The Relationship Between Insomnia and Health-Related Quality of Life in Patients With Chronic Illness

,

Original Research

The Relationship Between Insomnia and Health-Related Quality of Life in Patients With Chronic Illness

J Fam Pract. 2002 March;51(3):229-235

By

David A. Katz, MD, MSc

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References

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ABSTRACT

OBJECTIVES: To determine the association between insomnia and health-related quality of life (HRQOL) in patients with chronic illness after accounting for the effects of depression, anxiety, and medical comorbidities.

STUDY DESIGN: We used a cross-sectional analysis of Medical Outcomes Study (MOS) data.

POPULATION: The sample consisted of 3445 patients who completed a self-administered questionnaire and who were given a diagnosis of 1 or more of 5 chronic medical and psychiatric conditions by an MOS clinician. Patients were recruited from the offices of clinicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry in 3 US cities.

OUTCOMES MEASURED: Outcomes were sleep items, health-related quality of life as measured by the Medical Outcomes Study Short Form Health Survey (SF-36), chronic medical comorbidity, depression, and anxiety. Insomnia was defined as the complaint of difficulty initiating or maintaining sleep.

RESULTS: Insomnia was severe in 16% and mild in 34% of study patients. Patients with insomnia demonstrated significant global decrements in HRQOL. Differences between patients with mild insomnia versus no insomnia showed small to medium decrements across SF-36 subscales ranging from 4.1 to 9.3 points (on a scale of 0 to 100); the corresponding decrements for severe insomnia (versus no insomnia) ranged from 12.0 to 23.9 points.

CONCLUSIONS: Insomnia is independently associated with worsened HRQOL to almost the same extent as chronic conditions such as congestive heart failure and clinical depression.

KEY POINTS FOR CLINICIANS

The prevalence of insomnia in patients with chronic medical or psychiatric conditions is high (50% in the current study sample).
Insomnia is independently associated with worsened health-related quality of life across several domains, especially mental health, vitality, and general health perceptions, even after accounting for the presence of comorbidities.
Clinicians should not ignore insomnia; identification and appropriate treatment of this disorder in primary care can significantly improve quality of life.

Insomnia, one of the most common complaints in primary care practice, affects more than 60 million Americans.¹ Inadequate sleep has been associated with reduced physical health,² subsequent decline in health status, and increased mortality.^3,4 Patients with chronic insomnia are more likely to develop affective disorders.^5,6 Insomnia may worsen somatic symptoms.⁷ Recent studies in health maintenance organization enrollees have demonstrated that insomnia is independently associated with significantly greater functional impairment, more days of disability related to health problems, and greater use of medical services.^8,9

Patients often present to primary care physicians with chronic comorbidities that may adversely affect sleep quality and that may also compromise functional status. While previous investigations have consistently shown decreased functional status in subjects with insomnia, these studies have tended to focus on general population samples,^10-12 health plan enrollees,^8,9,13 or volunteers recruited by media advertisement.¹⁴ In addition, most of the studies either lacked detailed assessment of medical or psychiatric comorbidities or did not control for the presence of these comorbidities in the analysis. Thus, our study aims to (1) determine whether insomnia is independently associated with decreased health-related quality of life (HRQOL) in patients with chronic conditions, and (2) compare the decrease in quality of life associated with insomnia with that associated with other chronic conditions.

Methods

We conducted a cross-sectional analysis of data from the Medical Outcomes Study (MOS), an observational study of health outcomes for patients with chronic medical and psychiatric conditions.^15-21

Sample and data collection

Study participants were English-speaking adults who had had an office visit with 1 of 523 clinicians trained in family practice, general internal medicine, cardiology, endocrinology, psychiatry, or clinical psychology during 9-day screening periods held from February to November 1986. Patients who were eligible for inclusion in the MOS baseline panel completed questionnaires addressing general health status (the Medical Outcomes Study Short Form Health Survey [SF-36]), alcohol use, exercise, and sleep.

Data from standardized physician-completed forms were used to identify patients with 5 index conditions: hypertension, diabetes, congestive heart failure, recent myocardial infarction, and depression.^15-20 We identified patients with depression using a short form of the Center for Epidemiologic Studies—Depression (CES-D) Scale²² and then used the National Institute of Mental Health Diagnostic Interview Schedule (DIS) to assess its severity.^18,22 The definition of current depressive disorder was based on Diagnostic and Statistical Manual, 3rd ed. (DSM-III ), criteria for lifetime major depression or dysthymia during the previous 12 months (DSM-IV was unavailable at the time of the MOS). Patients with depressive symptoms who did not satisfy this definition were considered to have subthreshold depression.²³

Measures of HRQOL

The SF-36 is a 36-item generic quality-of-life measure that assesses 8 domains: (1) physical functioning; (2) role limitation due to physical health problems (role physical); (3) bodily pain; (4) general health perceptions; (5) vitality; (6) social functioning; (7) role limitations due to emotional health problems (role emotional); and (8) mental health.^24-26 Physical function and role physical scales best distinguish between groups differing in severity of chronic medical conditions and have the purest interpretation with regard to physical health; mental health and role-emotional scales best distinguish between groups differing in severity of psychiatric disorders and have the purest interpretation with regard to mental health. Social function, vitality, and general health perception scales measure both physical and mental health status.²⁴ All health measures were scored on scales of 0 to 100, with higher scores indicating better health.