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Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 207-210  

Screening for sleep disorders and their medical and psychiatric comorbidities

Department of Psychiatry, Smt. Kashibai Navale Medical College, Pune, Maharashtra, India

Date of Submission09-Aug-2018
Date of Acceptance27-Oct-2018
Date of Web Publication15-May-2019

Correspondence Address:
Nikhil Sanjay Mankar
Psychiatry OPD 13, Building No 1, Smt. Kashibai Navale Medical College, Pune - 411 041, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_130_18

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Background: Sleep disorders are common in medical out-patients. They are seldom addressed despite being known to worsen overall health of patients. Detailed evaluation to differentiate these into primary sleep disorders, psychiatric and medical co-morbidity or both can be done by a liaison Psychiatrist. Managing these is necessary for providing good quality recovery for the patient. Method: Cross-sectional survey of 148 randomly selected medical out-patients in a tertiary care hospital was carried out to assess various sleep disorders. Pittsburgh sleep quality index was used for assessment. They were assessed by qualified psychiatrist to establish Psychiatric diagnosis by clinical interview as per ICD-10 classification. Co-occurrence of these with chronic medical problems as diagnosed by clinician was documented. Results: Sleep disorders were common in medical out-patients (48.64%). Commonest among them was difficulty initiating sleep and reduced duration. A significant number screened to have sleep disorders, also had psychiatric co-morbidities (63.8%), Depressive disorders being the commonest (52.1%). Chronic medical illnesses were present in 50 (33.8%) of the all patients assessed for having sleep disorders. Co-occurrence of medical and psychiatric co-morbidities was not statistically significant. Conclusion: Considering high prevalence, patients should be routinely assessed for various sleep problems by Physician and referred to Psychiatrist for management as many of them also have psychiatric co-morbidities. Physician and Psychiatrist liaison is important in managing complex medical and psychiatric co-morbidities associated with sleep disorders.

Keywords: Consultation-liaison psychiatry, prevalence of sleep disorders, psychiatric morbidity in medical outpatients, psychiatric morbidity in sleep disorders, sleep disorders in medicine outpatients

How to cite this article:
Mankar NS, Deshpande SS. Screening for sleep disorders and their medical and psychiatric comorbidities. Med J DY Patil Vidyapeeth 2019;12:207-10

How to cite this URL:
Mankar NS, Deshpande SS. Screening for sleep disorders and their medical and psychiatric comorbidities. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2021 Nov 28];12:207-10. Available from: https://www.mjdrdypv.org/text.asp?2019/12/3/207/258197

  Introduction Top

Sleep is an important human behavior required to function adequately during the day. It forms roughly a third of human life. Sleep is inherent to every living species, from bugs, pests, to mammals. The dearth of sleep leads serious physical and cognitive impairment, metabolic disorders, as well as psychiatric disorders.[1]

Insomnia is commonly associated with pain symptoms, chronic obstructive pulmonary disease, diabetes mellitus, cardiovascular diseases, anxiety, and depression.[1] Evidence points that sleep deficiencies and circadian disruption associated with metabolic dysregulation may contribute to weight gain, obesity, type 2 diabetes, and hypertension.[2],[3]

Sleep-related troubles are widespread in all populations, and they are more common in those suffering from physical and psychological disorders. Medical patients commonly report insomnia and seek “sleeping pills.” Research pertaining to sleep disorders have been carried out on multiple Indian settings,[4] but such liaison studies in medical outpatients are very few in literature. This study was undertaken to study overlap between sleep disorders, psychiatric disorders, and medical disorders by screening for sleep problems in the general medicine outpatient department (OPD) of a general hospital. The aim of this study was to screen for sleep problems in medical patients and to assess for comorbid psychiatric conditions in these patients with sleep disorders.

  Materials and Methods Top

Patients attending the medicine OPD were the reference population. Samples were selected by random sampling method based on the OPD muster. After obtaining informed consent, they were administered the Pittsburgh Sleep Quality Index (PSQI) scale.[5] The PSQI is a 19-item self-rated questionnaire for evaluating subjective sleep quality over the previous month. The 19 questions are combined into seven clinically derived component scores, each weighted equally from 0 to 3. The seven component scores are added to obtain a global score ranging from 0 to 21. The clinical and psychometric properties of the PSQI have been formally evaluated by several research groups.[6],[7] The PSQI has a sensitivity of 89.6% and specificity of 86.5% with Cronbach's alpha[8] of 0.736 and for identifying cases with sleep disorder, using a cutoff score of 5. The PSQI has been translated into 48 languages and has been used in a wide range of population-based and clinical studies. A PSQI score of 5 or more is suggestive of poor quality of sleep.[7] All the patients were assessed for concurrent medical conditions by physicians and also for any comorbid psychiatric diagnoses by clinical interview based on the International Classification of Diseases-10 by a psychiatrist.

Statistical analysis

Microsoft Excel was used to tabulate the data. Frequency tables were calculated using the same and nonparametric Chi-square test was applied where deemed necessary.

  Results Top

A total of 148 patients were screened and assessed over a period of 5 days. Psychiatric disorders were present in 46 of them. The most common psychiatric comorbidity was depressive disorder [Table 1].
Table 1: Psychiatric comorbidity in medical outpatients

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[Table 2] denotes patients with reported sleep difficulties, 48.64%, i.e., poor sleep quality. Out of those with poor sleep quality, 63.88% had a co-occurring psychiatric illness and 37.5% had a comorbid chronic medical illness.
Table 2: Summary of Pittsburgh Sleep Quality Index score, psychiatric disorders, and chronic medical comorbidities

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[Figure 1] depicts various medical comorbidities associated with various sleep problems.
Figure 1: Medical comorbidities with sleep problems. HTN: Hypertension, DM: Diabetes mellitus, IHD: Ischemic heart disease

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Out of those with poor sleep quality, the most common medical condition was hypertension followed by diabetes mellitus and ischemic heart disease (IHD).

Poor sleep quality was not statistically significantly (p - 0.124) associated with psychiatric as well as medical conditions.

It should be further noted that hypertension, diabetes, and IHD are common conditions which often have psychiatric comorbidities [Figure 1].

Thus, assessment of sleep disorders by physicians and psychiatrists both is necessary.

  Discussion Top

Sleep disorders are very common in the general population, but they are poorly identified and less than 20% of individuals with insomnia currently are diagnosed and treated.[9] Sleep quantity and quality is affected by a variety of cultural, social, psychological, behavioral, pathophysiological, and environmental influences. Technological advancements and various cultural changes have afforded modern society with 24-h work operations, transmeridian travel, and exposure to a myriad of electronic devices, such as televisions, computers, and cellular phones. Growing evidence suggests that various advancements take their toll on human functioning and health, namely their damaging effects on sleep quality, quantity, and timing.[10] Additional behavioral lifestyle factors associated with poor sleep include weight gain, insufficient physical exercise, and consumption of substances, such as caffeine, alcohol, and nicotine. These changes have led to increased tension, depression, tiredness, and excessive daytime sleepiness.[11] Chronic sleep restriction and poor sleep quality are associated with an increased risk of obesity, insulin resistance, type 2 diabetes, and metabolic syndrome.[12] Attention to sleep problems reported by patients and their prompt management are deemed necessary for optimal outcomes in chronic medical illnesses.

The Sleep Heart Health Study[13] was an observational study done on 2813 men and 3097 women. It was a community-based, prospective, cross-sectional study, which revealed increased prevalence of hypertension with sleep duration of less than the usual 8 h/night. Risk further increased with sleep duration of less than 6 h/night. Poor quality of sleep and short sleep duration independently associated with coronary artery disease.[14]

Psychiatric comorbidities are common in medical outpatients.[12],[13],[14] Most of them (54%) had poor sleep quality as measured by PSQI [Table 2]. Asking about sleep-related problems by a physician can thus help in screening of most of the psychiatric problems. Patients are also often more willing to discuss these problems than their emotional problems or personal stresses. Various sleep problems as mentioned in PSQI, such as excess daytime sleepiness and snoring, need to be asked rather than only focusing on insomnia.

Secondly, this study discovered poor sleep quality in chronic medical illnesses as well as psychiatric illnesses [Table 2]. The physician should, therefore, routinely ask about sleep-related problems to each patient, especially those with chronic ailments as well. Referral to a psychiatrist would be necessary if the sleep problems are secondary to anxiety or mood disorder.

Out of chronic medical illnesses, this three are most common, namely hypertension, diabetes mellitus, and IHD, were more commonly associated with sleep problems [Figure 1].

With availability of nonbenzodiazepine hypnotic agents, such as zolpidem, melatonin, and its agonists, management of primary insomnia and circadian rhythm disorders is possible without significant side effects. However, they are seldom used by physicians in place of conventionally used benzodiazepines which have risk of dependence and cognitive impairments. Furthermore, in case of anxiety and depressive disorders, use of appropriate psychopharmacological agent with due consideration of drug interactions is necessary. Consultation-liaison psychiatry has become important in recent years of managing these sleep-related problems, which eventually lead to psychosomatic disorders.

However, there are barriers in liaison work. First, as perceived by the physician, barriers include anticipation of patient's negative reaction to referral, physician's own inhibitions due to stigma to psychiatric referral, and effects and side effects of drugs and fear of dependency among others. Second, as perceived by the patient, barriers include stigma, cost factor, doubts about necessity of referral, time spent by patient, side effects of drugs, and dependency on drugs among others.

Some common sleep hygiene tips are important and should be routine part of counseling. Fixing a bedtime and an awakening time, avoiding napping during the day, avoiding alcohol, caffeine, heavy, spicy, or sugary foods 4–6 h before bedtime, and exercising regularly are helpful in getting good sleep.[1]


Relatively small sample size, which may not be representative of the whole population. Structured diagnostic tool not used for psychiatric diagnosis. Multiple regression analysis was not done due to small sample size.

  Conclusion and Future Directions Top

Problems with sleep should be regarded as an important risk factor determined by the environment. Sleep problems are common in medical outpatients (in 48.64% of samples in this study). Psychiatric comorbidities, especially depressive and anxiety disorders, are common in these patients (63.8%). Sleep problems can be amenable to modification through individual education and counseling as well as measures of public health education. Public health measures should aim at modifications of physical and working environments avoiding habitual and sustained sleep deprivation. Physicians' awareness of problem and prompt treatment is vital for the better outcome so is the role of liaison psychiatrist.


We would like to thank Dr. Shreepad Bhat, Prof and Head, Department of Medicine, SKN Medical College, Pune, for administrative support and Dr. Siddharth S. Gundecha, Senior Resident, Department of Psychiatry, for general support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sadock BJ, Sadock VA, Ruiz P. Kaplan and Saddock's Synopsis of Psychiatry: Behavioural Sciences/Clinical Psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2015. p. 465-503.  Back to cited text no. 1
Depner CM, Stothard ER, Wright KP Jr. Metabolic consequences of sleep and circadian disorders. Curr Diab Rep 2014;14:507.  Back to cited text no. 2
Fernandez-Mendoza J, He F, Liao D, Vgontzas AN, Bixler EO. 0874 Insomnia with objective short sleep duration is associated with an increased risk of cardiocerebrovascular disease. Sleep 2018;41 Suppl 1. p. 325.  Back to cited text no. 3
Shah N, Bang A, Bhagat A. Indian research on sleep disorders. Indian J Psychiatry 2010;52:S255-9.  Back to cited text no. 4
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.  Back to cited text no. 5
Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh sleep quality index in primary insomnia. J Psychosom Res 2002;53:737-40.  Back to cited text no. 6
Hinz A, Glaesmer H, Brähler E, Löffler M, Engel C, Enzenbach C, et al. Sleep quality in the general population: Psychometric properties of the Pittsburgh sleep quality index, derived from a German community sample of 9284 people. Sleep Med 2017;30:57-63.  Back to cited text no. 7
Manzar MD, Moiz JA, Zannat W, Spence DW, Pandi-Perumal SR, BaHammam AS, et al. Validity of the Pittsburgh sleep quality index in Indian university students. Oman Med J 2015;30:193-202.  Back to cited text no. 8
Ohayon MM. Epidemiological overview of sleep disorders in the general population. Sleep Med Res 2011;2:1-9.  Back to cited text no. 9
Shochat T. Impact of lifestyle and technology developments on sleep. Nat Sci Sleep 2012;4:19-31.  Back to cited text no. 10
Yazdi Z, Sadeghniiat-Haghighi K, Loukzadeh Z, Elmizadeh K, Abbasi M. Prevalence of sleep disorders and their impacts on occupational performance: A comparison between shift workers and nonshift workers. Sleep Disord 2014;2014:870320.  Back to cited text no. 11
Koren D, Dumin M, Gozal D. Role of sleep quality in the metabolic syndrome. Diabetes Metab Syndr Obes 2016;9:281-310.  Back to cited text no. 12
Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, et al. Association of usual sleep duration with hypertension: The sleep heart health study. Sleep 2006;29:1009-14.  Back to cited text no. 13
Sharma M, Sawhney JP, Panda S. Sleep quality and duration-potentially modifiable risk factors for coronary artery disease? Indian Heart J 2014;66:565-8.  Back to cited text no. 14


  [Figure 1]

  [Table 1], [Table 2]


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