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1.  Prevalence of restless leg syndrome in subjects with depressive disorder 
Indian Journal of Psychiatry  2013;55(1):70-73.
Restless legs syndrome (RLS) is known to be associated with depression. We hypothesized that RLS in depression is linked to the severity, duration, and frequency of depressive episodes.
Materials and Methods:
Subjects fulfilling DSM-IV-TR criteria of depressive disorders were included in this study after seeking informed consent. Using structured interview of MINI-Plus their demographic data and history were recorded. Severity of depression was assessed with the help of HAM-D. Insomnia was diagnosed following ICSD-2 criteria. RLS was diagnosed according to IRLSSG criteria. Descriptive statistics, Chi-square test, independent sample t test and MANOVA were computed with the help of SPSS v 17.0.
RLS was reported by 31.48% of sample. There was no gender difference in prevalence of RLS (X2 =0.46; P=0.33). There was no difference in the age , total duration of depressive illness and number of depressive episodes between RLS and non-RLS groups (F=0.44; P=0.77; Wilk's Lambda=0.96). The HAM-D score was higher in the non-RLS group (P=0.03). Onset of RLS symptoms was not related to onset of depressive symptoms.
RLS is prevalent in depressive disorder. However, onset of RLS is unrelated to age and number or duration of depressive disorders.
PMCID: PMC3574459  PMID: 23439849
Adults; depression; prevalance; restless leg syndrome
2.  Prevalence of insomnia and its impact on daily function amongst Malaysian primary care patients 
Insomnia is a common public health problem and the prevalence and impact of insomnia in primary care attendees is not well documented in the Asian population.
To determine the prevalence of self-reported insomnia symptoms amongst adult primary care attendees and the association with socio-demographic factors; to ascertain the impact of insomnia on daily functioning and to describe the psychological profile of patients with insomnia.
In this cross-sectional survey, 2049 adult patients (≥18 year old) attending seven primary care clinics in Peninsular Malaysia, completed the questionnaire asking about symptoms of insomnia (defined according to the International Classification of Sleep Disorders and DSM IV criteria) daytime impairment and psychological symptoms (assessed by Hospital Anxiety and Depression Scale).
The response rate was 86.2%. A total of 60% reported insomnia symptoms, 38.9% had frequent insomnia symptoms (>3 times per week), 30.7% had chronic insomnia without daytime consequences and 28.6% had chronic insomnia with daytime dysfunction. Indian ethnicity (OR 1.79; 95%CI, 1.28-2.49), age ≥ 50 or older (OR 1.82; 95%CI, 1.10-3.01), anxiety symptoms (OR 1.65; 95%CI, 1.21-2.22) and depression symptoms (OR 1.65; 95%CI, 1.21-2.26) were risk factors for chronic insomnia with daytime dysfunction. Amongst those with chronic insomnia with daytime dysfunction, 47.8% had anxiety symptoms (OR, 2.01; 95%CI, 1.57-2.59) and 36.5% had depression symptoms (OR, 2.74; 95%CI, 2.04-3.68) based on HADs score. They also had tendency to doze off while driving and to be involved in road traffic accidents.
A third of primary care attendees have insomnia symptoms and chronic insomnia, associated with significant daytime dysfunction and psychological morbidity. By identifying those at risk of having chronic insomnia, appropriate interventions can be commenced.
PMCID: PMC3541070  PMID: 23186221
Insomnia; Psychological morbidity; Prevalence; Primary care; Malaysia
3.  Relationship between Personality and Insomnia in Panic Disorder Patients 
Psychiatry Investigation  2011;8(2):102-106.
Panic disorder (PD) is frequently comorbid with insomnia, which could exacerbate panic symptoms and contribute to PD relapse. Research has suggested that characteristics are implicated in both PD and insomnia. However, there are no reports examining whether temperament and character affect insomnia in PD. Thus, we examined the relationship between insomnia and personality characteristics in PD patients.
Participants were 101 patients, recruited from 6 university hospitals in Korea, who met the DSM-IV-TR criteria for PD. We assessed sleep outcomes using the sleep items of 17-item Hamilton Depression Rating Scale (HAMD-17)(item 4=onset latency, item 5=middle awakening, and item 6=early awakening) and used the Cloninger's Temperament and Character Inventory-Revised-Short to assess personality characteristics. To examine the relationship between personality and insomnia, we used analysis of variance with age, sex, and severity of depression (total HAMD scores minus sum of the three sleep items) as the covariates.
There were no statistical differences (p>0.1) in demographic and clinical data between patients with and without insomnia. Initial insomnia (delayed sleep onset) correlated to a high score on the temperamental dimension of novelty seeking 3 (NS3)(F1,96=6.93, p=0.03). There were no statistical differences (p>0.1) in NS3 between patients with and without middle or terminal insomnia.
The present study suggests that higher NS3 is related to the development of initial insomnia in PD and that temperament and character should be considered when assessing sleep problems in PD patients.
PMCID: PMC3149103  PMID: 21852985
Personality; Temperament; Character; Insomnia; Panic disorder
4.  Primary headaches in restless legs syndrome patients 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S104-S108.
Earlier studies conducted among migraineurs have shown an association between migraine and restless legs syndrome (RLS). We chose RLS patients and looked for migraine to exclude sample bias.
Materials and Methods:
99 consecutive subjects of idiopathic RLS were recruited from the sleep clinic during four months period. Physician diagnosis of headache and depressive disorder was made with the help of ICHD-2 and DSM-IV-TR criteria, respectively. Sleep history was gathered. Severity of RLS and insomnia was measured using IRLS (Hindi version) and insomnia severity index Hindi version, respectively. Chi-square test, one way ANOVA and t-test were applied to find out the significance.
Primary headache was seen in 51.5% cases of RLS. Migraine was reported by 44.4% subjects and other types of ‘primary headaches’ were reported by 7.1% subjects. Subjects were divided into- RLS; RLS with migraine and RLS with other headache. Females outnumbered in migraine subgroup (χ2=16.46, P<0.001). Prevalence of depression (χ2=3.12, P=0.21) and family history of RLS (χ2=2.65, P=0.26) were not different among groups. Severity of RLS (P=0.22) or insomnia (P=0.43) were also similar.
Migraine is frequently found in RLS patients in clinic based samples. Females with RLS are prone to develop migraine. Depression and severity of RLS or insomnia do not affect development of headache.
PMCID: PMC3444227  PMID: 23024558
Migraine; primary headache; restless legs syndrome
5.  Assessing depression symptoms in those with insomnia: An examination of the Beck Depression Inventory Second Edition (BDI-II) 
Journal of psychiatric research  2008;43(5):576-582.
Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the Beck Depression Inventory (BDI-II) has been assessed in various medical populations. Although Major Depressive Disorder (MDD) and Primary Insomnia (PI) share some daytime symptoms, the BDI-II has not been evaluated for use with insomnia patients.
Participants (N = 140) were screened for the presence of insomnia using the Duke Structured Clinical Interview for Sleep Disorders (DSISD), and evaluated for diagnosis of MDD using the Structured Clinical Interview for DSM-IV-TR (SCID). Participants’ mean BDI-II item responses were compared across two groups [insomnia with or without MDD) using multivariate analysis of variance (MANOVA), and the accuracy rates of suggested clinical cutoffs for the BDI-II were evaluated using a Receiver Operating Characteristic (ROC) curve analysis.
The insomnia with depression group had significantly higher scores on several items; however, the groups did not differ on insomnia, fatigue, concentration problems, irritability, libido, increased appetite, and thoughts relating to suicide, self-criticism and punishment items. The ROC curve analysis revealed moderate accuracy for the BDI-II’s identification of depression in those with insomnia. The suggested BDI cutoff of ≥ 17 had 81% sensitivity and 79% specificity. Use of the mild cutoff for depression (≥14) had high sensitivity (91%) but poor specificity (66%).
Several items on the BDI-II might reflect sleep disturbance symptoms rather than depression per se. The recommended BDI-II cutoffs in this population have some support but a lower cutoff could result in an overclassification of depression in insomnia patients, a documented problem in the clinical literature. Understanding which items discriminate insomnia patients without depression may help address this nosological issue.
PMCID: PMC2677199  PMID: 18954876
Insomnia; Major Depressive Disorder; Insomnia Assessment; Depression Assessment
To provide information on the profile, comorbidity and impact of insomnia among an understudied group of elderly Africans.
Using the WHO Composite International Diagnostic Interview (CIDI), the 12-month prevalence of three forms of insomnia was assessed in face-to-face interviews conducted with a regionally-representative sample of elderly Nigerians, aged 65 years and over (n=2152). The association of insomnia with quality of life, rated with the WHO Quality of Life instrument, was analyzed controlling for comorbid chronic pain, chronic medical conditions and DSM-IV major depressive disorder.
At least one insomnia problem was reported by 30.72%. Insomnia was more frequent among females, persons aged 70 years and over, and those who were unmarried. Insomnia was comorbid with major depressive disorder (OR = 3.9, 95% CI 2.5 – 6.1), chronic pain (OR = 4.3, 95% CI 3.2 – 6.1; particularly arthritis and spinal pain), and chronic medical conditions (OR = 2.1, 95% CI 1.8 – 2.5, particularly heart disease, high blood pressure or asthma). Persons with insomnia were more likely to report having had a fall in the previous year (OR = 1.4, 95% CI 1.0 – 1.8) and, among those with fall, injury was more commonly reported by those with insomnia. Every form of insomnia was associated with decrement in quality of life. After controlling for comorbid mental and physical conditions, the β coefficients ranged between −17.9 and −20.0.
Insomnia was highly comorbid with chronic physical conditions and with depression. These comorbid conditions partly but do not entirely account for the considerable decrement in quality of life associated with insomnia.
PMCID: PMC2820713  PMID: 19156751
Insomnia; Elderly; Community; Impairment
7.  Insomnia and Objectively Measured Sleep Disturbances Predict Treatment Outcome in Depressed Patients Treated with Psychotherapy or Psychotherapy-Pharmacotherapy Combinations 
Insomnia and objectively measured sleep disturbances predict poor treatment outcomes in patients with major depressive disorder (MDD). However, prior research has utilized individual clinical trials with relatively small sample sizes and has focused on insomnia symptoms or objective measures, but not both. The present study is a secondary analysis that examines the degree to which insomnia, objective sleep disturbances, or their combination, predicts depression remission following pharmacotherapy and/or psychotherapy treatment.
Participants were 711 depressed patients drawn from six clinical trials. Remission status, defined as a score of ≤ 7 on the Hamilton Rating Scale for Depression (HDRS) over two consecutive months, served as the primary outcome. Insomnia was assessed via the 3 sleep items on the HDRS. Objectively measured short sleep duration (total sleep time < = 6 hours), and prolonged sleep latency (SL >30 minutes) or wakefulness after sleep onset (WASO>30) were derived from in-laboratory polysomnographic (PSG) sleep studies. Logistic regression predicted the odds of non-remission according to insomnia, each of the objective sleep disturbances, or their combination, after adjusting for age, sex, treatment modality, and baseline depressive symptoms.
Prolonged sleep latency alone (OR = 1.82; CI: 1.23, 2.70) or in combination with insomnia (OR = 2.03; CI: 1.13, 3.95) predicted increased risk of non-remission. In addition, insomnia and sleep duration individually and in combination were each associated with a significantly increased risk of non-remission (p’s < .05).
Findings suggest that objectively measured prolonged sleep latency and short sleep duration independently, or in conjunction with insomnia are risk factors for poor depression treatment outcome.
PMCID: PMC3310298  PMID: 22152403
8.  Cognitive behavioral therapy for insomnia in euthymic bipolar disorder: study protocol for a randomized controlled trial 
Trials  2014;15:24.
Patients with bipolar disorder experience sleep disturbance, even in euthymic phases. Changes in sleep pattern are frequent signs of a new episode of (hypo)mania or depression. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for primary insomnia, but there are no published results on the effects of CBT-I in patients with bipolar disorder. In this randomized controlled trial, we wish to compare CBT-I and treatment as usual with treatment as usual alone to determine its effect in improving quality of sleep, stabilizing minor mood variations and preventing new mood episodes in euthymic patients with bipolar disorder and comorbid insomnia.
Patients with euthymic bipolar I or II disorder and insomnia, as verified by the Structured Clinical Interview for DSM Disorders (SCID-1) assessment, will be included. The patients enter a three-week run-in phase in which they complete a sleep diary and a mood diary, are monitored for seven consecutive days with an actigraph and on two of these nights with polysomnography in addition before randomization to an eight-week treatment trial. Treatment as usual consists of pharmacological and supportive psychosocial treatment. In this trial, CBT-I will consist of sleep restriction, psychoeducation about sleep, stabilization of the circadian rhythm, and challenging and correcting sleep state misperception, in three to eight sessions.
This trial could document a new treatment for insomnia in bipolar disorder with possible effects on sleep and on stability of mood. In addition, more precise information can be obtained about the character of sleep disturbance in bipolar disorder.
Trial registration NCT01704352.
PMCID: PMC3903553  PMID: 24433249
Bipolar disorder type I and II; CBT-I; Cognitive behavioral therapy; Euthymic; Insomnia; Randomized controlled trial
9.  Depressive symptoms in Parkinson’s disease and in non-neurological medical illnesses 
Patients with neurological and non-neurological medical illnesses very often complain of depressive symptoms that are associated with cognitive and functional impairments. We compared the profile of depressive symptoms in Parkinson’s disease (PD) patients with that of control subjects (CS) suffering from non-neurological medical illnesses.
One-hundred PD patients and 100 CS were submitted to a structured clinical interview for identification of major depressive disorder (MDD) and minor depressive disorder (MIND), according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), criteria. The Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI) were also administered to measure depression severity.
When considering the whole groups, there were no differences in depressive symptom frequency between PD and CS apart from worthlessness/guilt, and changes in appetite reduced rates in PD. Further, total scores and psychic and somatic subscores of HDRS and BDI did not differ between PD and CS. After we separated PD and CS in those with MDD, MIND, and no depression (NODEP), comparing total scores and psychic/somatic subscores of HDRS and BDI, we found increased total depression severity in NODEP PD and reduced severity of the psychic symptoms of depression in MDD PD, with no differences in MIND. However, the severity of individual symptom frequency of depression was not different between PD and CS in MDD, MIND, and NODEP groups.
Although MDD and MIND phenomenology in PD may be very similar to that of CS with non-neurological medical illnesses, neurological symptoms of PD may worsen (or confound) depression severity in patients with no formal/structured DSM-IV-TR, diagnosis of depressive mood disorders. Thus, a thorough assessment of depression in PD should take into consideration the different impacts of neurological manifestations on MDD, MIND, and NODEP.
PMCID: PMC3615851  PMID: 23569379
Parkinson’s disease; neuropsychiatry; depression; nonmotor symptoms
10.  The relationship of primary health care use with persistence of insomnia: a prospective cohort study 
BMC Family Practice  2012;13:8.
Prevalence of insomnia symptoms in the general population is high. Insomnia is linked with high health care use and within primary care there are a number of treatment options available. The objective of this study was to determine the association of persistence and remission of insomnia with primary health care using a longitudinal study.
A postal survey of registered adult (over 18 years) populations of five UK general practices, repeated after 1 year, linked to primary care records. Baseline survey responders were assessed for persistence of insomnia symptoms at 12 months. The association of primary care consultation or prescription for any mood disorder (defined as anxiety, depression, stress, neurosis, or insomnia) in the 12 months between baseline and follow-up surveys with persistence of insomnia was determined.
474 participants reporting insomnia symptoms at baseline were followed up at 12 months. 131(28%) consulted for mood problem(s) or received a relevant prescription. Of these 100 (76%) still had insomnia symptoms at one year, compared with 227 (66%) of those with no contact with primary care for this condition (OR 1.37; 95% CI 0.83, 2.27). Prescription of hypnotics showed some evidence of association with persistence of insomnia at follow-up (OR 3.18; 95% CI 0.93, 10.92).
Insomniacs continue to have problems regardless of whether or not they have consulted their primary care clinician or received a prescription for medication over the year. Hypnotics may be associated with persistence of insomnia. Further research is needed to determine more effective methods of identifying and managing insomnia in primary care. There may however be a group who have unmet need such as depression who would benefit from seeking primary health care.
PMCID: PMC3293729  PMID: 22340760
Primary health care; Insomnia; Persistence; Cohort study
11.  Subjective and objective evaluation of alertness and sleep quality in depressed patients 
BMC Psychiatry  2004;4:14.
The reliability of the subjective statements reports on disturbed night sleep and alertness in the daytime was assessed by their correlation to the objective indicators in patients with mild deprsssion.
Among patients with depression, altogether 28 patients with insomnia were examined. Their answers to typical questions, as they are used during a psychiatric interview, were scored. In parallel, night sleep quality and alertness level in the daytime were objectively estimated by means of polygraphic recording.
The subjective statements on the type of insomnia, the estimated time of falling asleep, frequent awakenings and occurrence of disturbing dreams seem to be unreliable. Similarly, the results were disappointing when the patients were asked about alertness disturbances in the daytime. An unexpected finding was the lack of any significant correlation to the scores obtained by means of Epworth's scale. Among the factors possibly influencing the patients' reports, age, sex, coffee intake and also chronic administration of sedatives or hypnotics showed a low correlation with the sleep and alertness indicators.
The statistical evaluation indicated rather poor agreement between the subjective and objective items. The statistical evaluation suggested that anxiety and depression significantly influence reports on sleep quality and alertness disturbances in the daytime.
PMCID: PMC442129  PMID: 15163350
12.  Delayed sleep phase syndrome in adolescents: prevalence and correlates in a large population based study 
BMC Public Health  2013;13:1163.
The aims of this study were to estimate the prevalence of Delayed Sleep Phase Syndrome (DSPS) in adolescence, and to examine the association to insomnia and school non-attendance.
Data stem from a large population based study in Hordaland County in Norway conducted in 2012, the ung@hordaland study. In all, 10,220 adolescents aged 16–18 years (54% girls) provided self-reported data on a range of sleep parameters: DSPS was defined according to the International Classification of Sleep Disorders, Revised (ICSD-R) criteria, while insomnia was defined according to the Quantitative Criteria for Insomnia. Other sleep parameters included time in bed, sleep duration, sleep efficiency, oversleeping, sleep onset latency, wake after sleep onset, subjective sleep need, sleep deficiency, sleepiness and tiredness. Sleep data were calculated separately for weekdays and weekends. Data on school non-attendance were provided by official registers.
The prevalence of DSPS was 3.3%, and significantly higher among girls (3.7%) than boys (2.7%). There was a strong overlap between DSPS and insomnia, with more than half of the adolescents with DSPS also meeting the criteria for insomnia (53.8% for boys and 57.1% for girls). Adolescents with DSPS had significantly higher odds ratios (OR) of non-attendance at school. After adjusting for sociodeographical factors, insomnia and depression, the adjusted ORs for days of non-attendance were OR = 3.22 (95% CI: 1.94-5.34) for boys and OR = 1.87 (95% CI: 1.25-2.80) for girls. A similar effect was found for hours of non-attendance for boys, with an adjusted OR = 3.05 (95% CI: 1.89-4.92). The effect for girls was no longer significant after full adjustment (OR =1.48 [95% CI: 0.94-2.32]).
This is one of the first studies to estimate the prevalence of DSPS in adolescents. The high prevalence of DSPS, and overlap with insomnia, in combination with the odds of school non-attendance, suggest that a broad and thorough clinical approach is warranted when adolescents present with symptoms of DSPS.
PMCID: PMC3878844  PMID: 24330358
Delayes sleep phase syndrome; Sleep; Prevalence; Correlates; Epidemiology
13.  The Effect of Interpersonal Psychotherapy for Depression on Insomnia Symptoms in a Cohort of Women with Sexual Abuse Histories 
Journal of traumatic stress  2009;22(6):634-638.
Insomnia frequently occurs with trauma exposure and depression, but can ameliorate with improvements in depression. Insomnia was assessed by the insomnia subscale of the Hamilton Rating Scale for Depression in 106 women with childhood sexual abuse (CSA) and major depression receiving Interpersonal Psychotherapy in an uncontrolled pilot (n = 36) and an immediately subsequent randomized controlled trial (n = 70) comparing IPT to treatment as usual. Depression improved in each study and in both treatment conditions; insomnia had smaller, non-significant improvements. Overall, 95 women (90%) endorsed insomnia on the Structured Clinical Interview for DSM-IV at baseline and, of those, 90% endorsed insomnia following treatment. Despite improvements in depression, insomnia persists for most women with CSA.
PMCID: PMC2798908  PMID: 19885874
14.  Comparison of Two Assessment Tools That Measure Insomnia: The Insomnia Severity Index and Polysomnography 
Insomnia is a common sleep disorder, characterized by difficulties in sleep initiation, sleep maintenance or early morning awakening. Although polysomnography (PSG) is a standard method in the evaluation of sleep disorders, it is not recommended for routine use in the clinical assessment of insomnia. Instead, standard questionnaires could be used in the primary evaluation of insomnia.
The main object of this study was to compare the type and severity of patients’ subjective complaints of insomnia gathered from insomnia severity index (ISI) questionnaire with the result of their polysomnographic evaluation.
Materials and Methods:
In this cross-sectional study conducted during 2010-2011 in Iran, all patients in one clinic with sleep disorders were evaluated. The study consisted of self-administered questionnaires completed by participants to provide information on demographic characteristics and ISI questionnaire. After completing the questionnaire, all the participants underwent standard overnight PSG.
Subjects were 151 patients (47.2 ± 10.8 years old). The average ISS was 6.1 ± 4. There was a significant relationship between the subjective complaint of difficulty in sleep initiation and sleep onset latency in PSG (r = 0.5, P < 0.001). Furthermore, there was a correlation between the subjective complaint of difficulty in sleep maintenance and number of awakening in PSG (r = 0.19, P = 0.01). A low patients’ satisfaction from their sleep was associated with lower total sleep time (r = −0.2, P = 0.02) and a lower percentage of rapid eye movement (REM) sleep in their PSG study (r = −0.25, P = 0.002). No relation was found between patients’ satisfaction and sleep efficiency measured with PSG (r = −0.04, P = 0.6).
Our findings suggest that objective insomnia, measured with ISI, is related with PSG variables and ISI could be a useful tool to quantify perceived insomnia severity. Further studies are needed to determine the sensitivity and specificity of this questionnaire.
PMCID: PMC3959020
Insomnia; insomnia severity index; polysomnography
15.  Prevalence and Clinical Correlates of Insomnia in Depressive Disorders: The CRESCEND Study 
Psychiatry Investigation  2013;10(4):373-381.
To investigate the prevalence, clinical manifestations, and clinical correlates of insomnia in a large cohort of Korean patients with depressive disorders.
We recruited 944 patients with depressive disorders from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Psychometric scales were used to assess depression (HAMD), anxiety (HAMA), psychotic symptoms (BPRS), global severity (CGI-S), and functioning (SOFAS). Insomnia levels were determined by adding the scores for all items on the HAMD insomnia subscale. The clinical characteristics of the patients with 'low insomnia' (summed score ≤3 on the HAMD subscale) and 'high insomnia' (score ≥4) were compared using statistical analyses. A logistic regression model was constructed to identify factors associated with 'high insomnia' status.
Symptoms of insomnia were present in 93% of patients, while simultaneous early, middle, and late insomnia affected 64.1%. The high insomnia patients were characterized by significantly greater age, higher symptom levels (including core, gastrointestinal somatic and anxiety symptoms, and suicidal ideation), higher global severity and incidence of physical disorders, and greater insight. Explanatory factors of 'high insomnia' status were older age, higher gastrointestinal somatic and anxiety symptom levels, higher global severity, and greater insight.
In clinical psychiatry, insomnia has been significantly underdiagnosed and undertreated. It affects most patients with depressive disorders, and is indicative of the global severity of depression. Active efforts to diagnose and treat insomnia in patients with depressive disorders should be strongly encouraged. Further research is needed to improve the diagnosis and treatment of insomnia in depressive patients.
PMCID: PMC3902155  PMID: 24474986
Insomnia; Depressive disorders; Anxiety symptoms; Gastrointestinal somatic symptoms; Global severity
16.  Healthcare use in adults with insomnia: a longitudinal study 
Insomnia is common and associated with high rates of anxiety and depression.
To determine the association of insomnia with future primary care for sleep and mood problems, and explore the link with psychological distress.
Design of study
Questionnaire survey of adults aged ≥18 years, linked to primary care records.
Five UK general practices.
Survey responses were linked to recorded consultations and prescribed medication for sleep and mood problems for 12 months following the survey. Baseline self-reported insomnia was defined as the presence of at least one of four sleep problems. Psychological distress was measured using the Hospital Anxiety and Depression Scale.
A total of 2662 (56%) responded and 2192 (82%) consented to record review. Nineteen per cent had a subsequent recorded consultation or prescription for sleep or mood problems (‘relevant healthcare use’). Self-reported insomnia was related to future relevant healthcare use (odds ratio = 1.77; 95% confidence interval = 1.35 to 2.33). This relationship was stronger in those with psychological distress. Sixty-three per cent of those with baseline insomnia and psychological distress had no relevant healthcare use. ‘Trouble falling asleep’ was most strongly associated with relevant healthcare use in persons without psychological distress; in persons with psychological distress, it was waking after a usual amount of sleep feeling tired and worn out.
Specific symptoms of insomnia are associated with consultation for sleep or mood problems, regardless of the presence of anxiety and depression. There is a large group of people who have combined insomnia and anxiety or depression who do not contact primary care about either sleep or mood problems.
PMCID: PMC2858531  PMID: 20423585
anxiety; depression; insomnia; longitudinal study; primary care
17.  The societal costs of insomnia 
Insomnia can be broadly defined as difficulty initiating or maintaining sleep, or sleep that is not refreshing or of poor quality with negative effect on daytime function. Insomnia can be a primary condition or comorbid to an underlying disorder. Subjective measures of insomnia used in population studies, usually based on complaints of unsatisfactory sleep, put the prevalence at about 10%. Insomnia is more common in the elderly and in women, and is often associated with medical and psychiatric disorders. This review examines the measures used to assess quality of sleep (QOS) and daytime functioning and the impact of insomnia on society using these measures.
Literature searches were performed to identify all studies of insomnia (primary and comorbid) in adults (aged 18–64 years) and the elderly (aged ≥ 65 years) with baseline and/or outcomes relating to QOS or daytime functioning. The impact of poor QOS on quality of life (QOL), psychomotor and cognitive skills, health care resource utilization, and other societal effects was examined.
Although definitions and measurement scales used to assess sleep quality vary widely, it is clear that the societal consequences of insomnia are substantial and include impaired QOL and increased health care utilization. The impact of poor QOS and impaired daytime functioning common in insomnia can lead to indirect effects such as lower work productivity, increased sick leave, and a higher rate of motor vehicle crashes.
Insomnia is associated with substantial direct and indirect costs to society. It is almost impossible to separate the costs associated with primary and comorbid insomnia. More studies are required which control for the severity of any primary disorder to accurately evaluate the costs of comorbid insomnia. Development of standardized diagnostic and assessment scales will enable more accurate quantification of the true societal burden of insomnia and will contribute to greater understanding of this disorder.
PMCID: PMC3035597  PMID: 21326650
insomnia; quality of sleep; societal cost; quality of life; health care resource utilization
18.  Daytime symptom patterns in insomnia sufferers: is there evidence for subtyping insomnia? 
Journal of sleep research  2011;20(3):425-433.
The type and severity of daytime symptoms reported by insomnia sufferers may vary markedly. Whether distinctive daytime symptom profiles are related to different insomnia diagnoses has not been studied previously. Using profile analysis via multidimensional scaling, we investigated the concurrent validity of ICSD-2 insomnia diagnoses by analysing the relationship of prototypical profiles of daytime symptoms with a subset of ICSD-2 diagnoses, including insomnia associated to a mental disorder, psychophisiological insomnia, paradoxical insomnia, inadequate sleep hygiene, idiopathic insomnia, obstructive sleep apnea and restless legs syndrome. In a sample of 332 individuals meeting research diagnostic criteria for insomnia (221 women, Mage=46 yrs.), the profile analysis identified four prototypical patterns of daytime features. Pearson correlation coefficients indicated that the diagnoses of insomnia associated to a mental disorder and idiopathic insomnia were associated with a daytime profile characterized by mood disturbance and low sleepiness; whereas the diagnoses of psychophysiological insomnia and inadequate sleep hygiene were related to a profile marked by poor sleep hygiene, daytime tension and low fatigue. Furthermore, whereas paradoxical insomnia was consistently associated to lower daytime impairment, insomnia associated to a mental disorder was related to the most severe daytime impairment. This classification of insomnia sufferers along multiple defining dimensions provides initial validation for two basic insomnia subtypes, with a presumably distinct aetiology: insomnia characterized mainly by an “internal” component, and a “learned” insomnia. Research to determine which dimensions are critical for inclusion or differential weighting for defining a general typological system for insomnia sufferers is warranted.
PMCID: PMC3135706  PMID: 21205038
Insomnia; ICSD-2; Daytime symptoms; Concurrent validity
19.  Personality Disorder Features and Insomnia Status amongst Hypnotic-Dependent Adults 
Sleep medicine  2012;13(9):1122-1129.
To determine the prevalence of personality disorders and their relation to insomnia parameters among persons with chronic insomnia with hypnotic dependence.
Eighty-four adults with chronic insomnia with hypnotic dependence completed the SCID-II personality questionnaire, two-weeks of sleep diaries, polysomnography, and measures of insomnia severity, impact, fatigue severity, depression, anxiety, and quality of life. Frequencies, between-subjects t-tests and hierarchical regression models were conducted.
Cluster C personality disorders were most prevalent (50%). Obsessive-compulsive personality disorder (OCPD) was most common (n=39). These individuals compared to participants with no personality disorders did not differ in objective and subjective sleep parameters. Yet, they had poorer insomnia-related daytime functioning. OCPD and Avoidant personality disorders features were associated with poorer daytime functioning. OCPD features were related to greater fatigue severity, and overestimation of time awake was trending. Schizotypal and Schizoid features were positively associated with insomnia severity. Dependent personality disorder features were related to underestimating time awake.
Cluster C personality disorders were highly prevalent in patients with chronic insomnia with hypnotic dependence. Features of Cluster C and A personality disorders were variously associated with poorer insomnia-related daytime functioning, fatigue, and estimation of nightly wake-time. Future interventions may need to address these personality features.
PMCID: PMC3474889  PMID: 22938862
insomnia; hypnotic-dependence; personality disorders; Cluster C personality disorders; sleep-wake perception; daytime functioning
20.  A Randomized Double-Blind Pilot Trial of Gabapentin vs. Placebo to Treat Alcohol Dependence and Comorbid Insomnia 
Insomnia and other sleep disturbances are common, persistent, and associated with relapse in alcohol-dependent patients. The purpose of this study was to compare gabapentin vs. placebo for the treatment of insomnia and prevention of relapse in alcohol-dependent patients.
Twenty-one subjects including 10 women who met study criteria for alcohol dependence and insomnia, and expressed a desire to abstain from alcohol were recruited to the study. During a 1–2 wk placebo lead-in and screening phase, a complete medical history, physical exam, blood tests, urine drug test, and structured interviews were performed to determine eligibility and patterns of alcohol use and sleep. Insomnia due to intoxication or acute withdrawal, psychiatric or medical illness, medications, and other sleep disorders were ruled out. Subjects were then randomized to either placebo (n=11) or gabapentin (n=10) for 6 weeks and titrated over a 10-day period to 1500 mg or 5 pills at bedtime. After a 4-day taper, subjects were reassessed 6 weeks after ending treatment.
Gabapentin significantly delayed the onset to heavy drinking, an effect which persisted for 6 weeks after treatment ended. Insomnia improved in both treatment groups during the medication phase, but gabapentin had no differential effects on sleep as measured by either subjective report or polysomnography.
Because gabapentin is a short-acting medication that was taken only at nighttime in this study, it may possibly exert a nocturnal effect that prevents relapse to heavy drinking by a physiological mechanism not measured in this study.
PMCID: PMC2927959  PMID: 18540923
alcohol dependence; insomnia; pharmacotherapy; gabapentin; relapse
21.  Diagnostic and Statistical Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults 
Sleep Medicine  2012;13(7):958-960.
Diagnosis of insomnia disorder by Diagnostic and Statistical Manual (DSM)-IV, and as proposed by DSM-V, includes criteria for impairment in occupational- or social functioning due to sleep complaints. This study evaluated the clinical and polysomnographic correlates of impairment in daytime functioning in older adults with insomnia.
In older adults with DSM-IV chronic insomnia (n=68), clinical and demographic information, and measures of health functioning, medical co-morbidity, and polysomnographic sleep were obtained. Four questions that evaluated difficulties or distress in occupational- or social functioning related to sleep complaints were used to code DSM threshold criteria for impairment in daytime functioning. Stepwise regression was used to identify predictors of impairment in daytime functioning.
Impairment in daytime functioning was significantly associated with younger age (p<0.05), and the amount of wake time after sleep onset as assessed by polysomnography (p<0.001), controlling for health functioning and minority racial status.
Amount of wake time after sleep onset uniquely contributes to criteria symptoms of impairment in daytime functioning among older adults with insomnia. Treatments that target sleep maintenance have the potential to improve social and occupational functioning in older adults with sleep complaints.
PMCID: PMC3398224  PMID: 22721715
22.  Frequency and Predictors of Obstructive Sleep Apnea among Individuals with Major Depressive Disorder and Insomnia 
Journal of psychosomatic research  2009;67(2):135-141.
Disturbances in sleep continuity are common among individuals with major depressive disorder (MDD) and can impact the course of depression and response to treatment. Several studies have examined depressive symptom severity among sleep disordered patients with obstructive sleep apnea (OSA). In contrast little is known about OSA in patients with MDD. The goal of this study was to examine the frequency and predictors of OSA in a sample of individuals with comorbid MDD and insomnia.
Participants were 51 individuals who enrolled in a treatment study on insomnia and depression, met criteria for MDD and comorbid insomnia, and underwent an overnight polysomnography evaluation. An Apnea Hypopnea Index (AHI) ≥15 events per hour was used as a cut-off score for OSA. Regression analyses were conducted to examine clinical and demographic predictors of OSA severity as measured by the AHI.
The results revealed that 39% of the sample met criteria for OSA. The OSA group had significantly higher Body-Mass Index (BMI) scores and a significantly greater proportion of men. Regression analysis revealed that male gender, older age, and higher BMI were significant predictors of OSA severity. Neither depression severity nor insomnia severity were significant predictors.
These findings indicate that the frequency of OSA is higher among individuals with comorbid MDD and insomnia than was previously found among people with either MDD or insomnia alone. In addition, previously identified predictors of OSA (male gender, older age, and high BMI) also apply to this population.
PMCID: PMC3052782  PMID: 19616140
Depression; Insomnia; Sleep Apnea; Sleep; Mood Disorders
23.  Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD) 
Sleep medicine  2009;10(9):952-960.
Although the epidemiology of insomnia in the general population has received considerable attention in the past 20 years, few studies have investigated the prevalence of insomnia using operational definitions such as those set forth in the ICSD and DSM-IV, specifying what proportion of respondents satisfied the criteria to reach a diagnosis of insomnia disorder.
This is a cross-sectional study involving 25,579 individuals aged 15 years and over representative of the general population of France, the United Kingdom, Germany, Italy, Portugal, Spain and Finland. The participants were interviewed on sleep habits and disorders managed by the Sleep-EVAL expert system using DSM-IV and ICSD classifications.
At the complaint level, too short sleep (15.8%), light sleep (16.6%), and global sleep dissatisfaction (8.5%) were reported by 37% of the subjects. At the symptom level (difficulty initiating or maintaining sleep and non-restorative sleep at least 3 nights per week), 34.5% of the sample reported at least one of them. At the criterion level, (symptoms + daytime consequences), 9.8% of the total sample reported having them. At the diagnostic level, 6.6% satisfied the DSM-IV requirement for positive and differential diagnosis. However, many respondents failed to meet diagnostic criteria for duration, frequency and severity in the two classifications, suggesting that multidimensional measures are needed.
A significant proportion of the population with sleep complaints do not fit into DSM-IV and ICSD classifications. Further efforts are needed to identify diagnostic criteria and dimensional measures that will lead to insomnia diagnoses and thus provide a more reliable, valid and clinically relevant classification.
PMCID: PMC3715324  PMID: 19748312
Insomnia; Epidemiology; classifications; mental disorders
24.  The relationship between insomnia and depressive symptoms: genuine or artifact? 
Somatic symptom overlap between depression and insomnia has emerged as a major concern. Self-report measures such as the Beck Depression Inventory Second Edition (BDI-II) include somatic symptoms related to depression that are also present in the research diagnostic criteria for insomnia. This study aimed firstly to examine the relationship between the cognitive and somatic factors of the BDI-II and global scores on the Pittsburgh Sleep Quality Index (PSQI) in individuals presenting for insomnia treatment and secondly to examine whether treating insomnia in depressed individuals with insomnia will lead to a reduction in their depressive symptoms and whether this reduction is related to a decrease in the somatic or cognitive factors of depressive symptoms.
A total of 379 individuals (133 males and 246 females), with a mean (M) age of 49.95 (standard deviation [SD] = 14.15) years, were used to address the first aim. To address the second aim, a total of 64 participants (27 males and 37 females) with both insomnia and depressive symptoms were treated for their insomnia. Their ages ranged between 22 and 87 (M = 50.97, SD = 15.13) years.
A significant relationship was found between both the cognitive and somatic factors of the BDI-II and global scores on the PSQI. Furthermore, although results in this study are only suggestive, they lend support to the idea that the relationship between insomnia and depression is not due to somatic symptom overlap. Results may also support the hypothesis that insomnia is primary to the presentation of depressive symptoms.
Clinicians and health care providers could initially treat insomnia in individuals suffering from insomnia who also experience depressive symptoms, as this will not only remit insomnia but also abate the accompanying depressive symptoms.
PMCID: PMC3056174  PMID: 21430795
cognitive depressive symptoms; somatic depressive symptoms; symptom overlap
General hospital psychiatry  2006;28(5):374-378.
Examine the indications, baseline characteristics, duration of use, and clinical outcomes for older primary care patients prescribed benzodiazepines.
Computerized records were used to identify outpatients (n=129) aged 60 or over receiving new benzodiazepine prescriptions from primary care physicians of a group-model managed care organization. A baseline telephone survey assessed indication for prescription, sleep quality (Pittsburgh Sleep Quality Index), depression (Symptom Checklist depression scale and Structured Clinical Interview for DSM-IV), alcohol use (CAGE), and functional status (SF-36). A two-month follow-up survey assessed benzodiazepine use, sleep quality, and depression.
The most common indications for prescription were insomnia (42%) and anxiety (36%). At baseline, participants reported moderate sleep disturbance (mean Pittsburgh Sleep Index = 9.3, st. dev. 4.0), only 15% met criteria for current depressive episode, and only 3% reported at-risk alcohol use. After two months, 30% were using benzodiazepines at least daily. Both those continuing daily use and those not continuing reported significant improvements in sleep quality and depression, with no difference between groups in rate of improvement.
Initial benzodiazepine prescriptions to older adults are typically intended for treatment of anxiety or insomnia, with little evidence for occult depression or alcohol abuse. A significant minority develop a pattern of long term use, raising concerns about tolerance and dependence.
PMCID: PMC2262838  PMID: 16950371
benzodiazepine; sleep; anxiety; hypnotic; epidemiology

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