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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 35  |  Issue : 1  |  Page : 56-64

Sleep disorders and sleep quality among patients with anxiety or depressive disorders in relation to their quality of life


1 Department of Psychiatry, Faculty of Medicine, Suez Canal University, Ismailia, Egypt; Buraydah Mental Health Hospital, Buryda, Al-Qassim, Kingdom of Saudi Arabia
2 Department of Psychiatry, Faculty of Medicine, Al-Qassim University, Buraydah, Kingdom of Saudi Arabia
3 Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt; Department of Psychiatry, Faculty of Medicine, Al-Qassim University, Buraydah, Kingdom of Saudi Arabia
4 Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission10-Nov-2011
Date of Acceptance03-Dec-2011
Date of Web Publication18-Feb-2014

Correspondence Address:
Ashraf M.A. El-Tantawy
Department of Psychiatry, Faculty of Medicine, Sues Canal University, Ismailia, Egypt

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.127284

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  Abstract 

Background
Sleep is essential in our lives and is related to the physical, mental and psychological state of the individual. Sleep problems are prevalent among psychiatric patients with common anxiety or depressive disorders.
Patients and methods
In 200 patients with anxiety or depressive disorders, diagnosis of specific sleep disorders was carried out according to the Diagnostic and statistical manual of mental disorders, 4th ed., text revision criteria using a semistructured psychiatric interview. Comorbidity was assessed using the Charlson Comorbidity Index. The quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI); the negative emotional states of depression, anxiety and stress were measured using the Depression Anxiety Stress Scales and the quality of life was measured using the Short Form 36-item (SF-36).
Results
Overall, 36% of the patients showed sleep disorders: 43% of them had anxiety disorders and 29% of them had depressive disorders. Primary insomnia has a higher statistically significant difference among patients with anxiety or depressive disorders (27.5%) than the control group (4.0%) (P < 0.05). Patients with anxiety or depressive disorders who have sleep disorders have higher PSQI scores (P < 0.01) and lower SF-36 scores (P < 0.01) than patients with anxiety or depressive disorders who do not have sleep disorders. There was a correlation between the Depression Anxiety Stress Scales score with PSQI and SF-36 scores regarding both patients with anxiety disorders and patients with depressive disorders.
Conclusion
Sleep disorders and poor sleep quality would have a negative impact on important aspects of health-related quality of life of patients with anxiety or depressive disorders. Understanding of the prevalence, correlates and implications of sleep disturbances and sleep quality for healthcare utilization in this patient population could provide useful guidance for the design of services and targeted treatments that improve the quality of life of these patients. Clinicians should routinely screen for sleep problems in patients with anxiety or depressive disorders.

Keywords: Anxiety, depressive disorders, mood, quality of life, quality, sleep


How to cite this article:
El-Tantawy AM, Al-Yahya A, Raya YM, Mohamed SA. Sleep disorders and sleep quality among patients with anxiety or depressive disorders in relation to their quality of life. Egypt J Psychiatr 2014;35:56-64

How to cite this URL:
El-Tantawy AM, Al-Yahya A, Raya YM, Mohamed SA. Sleep disorders and sleep quality among patients with anxiety or depressive disorders in relation to their quality of life. Egypt J Psychiatr [serial online] 2014 [cited 2017 Oct 20];35:56-64. Available from: http://new.ejpsy.eg.net/text.asp?2014/35/1/56/127284


  Introduction Top


Sleep disorders are an important public health issue because they have a significant negative impact on individuals' physical and social performance, their ability to work and their quality of life (Billiard and Bentley, 2004). Individuals who regularly sleep an average of 7-8 h/day (intermediate sleep pattern) often have better physical health and lower risk of early mortality or the development of diabetes, cardiopathy or cognitive and psychological abnormalities, as compared with those who sleep less (short sleep pattern) or more (long sleep pattern) (Breslau et al., 1997; Chang et al., 1997; Pilcher et al., 1997; Pilcher and Ott, 1998; Kojma et al., 2000; Howard et al., 2002; Kripke et al., 2002; Parshuram et al., 2004). Insomnia is the most prevalent sleep disorder in both the general population and among psychiatric tablepatients (Szelenberger and Soldatos, 2005). Epidemiologic-based studies estimated that 7.5-15% of the general adult population suffers from chronic insomnia and an additional 25-35% experience insomnia on a transient or occasional basis (Leger and Poursain, 2005). The most common factors shown to be associated with sleep disorders include various demographic characteristics such as age, sex, education level, socioeconomic status, employment status and marital status as well as having psychiatric or somatic illnesses or experiencing other stressful life events (Ford and Kamerow, 1989; Kappler and Hohagen, 2003; Roth and Drake, 2004). Epidemiological and clinical studies have shown that a large number of people with sleep disorders also suffer from a concomitant mental disorder, mainly anxiety or depressive disorders, with between 40 and 60% of insomnia complainers falling into this category (Ford and Kamerow, 1989; Roth, 2001; Ohayon and Roth, 2003). In addition, there is a growing body of evidence suggesting that there is a significant relationship between substance abuse and insomnia (Johnson and Breslau, 2001; Teplin et al., 2006). Moreover, sleep disorders have also been suggested to be associated with some personality patterns, such as perfectionism and the tendency to internalize emotions (De Carvalho et al., 2003). Research has shown that a strong relationship exists between insomnia, depression and anxiety, where insomnia may be a risk factor (Taylor et al., 2003). Unfortunately, the exact nature of this relationship remains unclear because previous studies have had varied definitions of insomnia and sometimes did not control for confounds. Finally, there is a significant overlap between sleep disorders, anxiety disorders and depressive disorders of the patients. Age, depression scores, anxiety scores, education and stress level during the last year are accepted as factors that may have an impact on sleep quality scores (Hakan, 2011). In the general population, those who report poor sleep quality use more health services (Sabbatini et al., 2002). In addition, self-reported long and short sleepers have a higher risk for death and disability when compared with individuals who report average sleep duration (Kapur et al., 2002; Kripke et al., 2002; Patel et al., 2004). Therefore, sleep problems are associated with lower quality of life (Benz et al., 2000; Leung and Bradley, 2001; Iliescu et al., 2004; Wasserfallen et al., 2004). Recent evidence suggests a potential link between poor sleep quality and sleep disorders. Sleep disorders have been shown to be independent predictors of morbidity (Winkelman et al., 1996; Benz et al., 2000; Mucsi et al., 2004; Unruh et al., 2004). Validated instruments to detect specific sleep disorders were not used in most of the earlier surveys assessing sleep complaints in patients. Specific self-administered tools have been developed and validated to screen and diagnose sleep disorders (Netzer et al., 1999; Allen and Earley, 2001). Finally, psychiatric disorders are frequently associated with disturbances of sleep and circadian rhythms. The relationship between psychiatric disorders and sleep complaints is bidirectional. Approximately two-thirds of depressed patients complain of insomnia (sleep-onset insomnia, frequent awakenings and early morning awakenings 2-4 h earlier than desired, with difficulty returning to sleep), whereas 15% complain of hypersomnia (Rodin et al., 1988; Buysse, 2005). Similar to depressed individuals, individuals with anxiety disorders also experience sleep difficulties. Common sleep disturbances associated with anxiety disorders are sleep onset or sleep maintenance insomnia (The Numbers Count, 2005). Most anxiety disorders are moderately associated with a reduced sleep quality. Individuals with anxiety disorders and poor sleep experience significantly worse mental health-related quality of life and increased disability relative to those with anxiety disorders alone (Ramsawh et al., 2009).

Our study aimed to:

  1. determine the prevalence of sleep disorders and poor quality of sleep in patients with anxiety or depressive disorders;
  2. study the effect of sleep problems on important determinants of health-related quality of life of patients with anxiety or depressive disorders;
  3. compare patients with anxiety disorders and patient with depressive disorders regarding sleep disorders, quality of sleep and quality of life;
  4. investigate the effect of the demographic factors, scores of anxiety and scores of depression on the quality of sleep and the quality of life of these patients.



  Patients and methods Top


This was a cross-sectional study conducted on patients with anxiety or depressive disorders attending outpatient clinics of Buraydah Mental Health Hospital, Al-Qassim, Kingdom of Saudi Arabia, over a 6-month period. Patients were excluded if they were above18 years of age, if they showed psychotic features or dementia, were mentally retarded or if they were not competent to give consent. Two hundred patients with anxiety or depressive disorders and 50 persons as a control were included in the study according to these inclusion and exclusion criteria. Demographic characteristics were recorded.

Comorbidity

Comorbidity was measured using the Charlson Comorbidity Index (CCI) (Beddhu et al., 2000). The CCI is a composite score of multiple comorbid conditions and age. Comorbid conditions are given a score ranging from 1 to 6 and a score of 1 is added for each decade above 40 years of age. For the purpose of this study, comorbid conditions were determined from patients' files and scored according to the CCI.

Quality of sleep

Quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989). This self-administered questionnaire assesses the quality of sleep during the previous month and contains 19 self-rated questions yielding seven components: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medications and daytime dysfunction. Each component is scored from 0 to 3, yielding a global PSQI score between 0 and 21 with higher scores indicating lower quality of sleep. The PSQI is useful in identifying good and poor sleepers. A global PSQI score more than 5 indicates that a person is a poor sleeper, having severe difficulties in at least two areas or moderate difficulties in more than three areas.

Diagnosis of specific sleep, anxiety and depressive disorders

A semistructured psychiatric interview was used to diagnose specific sleep, anxiety or depressive disorders on the basis of the Diagnostic and statistical manual of mental disorders, 4th ed., text revision (DSM-IV-TR) criteria of the American Psychiatric Association (2000).

Depression anxiety stress scales

The Depression Anxiety Stress Scales (DASS) consists of three self-report scales that have been designed to measure the negative emotional states of depression, anxiety and stress. The depression scale measures: dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest, anhedonia and inertia. The anxiety scale measures: autonomic arousal, skeletal muscle effects, situational anxiety and subjective experience of anxious affect. The stress scale measures: difficulty relaxing, nervous arousal and being easily upset/agitated, irritable/over-reactive and impatient (Affonso et al., 2000). Validity for the DASS has been demonstrated, whereby the DASS depression scale correlated strongly with the Beck Depression Inventory (r = 0.74) and the DASS anxiety scale was highly correlated with the Beck Anxiety Inventory (r = 0.81) (Lovibond and Lovibond, 1995; Affonso et al., 2000). The DASS-21 is a brief 21-item version of the full DASS, which originally consisted of 42 items. Each of the three DASS-21 scales contains seven items representing the dimensions of depression, anxiety and stress. Participants are asked to rate the extent to which they experienced each state over the past week on a four-point likert rating scale. Subscale scores are derived by totaling the scores. No items are reverse scored. Scores for each subscale are multiplied by 2 to ensure consistent interpretation with the longer 42-item version. The DASS manual provides a series of cut-off values to classify individuals into severity rating categories. These severity ratings are based on percentile scores with 0-78 classified as normal, 78-87 as mild, 87-95 as moderate, 95-98 as severe and 98-100 as extremely severe (Brown et al., 1997; Affonso et al., 2000; Clara et al., 2001). The DASS was selected in the present study for three reasons: its ability to identify these three negative emotional states as separate phenomena, its capacity to identify comorbidity of these negative emotional states and its ability to identify mild symptoms of each negative affective state in order to more fully identify women who might be distressed.

Quality of life

Health-related quality of life was measured with the Short Form 36-item (SF-36) (Ware et al., 1993, 1994). This instrument has been used extensively in populations of patients with renal disease. The SF-36 is a 36-item self-administered questionnaire that yields scores for eight domains (physical functioning, role limitations physical, bodily pain, general health perceptions, vitality, social functioning, role limitations emotional and mental health) as well as two summary scores: a Mental Component Summary (MCS) score and a Physical Component Summary (PCS) score. Each of the eight domains is scored out of 100, with higher scores indicating better functioning (Valderrabano et al., 2001).

Statistical analyses

All data were analyzed with a personal computer using the SPSS statistical software program (version 13.0) (SPSS, 2002). Descriptive statistics will be calculated for the sample population, and group differences were compared for continuous variables with Student's t-test and an analysis of variance. Differences among categorical variables were analyzed using the χ2 -test or two-tailed Fisher's exact test as appropriate. Spearman's correlation coefficients were used to examine associations between continuous variables.


  Results Top


Demographic characteristics of the 200 patients are shown in [Table 1]. There were no significant differences regarding age, sex, socioeconomic status or educational level but being married and not employed appear to be risk factors for sleep disorders among patients with anxiety or depressive disorders (P < 0.05). The CCI shows that chronic pulmonary disease and diabetes mellitus are associated with patient with sleep disorders among patients with anxiety or depressive disorder as shown in [Table 2]. Regarding rating scales as shown in [Table 3], there were no significant difference between patients with anxiety or depressive disorder who have sleep disorders and those who do not have sleep disorders regarding the comorbidity index. Patients with anxiety or depressive disorder who have sleep disorders have higher PSQI scores (P < 0.01) and lower SF-36 scores (P < 0.01) than patients with anxiety or depressive disorder who do not have sleep disorders. All patients with anxiety or depressive disorder regardless of having sleep disorders or not, have higher scores in DASS-21 than the control group (P < 0.01). Regarding the severity of illness as shown in [Table 4], we found that most of patients with or without sleep disorder have mild to moderate severity in DASS-21. We found a high prevalence of sleep disorders in our sample: primary insomnia was the most common sleep disorder (27.50%), followed by circadian rhythm disorder (4.00%), and then primary hypersomnia (3.50%). Overall, 36.00% of the patients showed sleep disorder; 43.00% of them had anxiety disorder and 29.00% of them had depressive disorder. Primary insomnia has a higher statistically significant difference among patients with anxiety or depressive disorder than the control group (P < 0.05) as shown in [Table 5]. Regarding the quality of sleep, patients who had sleep disorders had higher scores in global PSQI and all other PSQI items (P < 0.05), except the daytime dysfunction item as shown in [Table 6]. [Table 7] shows that the use of psychotropic medications (antidepressants, antipsychotics, antiepileptics and benzodiazepines) is associated with patients who do not have sleep disorders (P < 0.01). [Table 8] shows that all patients had a lower quality of life compared with the control group in the MCS, the PCS and the total score. SF-36 was significantly lower in all components except in vitality in patients with sleep disorders than with those without sleep disorders as shown in [Table 9]. There was correlation between the DASS-21 score and the PSQI and the SF-36 scores regarding both patients with anxiety disorders and patients with depressive disorders as shown in [Table 10]. [Table 11] shows that there is correlation between SF-36, both MCS and PCS, and PSQI scores in all items except sleep latency.
Table 1: Demographic characteristics of different groups included in the study

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Table 2: Frequencies of comorbid conditions in the charlson comorbidity Index among the studied groups

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Table 3: Scores of rating scales of different groups included in the study

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Table 4: Severity of illness on depression anxiety stress Scales for different groups included in the study

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Table 5: Sleep disorders among the patients according to the Diagnostic and statistical manual of mental disorders, 4th ed., text revision criteria

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Table 6: Quality of sleep using the pittsburgh sleep quality index among patients

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Table 7: The use of psychotropic medications and its relation to sleep disorders

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Table 8: Quality of life according to short form 36-item scores (mean ± SD)

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Table 9: Quality of life among different studied groups according to short form 36-item (mean ± SD)

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Table 10: Correlation between illness severity depression anxiety stress scales score, the pittsburgh sleep quality index score and short form 36-item score

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Table 11: Correlation coefficients for the short form 36-item and the pittsburgh sleep quality index among the patients

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  Discussion Top


The aim of our study was to assess the prevalence of the most important sleep disorders and examine their predictors among patients with anxiety or depressive disorders. Furthermore, we wanted to study the relationship between sleep disorders, quality of sleep and different aspects of health-related quality of life. We have shown that sleep disorders are independent determinants of the quality of life in patients with anxiety or depressive disorders.

The prevalence of sleep disorders among patients with anxiety or depressive disorders was 36%, which is comparable to the 30-80% prevalence among patients reported in previous studies (Mellinger et al., 1985; Rodin et al., 1988; Ford and Kamerow, 1989; Roth, 2001; Ohayon and Roth, 2003; Taylor et al., 2003, 2005; Mucsi et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004; Abad and Guilleminault, 2005; Buysse, 2005; The Numbers Count, 2005; Loria-Castellanos et al., 2010; Hakan, 2011). The fact that the prevalence of sleep disorders in the present study is similar to the prevalence of sleep disorders in previous studies suggests that the magnitude of sleep problems in patients with anxiety or depressive disorders is similar among different populations. Our results are consistent with most of the recent studies (Mellinger et al., 1985; Rodin et al., 1988; Mucsi et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004; Abad and Guilleminault, 2005; Buysse, 2005; Leger and Poursain, 2005; Taylor et al., 2005; The Numbers Count, 2005; Szelenberger and Soldatos, 2005; Loria-Castellanos et al., 2010; Hakan, 2011) that insomnia was the most common sleep disorder. Insomnia (the most common sleep disorder in this sample) can be diagnosed from the history and from the typical symptoms according to the DSM-IV-TR criteria. We are inconsistent with other studies, which found that sleep apnea, periodic leg movement disorder and restless leg syndrome followed insomnia in prevalence among patients with anxiety or depressive disorders (Mellinger et al., 1985; Mucsi et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004; Abad and Guilleminault, 2005; Taylor et al., 2005; The Numbers Count, 2005; Loria-Castellanos et al., 2010; Hakan, 2011). Overnight polysomnography is needed, however, for the definitive diagnosis of sleep apnea, periodic leg movement disorder and restless leg syndrome. Polysomnography is considered as an expensive and not readily available procedure and might even be difficult to carry out with severely ill patients. It is therefore important to have reliable screening tools to identify these disorders in populations at significant risk.

We found no association between sleep disorders and the sex of the patients, their socioeconomic level or their educational level after correcting for other variables in this sample of patients with anxiety or depressive disorders. Earlier epidemiological studies showed that insomnia symptoms occur more frequently (about two-fold) in women compared with men (Ford and Kamerow, 1989; Kappler and Hohagen, 2003; Roth and Drake, 2004; Hakan, 2011). Furthermore, the prevalence of sleep disorders generally increases with age, but we did not observe this tendency either. We found an association between sleep disorders and currently married patients and also patients who were unemployed, which clarifies the importance of psychological and social care for these patients (Chang et al., 1997; Roth, 2001; Kripke et al., 2002; Sabbatini et al., 2002; Taylor et al., 2003; Billiard and Bentley, 2004; Leger and Poursain, 2005). The pathophysiology of certain sleep disorders such as insomnia, sleep apnea, periodic leg movement disorder and restless leg syndrome may differ in the general population and in the medically ill. This presence of anxiety or depressive disorder may be reflected partly in the high prevalence of sleep disorders and partly in the lack of the age and sex effect observed in the general population.

We examined the relationship between sleep disorders and the quality of life. As observed in the present study, earlier studies also found that poor sleep quality and the presence of sleep disorders were associated with an impaired quality of life in patients with anxiety or depressive disorders. We are also inconsistent with recent studies that have examined the relationship between sleep disorders and the quality of life in patients with anxiety or depressive disorders (Mellinger et al., 1985; Breslau et al., 1997; Chang et al., 1997; Pilcher et al., 1997; Pilcher and Ott, 1998; Benz et al., 2000; Kojma et al., 2000; Howard et al., 2002; Kapur et al., 2002; Kripke et al., 2002; Sabbatini et al., 2002; Billiard and Bentley, 2004; Parshuram et al., 2004; Patel et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004; Abad and Guilleminault, 2005; Taylor et al., 2005; Ramsawh et al., 2009; Loria-Castellanos et al., 2010) because sleep disorders can be treated successfully, and improving sleep may, in turn, improve patients' quality of life. There was a strong association between the quality of sleep and the mental and physical quality of life. In the present study, both poor mental quality of life (SF-36 MCS) and poor physical quality of life (SF-36 PCS) were associated with sleep disturbance and daytime dysfunction. Also, the physical quality of life (SF-36 PCS) was associated with sleep efficiency. Compared with patients who have no sleep disorder, patients who have sleep disorders had a lower quality of life in most of the SF-36 domains. The association between sleep quality and quality of life may be explained by a direct influence of sleep quality on the quality of life (or vice versa) or an overlap in the instruments used to measure sleep quality and quality of life or a combination of these.

We hypothesize that anxiety-related and depressive disorder-related sleep disturbances impact the quality of life directly and are responsible for a component of the association between sleep quality and quality of life observed in the present study. In the present study, we are in agreement with previous studies that the quality of sleep remained a significant predictor of mental and physical quality of life (Winkelman et al., 1996; Benz et al., 2000; Leung and Bradley, 2001; Iliescu et al., 2004; Mucsi et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004). Quality of sleep and quality of life were associated with the comorbidity of the following diseases: diabetes and chronic pulmonary disease. The use of any psychotropic medications (benzodiazepines, antidepressants, antipsychotics, antiepileptics) is associated with patients who do not have sleep disorders. This result was consistent with most of the recent studies that showed that the use of benzodiazepines is associated with good sleep quality and better quality of life in patients with anxiety or depressive disorders (Iliescu et al., 2004; Unruh et al., 2004; Wasserfallen et al., 2004).

In the present study, quality of sleep and quality of life were measured using validated questionnaires. PSQI and SF-36 evaluate the quality of sleep and the quality of life during the preceding 4-week period. SF-36 has been rigorously evaluated as a tool for the measurement of the quality of life in patients with sleep disorders (Mellinger et al., 1985; Buysse et al., 1989; Ware et al., 1993, 1994; Iliescu et al., 2004; Wasserfallen et al., 2004; Abad and Guilleminault, 2005; Taylor et al., 2005; Loria-Castellanos et al., 2010). SF-36 and PSQI do not ask the same questions; however, some overlap is likely, particularly with regard to daytime dysfunction such as feeling tired. This would result in an overestimation of the relationship between this component of PSQI and SF-36. In contrast, PSQI components such as sleep efficiency and sleep disturbance are evaluated by specific questions regarding sleep times and disturbances. The strong associations between these PSQI components and SF-36 PCS suggest that the relationship between sleep quality and the quality of life is not simply due to potential overlap between the two questionnaires in regard to daytime dysfunction.

Clinical implications

Clinicians should routinely screen for sleep problems in patients with anxiety or depressive disorders, as they may signify worse functioning and warrant treatment augmentation.

Limitations

The main limitation of this study is the absence of polysomonograph results without which it is not possible to ascertain the exact causes of insomnia and sleep disturbance. Because of the cross-sectional design, it was not possible to establish the cause and the effect in the associations examined. It was not possible to accurately measure all variables that may impact the quality of sleep and the quality of life. Comorbidity was measured with a validated index that is a strong predictor of clinical outcomes in patients. The advantage of using an index is the evaluation of a large number of conditions while limiting comorbidity to only one independent variable.


  Conclusion Top


In conclusion, the results of this study suggest that sleep disorders are common in patients with anxiety or depressive disorders and that the quality of sleep is an independent predictor of the quality of life. We hypothesize that a component of this association is due to the direct influence of anxiety or depressive disorders on the quality of sleep, which in turn influences the quality of life. In patients with a low quality of life, measurement of quality of sleep in conjunction with specific questions about symptoms of sleep disorders may be useful in identifying patients who would benefit from formal polysomnography. Additional studies are needed to examine the influence of objective sleep disturbances on the quality of life in patients with anxiety or depressive disorders and to evaluate potential treatments such as sleep medications and others psychotropic medications. Longitudinal studies of quality of sleep in patients with anxiety or depressive disorders are needed to examine the sequence of the decrease in the quality of sleep and the quality of life.


  Acknowledgements Top


This study was supported by Al-Qassim University, Kingdom of Saudi Arabia. The authors appreciate the help and cooperation extended by the Ministry of Health, Buraydah Mental Health Hospital, Al-Qassim, Kingdom of Saudi Arabia.[52]

Conflicts of interest

No conflict of disclosure.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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