EFFECTS OF DIAGNOSIS ON TREATMENT RECOMMENDATIONS IN CHRONIC INSOMNIA-A REPORT FROM THE APA NIMH DSM-IV FIELD TRIAL/

The objective of this study was to determine whether sleep specialists and nonspecialists recommend different treatments for different insom nia diagnoses according to two different diagnostic classifications. T wo hundred sixteen patients with chronic insomnia at five sites were e ach interviewed by two clinicians: one sleep specialist and one nonsle ep specialist. All interviewers indicated diagnoses using the Diagnost ic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) ; sleep specialists also indicated diagnoses according to the Internat ional Classification for Sleep Disorders (ICSD). Interviewers then ind icated how strongly they would recommend each item in a standard list of treatment and diagnostic interventions for each patient. We examine d differences in treatment recommendations among the six most common D SM-IV diagnoses assigned by sleep specialists at different sites (n = 192), among the six most common ICSD diagnoses assigned by sleep speci alists at different sites (n = 153), and among the six most common DSM -IV diagnoses assigned by nonspecialists at different sites (n = 186). In each analysis, specific treatment and polysomnography recommendati ons differed significantly for different diagnoses, using either DSM-I V or ICSD criteria. Conversely, different diagnoses were associated wi th different rank orderings of specific treatment and diagnostic recom mendations. Sleep specialist and nonspecialist interviewers each disti nguished treatment recommendations among different diagnoses, but in g eneral, nonspecialists more strongly recommended medications and relax ation treatments. Significant site-related differences in treatment re commendations also emerged. Differences in treatment recommendations s upport the distinction between different DSM-IV and ICSD diagnoses, al though they do not provide formal validation. Site-related differences suggest a lack of consensus in how these disorders are conceptualized and treated.