Peter L. Salgo, MD: You know, this is frustrating. But it is medicine. It’s an art.
Karl Doghramji, MD: It’s the art of medicine.
Peter L. Salgo, MD: It’s tricky. Where are we going? Where are we evolving in terms of the landscape of insomnia? Where are we heading? Where do you think?
Karl Doghramji, MD: I think the next step really will be to try and identify where insomnia comes from. What causes it? Where does it start and why is it there? We really have to zero in on the causes, and we’re very ignorant about that at this point. But I think the second area that we really need to go into is the ability to probe the brain and calm it down—slow it down without necessarily resorting to medication. What that is yet we just don’t understand. Interestingly, there are some devices coming out that can possibly do that, or at least promise to start doing that. For example, there’s a head cooling device, believe it or not.
Peter L. Salgo, MD: Really?
Karl Doghramji, MD: Which has just come out. And the data on it are not that dramatic. But the direction is going towards globally suppressing brain activity.
Peter L. Salgo, MD: Oh man, that would be interesting—a cold head, warm heart? How do they cool the head?
Karl Doghramji, MD: Well it’s a helmet that goes on top of the head, and the entire head cools down.
Peter L. Salgo, MD: I just had this vision of a big helmet in bed, and it doesn’t sound restful to me at all. It’s been great. And I don’t make light of this, it’s a very serious issue. What’s fascinating to me is how much subjective medicine exists, and how artful the medicine is that’s involved. It’s not bacteriology. This is not surgery. This is medicine, and it’s tricky. In the little time that we have before we end this tremendous discussion, I want to give each of you the opportunity to leave us with one thought—one thing you’d like our audience to know. Dr Auerbach, why don’t we start with you?
Sanford H. Auerbach, MD: Insomnia is complex. It’s not a simple thing. And I think it’s really labor-intensive effort on the part of the clinician, to address it with their patients. It needs to be addressed. And the one thing I think that’s oftentimes overlooked is that too often, the emphasis is placed on the sleep minutes—your avatar—rather than being placed on the patient’s quality of life. Instead we’re underestimating the degree of associated anxiety and depression.
Peter L. Salgo, MD: Dr Brandt?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: When we’re working with older adults, paying attention to the benefits versus harm, and doing more studies looking at comparisons among the different agents out there, and appreciating them—even within clinical trials—the use of some of the self-treatment, which I feel is under identified, is very important. But I think we really want to do less harm to our older adults with medications.
Peter L. Salgo, MD: Dr Doghramji?
Karl Doghramji, MD: If I could recommend one thing, which is to try and do a work-up of the patient with insomnia, as much as possible, to identify the comorbidities and treat them. Be as specific and as targeted in your treatment as possible.
Peter L. Salgo, MD: Dr Johnson, the last word.
Gary L. Johnson, MD, MS, MBA: I go back to one of the things that my mentor taught me—he said, “When in doubt, ask the patient.” And what it really means is, take the history, which so often not done, because the history usually can lead you to an appropriate diagnosis, consequently leading to the appropriate treatment.
Peter L. Salgo, MD: Well, this has just been great. This is not a topic I know that I focused on, but it’s something that’s really important. As I look around at the patients and folks in my social circle, it’s something that bothers a lot of people, and which we really haven’t focused on enough. I’m delighted to have had the opportunity to do so with you guys today. I want to thank everybody for your contributions, and on behalf of our panel, I want to thank you for joining us. We hope you found this Peer Exchange discussion to be useful and informative. I’m Dr Peter Salgo, and I’ll see you next time.