What is the recommended approach for taking a medical history in a middle-aged female patient with a history of depression or anxiety presenting with insomnia?

History Taking for Insomnia in Middle-Aged Women with Depression or Anxiety

Begin with two screening questions from the American Academy of Sleep Medicine: (1) "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" and (2) "Does the problem with your sleep negatively affect your daytime functioning?" If both answers are yes, proceed with comprehensive assessment. 1

Initial Sleep Characterization

Core Insomnia Symptoms

• Ask specifically about difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, and nonrestorative/poor quality sleep 2
• Determine the duration: acute (less than 3 months) versus chronic (3 months or longer) 1
• Request a 2-week sleep diary documenting bedtime, wake times, sleep onset latency, number and duration of awakenings, total sleep time, and nap frequency/duration 1, 3
• Consider the Insomnia Severity Index to quantify severity and track treatment response 1

Daytime Consequences

• Assess specific functional impacts beyond general "daytime functioning": employment/work performance, relationships, social withdrawal, ability to drive safely, and cognitive difficulties 3
• Distinguish fatigue from sleepiness—these are different constructs requiring different evaluation approaches 3
• Note that excessive daytime sleepiness is NOT typical of primary insomnia and should prompt investigation for other sleep disorders like obstructive sleep apnea 4

Screening for Comorbid Sleep Disorders

Obstructive Sleep Apnea

• Use the Epworth Sleepiness Scale to screen for excessive daytime sleepiness 1
• Ask about waking with headaches, witnessed breathing pauses, and loud snoring 3
• Obtain collateral history from bed partner about snoring patterns, breathing pauses, and gasping episodes 3

Restless Legs Syndrome

• Ask: "Do you have the urge to move your legs or experience uncomfortable sensations in your legs during rest or at night?" 2, 3
• Inquire about problems controlling leg movements 3

Nocturia

• Ask: "Do you have to get up often to urinate during the night?" 2, 3
• If present, order a 72-hour bladder diary and check electrolytes/renal function, thyroid function, calcium, HbA1c, urine dipstick with albumin:creatinine ratio, and blood pressure 3

Psychiatric and Psychosocial Assessment

Depression and Anxiety Screening

• Patients with depression are 2.5 times more likely to report insomnia, with a bidirectional relationship where insomnia can both precede and result from depression 4
• Screen for generalized anxiety disorder, panic disorder, and post-traumatic stress disorder, all strongly associated with insomnia 4
• Assess for suicidal ideation, particularly important given the dose-dependent increase in suicidal ideation observed with some hypnotics 5
• Recognize that untreated insomnia is a risk factor for new onset and recurrent depression 2

Recent Life Stressors

• Ask: "Have you suffered any personal losses recently?" to identify psychosocial precipitants requiring specific therapeutic attention 2, 3
• Document pre-bedtime stress levels in the sleep diary 3

Medical Comorbidity Review

Cardiovascular and Pulmonary

• Screen for heart disease, chronic obstructive pulmonary disease, and shortness of breath—respiratory symptoms increase insomnia risk by 40% 2, 4
• Ask about ankle swelling and lightheadedness on standing 3

Pain Conditions

• Assess for osteoarthritis, fibromyalgia, neuropathic pain, cancer-related pain, and diabetes-related pain 2, 4

Neurological Disorders

• Screen for Parkinson's disease, Alzheimer's disease, and other neurodegenerative conditions 4

Endocrine and Gastrointestinal

• Ask about excessive thirst, changes in menstrual periods, and nocturnal gastrointestinal symptoms 3, 4

Medication and Substance Use Review

Medications That Cause Insomnia

• SSRIs, venlafaxine, duloxetine, and monoamine oxidase inhibitors (common in this population with depression/anxiety) 4
• Beta-blockers, alpha-receptor agonists/antagonists, diuretics, and lipid-lowering agents 4
• Decongestants (pseudoephedrine, phenylephrine) 4
• Bronchodilators (theophylline, albuterol) 4
• Corticosteroids 1

Substance Use

• Assess caffeine consumption (timing and amount) 3
• Alcohol use—can disrupt sleep architecture and cause sleep fragmentation despite initial sedation 4
• Nicotine use 1
• Over-the-counter sleep aids and recreational drugs 1

Behavioral and Environmental Factors

Sleep Hygiene Assessment

• Document evening meal timing 3
• Assess daily physical activity and exercise patterns 2, 3
• Inquire about daytime napping: frequency, duration, and whether dreaming occurs during naps 2, 3
• Evaluate bedroom environment and pre-sleep routines 3

Objective Measurement Considerations

• Consider actigraphy for at least 7 days when circadian rhythm disorders are suspected or when sleep diary data is unreliable 1, 3
• Polysomnography is NOT routinely indicated for insomnia evaluation unless other sleep disorders (sleep apnea, periodic limb movements) are suspected 6

Critical Pitfalls to Avoid

• Failing to obtain bed partner input—critical observations about snoring, breathing pauses, and limb movements may be missed 3
• Overlooking the bidirectional relationship between insomnia and depression—both conditions can exacerbate each other and require concurrent treatment 4
• Missing medication side effects or substance use as insomnia causes—particularly SSRIs/SNRIs commonly prescribed for depression/anxiety 4
• Neglecting to assess for underlying sleep disorders—sleep apnea or restless legs syndrome masquerading as insomnia leads to treatment failure 4
• Relying solely on subjective reports without objective measures—sleep diaries provide more accurate data than patient recall 3, 6

When to Refer

• If insomnia fails to remit after 7-10 days of appropriate treatment, indicating possible primary psychiatric or medical illness requiring further evaluation 7, 5
• If complex sleep behaviors (sleep-walking, sleep-driving) occur 5
• If severe obstructive sleep apnea or other primary sleep disorders are suspected 5