When to Refer Insomnia to a Sleep Clinic
Refer patients with chronic insomnia to a sleep medicine specialist when the diagnosis is uncertain, initial treatment (particularly CBT-I) has failed, or when you suspect other underlying sleep disorders such as sleep apnea or movement disorders. 1
Specific Indications for Sleep Clinic Referral
Primary Referral Triggers
Diagnostic uncertainty: When you cannot clearly establish whether the patient has primary insomnia versus insomnia secondary to another sleep disorder 2, 1
Treatment failure: After attempting first-line cognitive behavioral therapy for insomnia (CBT-I) without adequate response 1
Suspected comorbid sleep disorders: When clinical features suggest obstructive sleep apnea (snoring, witnessed apneas, obesity), periodic limb movement disorder, or other primary sleep disorders 2, 1
Precipitous arousals with violent or injurious behavior: These may indicate REM sleep behavior disorder or other parasomnias requiring polysomnography 2
Excessive daytime sleepiness rather than fatigue: This suggests disorders requiring polysomnography and multiple sleep latency testing, such as narcolepsy or idiopathic hypersomnia 1
When Polysomnography is Indicated
The American Academy of Sleep Medicine specifies that polysomnography is not routinely indicated for uncomplicated chronic insomnia 2. However, refer for sleep study when:
- Reasonable clinical suspicion exists for sleep-related breathing disorders or movement disorders 2
- Initial diagnosis remains uncertain after thorough clinical evaluation 2
- Treatment fails despite appropriate behavioral and pharmacologic interventions 2
- Patient experiences violent or injurious behaviors during sleep 2
Essential Steps Before Referral
Initial Assessment Requirements
Complete sleep logs: Obtain 1-2 weeks of documented bedtime, sleep latency, number of awakenings, wake after sleep onset, time in bed, and total sleep time 1
Medication and substance review: Identify contributors such as SSRIs, stimulants, decongestants, beta-blockers, caffeine, and alcohol 1
Trial of CBT-I: The American College of Physicians strongly recommends CBT-I as initial treatment before considering specialist referral 2
Screening Tools to Complete
- General medical/psychiatric questionnaire to identify comorbid disorders 2
- Epworth Sleepiness Scale to differentiate sleepiness from fatigue and identify comorbid disorders 2
- Two-week sleep diary to establish patterns and variability 2
Critical Pitfalls to Avoid
Common Referral Errors
Assuming purely psychiatric etiology: Do not assume insomnia is exclusively psychiatric without screening for primary sleep disorders like obstructive sleep apnea 1
Delaying referral with significant sleepiness: Sleepiness (not just fatigue) suggests disorders requiring polysomnography and warrants prompt referral 1
Prolonged ineffective treatment: Continuing the same approach for extended periods without specialist input leads to poor outcomes, given insomnia's high relapse rate 1
Pharmacotherapy without behavioral intervention: Relying solely on medications without implementing CBT-I results in inferior long-term outcomes 1
When Insomnia Fails to Remit
Failure to improve after 7-10 days of treatment: This may indicate an unrecognized primary psychiatric or medical illness requiring evaluation 3
Worsening insomnia or new behavioral abnormalities: These may represent consequences of unrecognized psychiatric or physical disorders 3
Alternative Referral Options
When Sleep Medicine Specialists Are Unavailable
Pulmonology referral: Consider if obstructive sleep apnea is suspected and dedicated sleep medicine is unavailable 1
Behavioral health providers trained in CBT-I: Refer to psychologists or other providers specifically trained in CBT-I delivery 1
VA/DoD recommendation: Consultation with sleep medicine specialists is recommended for all patients with sleep disorders, especially when diagnosis is uncertain or treatment proves challenging 1
Treatment Expectations Before Referral
The American Academy of Sleep Medicine defines chronic insomnia as symptoms persisting at least three months at a frequency of at least three times per week 2. Before referring, ensure you have:
- Attempted CBT-I as first-line treatment (strong recommendation, moderate quality evidence) 2
- Considered short-term pharmacotherapy only after CBT-I trial or in conjunction with behavioral therapy 2
- Documented treatment response through repeated sleep diaries during active treatment 2
- Reassessed clinically every few weeks until insomnia appears stable or resolved 2