'How is your sleep?' collects an opinion. 'What time did you fall asleep and what time did you wake, each of the last three days?' collects data, and it takes about the same twenty seconds.
The answers separate things that look alike and are treated differently. Early-morning waking with a normal sleep onset points somewhere different from a two-hour sleep latency with a normal wake time; a person sleeping from 04:00 to noon has a phase problem rather than insomnia; a shrinking sleep requirement with rising energy in someone with bipolar disorder is the earliest reliable sign of a switch, and it appears before mood or speech change. The same question also catches the patient who is taking a sedating antipsychotic at breakfast, and the one whose 'insomnia' is four cups of tea after 20:00.
Write the times in the notes. A sequence of clock times across visits is the most useful longitudinal measure in a psychiatric record, and it costs nothing to collect.
- Ask for clock times - sleep onset and wake - for the last three days, every review
- Record them in the notes so the trend is visible at the next visit
- Treat a falling sleep requirement with rising energy in bipolar disorder as an early switch signal
- Separate delayed phase from insomnia before prescribing a hypnotic
- Check when sedating medication is actually being taken, not when it was prescribed for
Why it matters
The same complaint of poor sleep hides a phase disorder, an early switch and a caffeine habit, and only the times tell them apart.
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