International Journal of Clinical Medicine, 2015, 6, 845-851
Published Online November 2015 in SciRes.
How to cite this paper: Umesh, V. and Kavita, M. (2015) Original Research: Treating Sleep Disorders Has Positive Outcomes
in Psychiatric Illnesses. International Journal of Clinical Medicine, 6, 845-851.
Original Research: Treating Sleep
Disorders Has Positive Outcomes
in Psychiatric Illnesses
Vyas Umesh1,2,3,4,5, Mundey Kavita6
1Park Center Inc., Fort Wayne, USA
2Indiana University School of Medicine, Fort Wayne, USA
3Fort Wayne Medical Education Program-Family Medicine Residency, Fort Wayne, USA
4University of Saint Francis, Fort Wayne, USA
5Ivy Tech Community College of Indiana, Fort Wayne, USA
6Veteran’s Administration Medical Center (VAMC), Milwaukee, USA
Received 11 July 2015; accepted 16 November 2015; published 19 Nove mber 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
Introduction: Sleep and psychiatric disorders are common, and often co-morbid. Sleep disorders
may predispose to development or exacerbation of psychiatric disorders. Authors hypothesized
that treatment of sleep disorders improve outcomes in psychiatric illnesses. Methods: Charts of
patients diagnosed with sleep disorders from October 2007 to December 2007 were reviewed.
Outcomes in patients with co-morbid psychiatric disorders were recorded at 6, 12 and 24 months
after initiation of sleep disorder treatment. These patients received a baseline psychiatric status
score of 0. Change in status at each subsequent time point was scored as: 2 (marked worsening), 1
(mild worsening), 0 (no change), +1 (mild improvement) or +2 (marked improvement). We indi-
vidually compared change in average score at each time point to baseline using the signed rank
test. We compared provider documented compliance to sleep therapies between patients with and
without psychiatric disorders using Fisher’s exact test. Results: Of 127 charts reviewed, 10 were
excluded as patients died within follow-up period. No death was reported as suicide. Of 117 pa-
tients, 97.64% were men, 2.36% were women. Age range: 21 - 40: 7.69%, 41 - 60: 42.74%, 61 - 80:
47.87%, >81: 1.70%. 58 patients (45.67%) had coexistent psychiatric diagnoses. There was no
difference in provider documented compliance rate to sleep therapies between patients with and
without psychiatric disorders at 6, 12 and 24 months, (Fisher’s p value 0.1031, 0.2290 and 0.2248
respectively). Psychiatric status progressively improved compared to baseline (Change in average
score by +0.45, +0.56, and +0.79 at 6, 12, and 24 months, respectively, p < 0.0001). Conclusion:
Psychiatric disorders did not affect compliance to sleep related treatment. Treatment of co-m or-
bid sleep disorders is associated with improvement in psychiatric disorders. Authors recommend
need for prospective study with more subjects.
V. Umesh, M. Kavita
Psychiatric Illnesses/Dis o rder s, Sleep Illnesses/Dis o rd ers
1. Introduction
Sleep is an es sentia l ph ysiolo gical need, a nd it is an acti ve state t hat i s critical for our ph ysical, mental a nd e mo-
tional well-being. Sleep is also important for op timal cognitive functio ning and sleep disruption results in func-
tional impair ment.
Sleep and psychiatric disorde rs are common disorders in clinical pop ulations; existing data supp orts high rate
of co-morbidity between them, and the disturbance in quality and quantity of sleep due to sleep disorders pre-
disposes to the development or exacerbation of psychological distress and psychiatric illnesses. Likewise, the
presence of psychiatric illnesses may complicate the diagnosis and treatment of sleep disorders.
Sleep disturbances are so commonly seen in psychiatric disorders that they are listed as diagnostic criteria
under DSM (American Psychiatric Association) [1]. Sleep and psychiatric disorders, by themselves are disabling,
the treatment of the co-morbidity may reduce needless disability. The data not only underscore the high fre-
quency of psychopathology and psychological distress in sleep disorders and vice versa, but also suggest that
combined treatment of both should become the standard of care for effective therapy [2].
2. Literature Review
40% of those diagnosed with insomnia, in a population-based study, also have a psychiatric disorder, and with
hypersomnia the prevalence of psychiatric disorder is 46.5% [3]. Mood and anxiety disorders are associated with
high rates of insomnia [4]. Prevalence for insomnia complaints was 12.7% in general population. The preva-
lence of sleep disorders mostly insomnia due to mental disorder was 5.6%; primary psychiatric disorder diag-
nosed were applied to 8.4% [4].
Another study, which followed 1007 young adults at a health maintenance organization for 3.5 years, found
that a history of insomnia at baseline not only predicated new onset depression, but also other psychiatric dis-
orders (any anxiety disorder, alcohol abuse, drug abuse, and nicotine dependence), [5], the adjusted odds of de-
veloping a psychiatric disorders were highest for depression (OR = 3.95; 95% CI, 2.2 - 7.0), was based on 16
percent of the sample who developed depression with history of insomnia at baseline, as compared with 4.6
percent who developed depression without a history of insomnia. The study’s general findings are supported by
another large study of 10,000 adults. That stud y found insomnia to have increased the risk of major depression
by a similar magnitud e (5 -fold) and to have increased the risk of panic disorder even more strikingly, by 20-fold
(OR = 20.3; 95% CI, 4.4 - 93.8) [6]. Insomnia is also a predictor of acute suicide among patients with mood dis-
orders [7].
More than 2000 UK residents at baseline and 12-month follow up, measures of insomnia, depression and an-
xiety demonstrated that baseline insomnia was a significant risk factor for incidence of depression and anxiety at
follow up (adjusted risk ratio of 2.71 and 2.28 respectively) [8].
Zurich longitudinal epidemiologic study revealed that a new onset of depression developed in 17% to 50% of
patients with persistent, pure insomnia of 2 weeks duration at a later interview, wit h p r e dictive odds ra tio of 1.6
to 1.9 [9].
Wisconsin Sleep Cohort, found substantially higher rates of psychiatric symptoms and disorders among those
with daily Restless Leg S yndrome (RLS). Odds ratio to depression (Zung score > 50 or Anti-Depressant medi-
cation use) in those the daily RLS was 2.17 and 1.80 in those with “frequent” RLS (one or six times per week).
For anxiety disorders, odds ratio were 3.41 and 2.42 for the two RLS groups respectively [10].
Psychiatric co-morbidity in Obstructive Sleep Apnea (OSA) patients was examined in a large prospective
chart review of >100,000 Veterans Affairs Hospital OSA patients. A significantly high prevalence of psychiatric
disorders was found in this group, as compared with a non-OSA population. High co-morbidity was found for
major depression 21.8%, anxiety disorder 16.7%, PTSD 11.9%, psychosis 5.1%, and Bipolar disorder 3.3%
Depressive symptoms i mprove with treatment of OS A, and untreated OSA may contribute to treatment resis-
V. Umesh, M. Kavita
tance in some cases of mood disorders [12]. OSA is a common sleep disorder, is well recognized as a cause of
morbidity including psychiatric disorders. OSA needs to be excluded in cases of chronic or resistant depression
and treatment of OSA will make it easier to treat depressive disorder [13]. Treatment of depression in OSA
might improve acceptance of therapy, reduce sleepiness, fatigue and improve quality of life [14]. Reduction of
depression scores (seven-item BDI) in OSA patients treated with continuous positive airway pressure (CPAP)
[15]. Studies demonstrated high rates of depressive symptoms in OSA, as well as improvement of these symp-
toms with treatment of OSA [16]-[18].
Combined therapies for both depression and insomnia are superior to anti-depressant medications alone in pa-
tients with major depression [19] [20]. Study combining anti-depression medications with specific insomnia
treatment (cognitive-behavioral therapy for insomnia) demonstrated that the combined treat ment was superior to
anti -depressant alone both in terms of depression out-come (61.5% vs. 33.3% remission respectively) and in-
so mni a out-come (50% vs. 7.7% respectively) [21].
Guidelines on the management of insomnia from American Academy of Sleep Medicine (AASM) recom-
mend that treatment of insomnia in patients with co-morbid psychiatric disorders follow the general guidelines
of psychological and behavioral therapies, possibly coupled with a benzodiazepine receptor agonist, but they al-
so note the potential usefulness of sedating anti-depressant or atypical anti-psychotic medications in certain
populations [22].
Evidence suggests that individuals seeking medical attention for sleep complaints are more likely to have drug
or alcohol abuse problems than the general population. Withdrawal from nicotine, alcohol and drug abuse is also
associated with insomnia, and this may result in an increased risk of relapse if the sleep problems are remain
unresolved [23].
The Post-Traumatic Stress Disorder (PTSD), 37% had significant nightmare problems [24], and severity of
sleep disturbance correlated with PTSD severity [25].
3. Research Design
Retrospective, observational, chart review study.
4. Method
Electronic medical record reviewed for diagnosis of sleep disorders at VAMC Milwaukee, WI, USA from Oc-
tober 2007 to December 2007, Figure 1. Patients with confirmed diagnosis and treatment for sleep disorders
were included. Outcomes in patients with co-morbid psychiatric disorders were recorded at 6, 12 and 24 months
after initiation of sleep disorder treatment.
Measurements of change in psychiatric disorder defined as follows:
Baseline score = 0.
Marked improvement = +2.
Partial improvement = +1.
No change = 0.
Partial worsening = 1.
Mar ked wor s ening = 2.
Figure 1 . Details of chart reviewed.
57 charts excluded due to lack of treatment
57 charts excluded due to lack of treatment
or follow up
or follow up
117 char ts included in study
117 char ts included in study
184 charts reviewed
184 charts reviewed
10 charts excluded as patients died within
10 charts excluded as patients died within
-up period. (
up period. (
No death reported as suicide).
No death reported as suicide).
127 charts
127 charts
V. Umesh, M. Kavita
Various parameters used to assess outcomes of psychiatric disorders to assess improvement or worsening Ta-
ble 1.
Change in average score for psychiatric disorders was compared individually at each time point to baseline
using the signed rank test. Compliance was compared to sleep disorder treatment between patients with and
without psychiatric disorders using Fisher’s exact test. Difference in score changes at each time point to baseline
was compared for a specific psychiatric disorder using Wilcoxon test.
Compliance to management defined as:
Attendance o f follow up visits in sleep c linic/pri mary care clinic/respiratory therapist clinic.
Documentation of patient reported compliance to positive airway pressure therapy and other treatments of-
Clinic visit ca ncella tion 2 consecutive appointments.
5. Discussion, Results and Conclusions
Current data demonstrate important bidirectional relationship between sleep and psychiatric disorde rs, and men-
tal disorders co-morbid with sleep disorders contribute to disease burden and adversely affect the outcome of
patients with these conditions, therefore effective comprehensive evaluation and management of patients with
sleep disorders require careful psychological assessment and evaluation for specific psychiatric disorders and
vice versa. It also requires necessary independent pharmacological and psychological treatment of sleep disorder
and psychiatric disorder.
Our study subject’s demographic and age distribution (Age range: 21 - 40: 7.7%, 41 - 60: 42.7%, 61 - 80:
47.9%, >81: 1.7%) was very typical of Veteran’s Administration Medical Center (VAMC), Figure 2. Our st ud y
supports treatment of co-morbid sleep disorders was associated with significan t improvement in ps ychiatric d is-
orders, Wilcoxon Signed rank test used, Figure 3 and Table 2. Psychiatric disorders did not affect compliance
with sleep disorders treatment Table 3, Fisher’s exact test used. Compliance among patients with psychiatric
Table 1. Parameters to as sess ou tco mes of psychiatric disorders.
DSM Diagnosis Psychiatric
MHC Follow
Man agemen t
Improvement/Worsening Substance Abuse
Improvement (+2) Removal of Dx Completely stopped Discharged from
MHC Significant
Improvement Stopped
Improvement (+1) Mild/NOS
cat egory of Dx Lower doses
required Less fr equent
visit Mild/moderate
improvement Reduced ab use
No Change (0)
Worsening (−1)
New Mild
cat egory Dx
add ed
number/doses required More frequent
visits Mild/moderate
worsening More su bstan ce
Worsening (−2)
Changed or
added sever e
cat egory of Dx
Maximum doses and/or
augmentation required
Rela pse an d/or
new substance
Table 2. Changes in psychiatric disease statu s after treatment.
Comp aris on Mean (Time 1) Mean ( Time 2) p value
Baseline vs. 6 Months 0 0.45 0.0004
Base l i ne vs. 12 Mont hs 0 0.56 0.0002
Base l i ne vs. 24 Mont hs 0 0.79 <0.0001
6 Mon ths vs. 12 Mo nt hs 0.45 0.56 0.1094
6 Mon ths vs. 24 Mo nt hs 0.45 0.79 0.0005
12 Months vs. 24 Months 0.56 0.79 0.0039
V. Umesh, M. Kavita
Table 3. Comparison of compliance among patients with and without psychiatric diagnosis.
Tim e Fisher’s p V a lue
6 Months 0.1031
12 Months 0.2290
24 Months 0.2248
Figure 2 . Demographics and age distribution.
Figure 3 . Change in psychiatric illness status during two years follow-up period.
diseases was 77%, and compliance in patients without psychiatric disea ses was 87%. Wilcoxon test was used to
find if there were significant differences in score change at each time point based on the presence of a specific
psychiatric disorder. Authors found this was not statistically significant. This may be due to small number (N)
for a specific psychiatric disorder; since most subjects had various co-exist ing psychiatric disorders Table 4 . All
statistical analysis was performed in SAS (Cary, NC).
6. Limitations
Retrospective, chart review with small number of subjects.
Single author reviewed all charts, therefore personal bias cannot be ruled out.
Limitation of Li ker t Sc a le-Central tendency bias.
Most sleep disorder patients had diagnosis of sleep-related breathing disorder (OSA).
No objective compliance data were available for every subject to ascertain compliance.
VA elderly male patient population; cannot be a pplied to general slee p clinic patient p opulation.
There is a strong need for prospective studies with more subjects, to establish not only importance of man-
agement of sleep disorders in psychiatric disorders, but also need for comprehensive evaluation.
117 patients
117 patients
97.6% were men, 2.4%
97.6% were men, 2.4%
were women
were women
54 patients (46.2%) had
54 patients (46.2%) had
coexistent psychiatric
coexistent psychiatric
21-40 41-60 61-80>81
Change in psychiatric status during 2
Change in psychiatric status during 2
year follow
year follow-
-up period
up period
Baseline 6 months12 months24 months
Mean change score
V. Umesh, M. Kavita
Table 4. Wilcoxon test for significant difference in score change (baseline vs. 6, 12, 24 months) based on presence of psy-
chiatric disorder.
Psychiatric Disorder Mean Score Change
(disorder not present) Mean Score Change
(disorder present) p value
6 month s
12 mont hs
24 mont hs
6 month s
12 mont hs
24 mont hs
6 month s
12 mont hs
24 mont hs
6 month s
12 months
24 months
6 month s
12 months
24 months
Conflict of Interest
The authors declare that they have no conflict of interest.
Authors hypothesized that treatment of sleep disorders improve outcomes in psychiatric illnesses.
Evaluate effect of treatment of sleep disorders on outcomes of psychiatric disorders.
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