensus group and answer the questions:

  • What are the challenges that prevent insomnia from being diagnosed in the primary care setting?
  • Can you provide practical advice on how to fit in insomnia screening and diagnosis into primary care settings?
  • In what circumstances should primary care physicians refer patients to sleep specialists?
  • What are best practices for CBT-I in primary care settings?
  • Why is trazodone so frequently prescribed and is it a good choice for insomnia patients?
  • What is novel about dual orexin receptor antagonists?

For more information on insomnia in primary care, visit:

Podcast Transcript

Sree Roy:

Hello and welcome. I’m Sree Roy with Sleep Review and I’m thrilled to be here with two authors of the recently published paper, A 2023 Update on Managing Insomnia in Primary Care: Insights from an Expert Consensus Group.

Russell P. Rosenberg, PhD, is chief science officer and CEO of NeuroTrials Research Inc and the director of the Atlanta School of Sleep Medicine and Technology in Atlanta, Georgia. Dr. Rosenberg obtained his doctorate in clinical and research psychology from Ohio State University in Columbus and received specialized training in sleep disorder medicine and research at Rush Presbyterian, St. Luke’s Medical Center in Chicago, Illinois.

Paul Doghramji, MD, FAAFP, is the senior family practice physician at Collegeville Family Practice and the medical director of health services at Ursinus College both in Collegeville, Pennsylvania. He is also an attending physician in family practice at Pottstown Memorial Medical Center in Pottstown, Pennsylvania. He is past president co-chair for the National Sleep Foundation Sleep and Health Safety Course and has devoted almost three decades to sleep science and education.

We are chatting about managing insomnia in primary care.

How did the expert consensus group come together? Is it true that a person with insomnia was included too?

Russell P. Rosenberg, PhD:

Yes, the person was included, and essentially the group found several gaps in the literature and understanding of insomnia, not only in primary care but just in healthcare in general. And so we gathered experts in a variety of different fields—sleep research, and primary care medicine, and psychiatry—to try to fill some of those gaps in the publication that you mentioned that was in The Primary Care Companion: CNS Disorders. And so including various specialists from different areas that are really stakeholders in treatment of insomnia was really important to get everyone’s input.

Sree Roy:

What are some of the challenges that prevent insomnia from being diagnosed in the primary care setting?

Paul Doghramji, MD, FAAFP:

Some of the challenges have to do with what primary care providers have as their priorities and are pressing needs. When patients come in, they either come in for a medical problem like hypertension, cholesterol, diabetes, depression, anxiety, pain, that sort of stuff, and you deal with those issues, and there’s a tendency for sleep problems to sort of not come up or get swept under the rug. Although in those medical conditions that I just mentioned, insomnia is so incredibly frequent.

Patients may also come in for acute visits. They fell and hurt something; they have low back pain; they’re getting migraine headaches, et cetera. But even then sleep can be disturbed, but there’s a tendency for primary care to avoid asking questions about how those issues are affecting their sleep.

So I think that it’s just a matter of prioritizing and just not being as aware as primary care providers that sleep could be impacted by all the conditions that they deal with in primary care.

Sree Roy:

Primary care practices don’t typically have much time to spend per patient. Can you provide some practical advice on how to fit in insomnia screening and diagnosis into primary care settings?

Paul Doghramji, MD, FAAFP:

Well, there actually is enough time if you value or if you elevate the level of importance of sleep in your patients. So when a primary care provider is informed enough to know that sleep is a critical aspect of life, that without good sleep so many bad things can happen. But also when the primary care provider knows that when bad things are happening to a patient, like those conditions that I mentioned that it can impact the sleep and cause insomnia. That’s the place to start.

And if the clinician knows that, he or she will be much more apt to ask questions about sleep during a visit. So when a patient comes for depression, at some point you should ask about sleep. If they come in for diabetes, you should ask about sleep. Are you having any problems getting to sleep and/or staying asleep? Do you feel well-rested through the course of the day? Those are very simple questions that don’t take up that much time.

So valuing sleep, making sure that insomnia is very prevalent and needs to be addressed will allow the primary care provider then to have the time—make the time—to ask about sleep.

Russell P. Rosenberg, PhD:

I think Paul makes a great point here that insomnia is really comorbid with many other medical disorders. And that for a long period of time, insomnia was thought to be always secondary or caused by some other disorders. But we’re now looking at it in terms of insomnia being its own disorder independent but can also be comorbid with a lot of disorders including heart disease and some that Paul mentioned.

One screening device that might be of some value to primary care, and I know we use it in the sleep clinics, is the Insomnia Severity Index. It’s a fairly brief questionnaire and it’s used much like some primary care physicians use depression screenings that help them decide whether this rises to the degree of it needing further attention or needing special attention and some resolution to the problem.

Sree Roy:

In what circumstances should primary care physicians refer patients to sleep specialists?

Paul Doghramji, MD, FAAFP:

Well, there are several instances where if a patient is identified with a sleep problem, whether it is insomnia or otherwise, if the primary care provider feels uncomfortable managing the condition, he or she should obviously refer the patient to a sleep specialist. But there are also a couple of other situations that really mandate the primary care provider to refer. If there is suspicion of obstructive sleep apnea, if there is suspicion of periodic limb movement disorder, or if there are parasomnias, or if there’s a suspicion of narcolepsy. These are instances where the primary care provider should refer the patient to a specialist.

Russell P. Rosenberg, PhD:

I would think that some of the disorders specifically that are needing attention beyond the specialty of primary care, the central disorders of hypersomnolence. Paul mentioned narcolepsy, idiopathic hypersomnia, certainly just when patients are sleepy, despite getting what they believe to be a reasonable night’s sleep, should raise an eyebrow or should raise a flag that further investigation is needed.

Sree Roy:

CBT-I, cognitive behavioral therapy for insomnia, is first line therapy for insomnia. What are best practices for CBT-I in primary care settings? Should primary care be delivering CBT-I to their patients, refer them to behavioral sleep specialists, prescribe digital CBT-I programs or something else?

Paul Doghramji, MD, FAAFP:

Many different organizations have suggested that cognitive behavioral therapy for insomnia, CBT-I, should be considered as first line therapy for patients who are suffering from insomnia, especially of the chronic type. It’s been going on more than three months and their symptoms are at least three nights a week. So they’re really doing very badly with their sleep. It should be considered that CBT-I be first line therapy.

The problem with it is that in most parts of this country therapists that do CBT-I are at a premium and they’re very scant. So then the next question comes up, as you asked is: should we in primary care be delivering CBT-I?

Well, most primary care providers are not trained to do it and they’re not getting training to be able to administer CBT-I to their patients. So ostensibly what is turning out is even though CBT-I is very effective for treating insomnia, I mean it’s only four to six weekly sessions that allows a patient to sleep better with those therapy sessions. Even though it’s effective and it’s resilient, it’s just for some reason and for many reasons actually, it’s either impractical or it’s just not done.

So are there digital CBT-I programs? There are some on the web. There are actually even not just programs, but clinicians who will do telemedicine for CBT-I on the web that you can do fee for service. So that’s also going on. But again, it’s a very effective way of doing so, but it’s very infrequently used in primary care.

Russell P. Rosenberg, PhD:

What I found is that in most primary care practices, there isn’t the time or necessarily as Paul said, the expertise. But in some, and I think it’s pretty progressive of them, the nurse practitioner or a PA [physician assistant] or nurse will do some training in CBT-I and be sort of the sleep person in that practice and can provide at least some framework. There are some shortened versions of CBT-I that can be used and have been found to be effective.

The one thing I do want to mention that’s a component of CBT-I is sleep hygiene and probably every primary care physician I know will discuss sleep hygiene with patients and try to make sure they’re not violating any of those sleep hygiene rules that may be perpetuating their insomnia. Unfortunately, most of the literature out there that examines sleep hygiene as a solo type of intervention by itself is not that effective. So a primary care physician may be able to detect some really bad behavior that is contributing to insomnia and make a big difference, but for the chronic insomnia, while sleep hygiene is a necessary, but oftentimes insufficient by itself kind of treatment.

Sree Roy:

Some patients do also use pharmacotherapies for insomnia. I was surprised to read that trazodone is the most frequently prescribed drug for insomnia in the US primary care setting, particularly since it’s not FDA-approved for insomnia. Why is trazodone so frequently prescribed and is it a good choice for insomnia patients?

Paul Doghramji, MD, FAAFP:

Well, there are many reasons why trazodone is first line in primary care. First of all, it is inexpensive and insurances will never have a problem with it. In our day and age when we prescribe brand name products for insomnia that are indicated for insomnia, we often get kickbacks from the insurance that they will not pay for it until a patient tries and fails a generic medication like trazodone. So one of them is just practically speaking, it’s available in a low cost and insurances will pay for it.

The second thing is that the trazodone is unscheduled. A lot of the sleep medications are scheduled products. Like the benzodiazepines, the selective benzodiazepine receptor agonists, the dual orexin receptor antagonists. These are all scheduled medications and there is hesitancy amongst all clinicians including primary care to prescribe something that’s scheduled when there is something that is unscheduled such as trazodone.

So again, even though it is not indicated to treat insomnia—it was invented as an antidepressant—it does have some sedating properties, which help with sleep. And for the reasons that I describe, there’s a huge tendency for it to be used first line, not just amongst primary care providers but also in psychiatry. Trazodone is the number one medication to be used for insomnia.

Sree Roy:

The newest insomnia drugs are dual orexin receptor antagonists. What is novel about these drugs?

Russell P. Rosenberg, PhD:

Well, the dual orexin receptor antagonists provide a completely different mechanism of action from the often used benzodiazepines or benzodiazepine agonists, BCRAs. So these drugs, which are commonly known as DORAs, work a mechanism of action that provides sort of a tamping down of the arousal mechanisms that sometimes inhibit sleep. The typical drugs for sleep, that we’ve known about for years have been used quite a bit, really work to promote the sleep system per se. But these drugs, the DORAs, really do work to reduce the amount of wake signaling, so allowing sleep to occur.

So it’s a completely different mechanism of action they have found to be, they’ve been found relatively safe and without a high abuse potential like some of the previous drugs that have been used in recent years. So they do represent sort of an exciting new direction for sleeping drugs, and I think we’ll see their uptake more in the years to come.

They are scheduled, as Paul mentioned, so many physicians still are not completely comfortable with them or understand them that well. So they’re still a lot of learning or there are gaps in understanding of what this class of drugs does.

Sree Roy:

Is there anything else that either of you would like to add or emphasize about insomnia in the primary care setting?

Paul Doghramji, MD, FAAFP:

I’d like to just mention that since there is a general tendency for the primary care provider to put sleep problems, and specifically insomnia, lower on their interest level that it might be a good idea for patients who suffer from insomnia to bring up the topic themselves. We also know statistically that not only is there a lot of insomnia in patients in primary care, but we also know that the great majority of patients that come to a primary care provider who have insomnia don’t bring it up to their primary care providers. Only about 5% or so will come in if they have insomnia and bring it up with their providers. So I urge anybody with insomnia to bring it up to their primary care provider because that is the best point person to start with figuring out what’s going on with their sleep problem and what to do to remedy it.

Russell P. Rosenberg, PhD:

I would just mention, in addition to what Paul said, it’s not normal to have persistent sleepiness and/or to have persistent problems sleeping at night. It’s not just a part of the normal aging process.

So I really do think that this point about taking sleep seriously and addressing it with your primary care physician is really important. And the flip side is also true. That is, if you’re sleepy during the daytime, whether you’re sleeping well or not, that should be taken seriously and discussed with your primary care physician as well because there are a lot of things that can be done to help these chronic problems.

Sree Roy:

And is there anywhere our audience can go for more information on this topic? Any specific websites, social media handles, that sort of thing?

Russell P. Rosenberg, PhD:

Well, I always point people to the National Sleep Foundation site. I think they’re a good unbiased provider of information about sleep in general, but I do know that they have some information about insomnia specifically. And if any of your listeners want to see the article that Paul and I both authored, again, point them to the Primary Care Companion: CNS Disorders and it was just recently published, and they can read more about our task force and some of the recommendations that we make.

Paul Doghramji, MD, FAAFP:

Yeah, and that website is thensf.org.

Sree Roy:

Excellent. Thank you so much for chatting with us about insomnia in primary care. You can find Sleep Review at sleepreviewmag.com and on LinkedIn, Facebook, Twitter, and YouTube. Thank you so much for tuning in to this episode.