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Sleep-EVAL
Research
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Background: A chronic painful physical condition (CPPC) can be a major cause of sleep disturbances. Few community-based surveys examined the specific relationship between these two conditions. Methods: 18,980 participants aged 15 years or older from five European countries (the United Kingdom, Germany, Italy, Portugal and Spain) and representative of approximately 206 millions Europeans were interviewed by telephone. The interview included questions about sleeping habits, health, sleep and mental disorders. Painful physical conditions were ascertained through questions about medical treatment, consultations and/or hospitalizations for medical reasons and a list of 42 diseases. A painful physical condition was considered chronic when it lasted at least six months. Insomnia symptoms were defined as difficulty initiating or maintaining sleep or non-restorative sleep, present at least 3 nights per week, lasting at least one month ,and accompanied by daytime consequences. Results: 1) The point prevalence of at least one CPPC was set at 17.1% (95% CI: 16.5% to 17.6%) in the sample. 2) Difficulty initiating sleep was found in 5.1% (95% Confidence Intervals: 4.8% to 5.4%) of the sample, disrupted sleep in 7.5% (95% CI: 7.2% to 7.9%); early morning awakenings in 4.8% (95% CI: 7.2% to 7.9%) and non-restorative sleep in 4.5% (95% CI: 4.2% to 4.8%). 3) More than 40% of individuals with insomnia symptoms reported at least one CPPC. 4) CPPC was associated with more frequent difficulty or inability to resume sleep once awake and a shorter sleep duration. 5) In middle-aged subjects (45 to 64 years of age), CPPC was associated with longer insomnia duration. At any age, insomnia with CPPC was associated with a greater number of daytime consequences (average of four consequences) than in insomnia without CPPC (average of 2.3 consequences). 6) In multivariate models, CPPC, especially backaches and joint/articular diseases, were at least as importantly associated with insomnia than were mood disorders with odds ratios ranging from 4.1 to 5.0 for backaches and from 3.0 to 4.8 for joint/articular diseases. Conclusions: CPPC is associated with a worsening of insomnia on several aspects: a greater number of insomnia symptoms, more severe daytime consequences and more chronic insomnia situation. CPPC plays a major role on insomnia. Its place as major contributive factor for insomnia is as much important as mood disorders.
Objectives: The purposes of this study were to identify age-related changes in objectively recorded sleep patterns across the human life span in healthy individuals and to clarify whether sleep latency, percentages of stage 1, stage 2 and REM sleep significantly change with age. Design: Review of literature of articles published between 1960 and 2003 in peer-reviewed journals and meta-analysis. Participants: 65 studies representing 3,577 subjects aged 5 years to 102 years. Measurement: The research reports included in this meta-analysis met the following criteria: a) included non-clinical participants aged five years or older; b) included measures of sleep characteristics by all night polysomography (PSG) or actigraphy on sleep latency (SL), sleep efficiency (SE), total sleep time (TST), stage 1, stage 2, slow wave sleep (SWS), REM, REM latency, or minutes awake after sleep onset (WASO); c) included numeric presentation of the data; d) were published between 1960 and 2003 in peer-reviewed journals. Results: In children and adolescents, total sleep time decreased with age only in studies performed on school days. Percentage of SWS was significantly negatively correlated with age. Percentages of stage 2 and REM sleep significantly changed with age. In adults, total sleep time, sleep efficiency, %SWS, %REM sleep and REM latency all significantly decreased with age; while sleep latency, % stage 1, % stage 2 and WASO significantly increased with age. However, only sleep efficiency continued to significantly decrease after 60 years of age. The magnitudes of the effect sizes noted changed depending on whether or not studied participants were screened for mental disorders, organic diseases, use of drug or alcohol, OSAS, or other sleep disorders. Conclusions: It appeared that sleep latency, percentages of stage 1, stage 2 and REM sleep significantly increased with age. However, effect sizes for the different sleep parameters were greatly modified by the quality of subject screening, diminishing or even masking age associations with different sleep parameters. The number of studies that examine the evolution of sleep parameters with age are scant among school-aged children, adolescents and middle-aged adults. There are also very few studies that examined the effect of race on PSG sleep parameters.
Several epidemiological surveys performed in Western Europe reported a prevalence of insomnia symptoms between 20% and 40% of the general population. Women and elderly individuals were the most affected. Many events can occur during sleep and affect its quality. Daytime sleepiness, a consequence of lack of sleep and/or insomnia, is responsible for many road, work and domestic accidents. Therefore, insomnia may have important consequences both for individuals and society. This study performed in the non institutionalized French population reports the sleep habits of that population and the factors associated with insomnia. This epidemiological study was conducted with 5622subjects representative of the French general population. They were aged between 15 and 96 Years. The participation rate was 80.8%. The results showed that men and women have different sleep habits. Generally speaking, women went to bed about 12 minutes earlier than men and woke up later than men (p<0.001). Women also took more time to fall asleep than men but only when they were aged between 35 and 65 Years. Furthermore, women had a longer sleep than men except between the ages of 55 and 74, where men slept significantly more than women. However, sleep efficiency was lower in women than in men who were over age 35. This was due to a greater frequency of nocturnal awakenings in women than in men. Sleep habits also changed with age: Bedtime became progressively earlier with advancing age and wake-up time was later when the subjects reached retirement age. Sleep latency progressively increased with age after 35. Similarly, disrupted sleep increased with age and was reported by more than half of subjects 75 Years or older. We found also that evening or night workers showed irregularities in their sleep patterns: sleep latency was significantly longer - at least 12 minutes - compared to daytime and shift workers (p<0.001). They also had a shorter sleep duration of about 30 minutes compared to shift workers, and 40 minutes compared to daytime workers (p<0.001). Shift workers and evening or night workers had a lower sleep efficiency compared to daytime workers. Finally, in regions with greater density population (>100000inhabi-tants) sleep duration was shorter by approximately 10 minutes compared to localities with fewer than 5 000 residents (p<0.01). Similarly, bedtime and wake up hours were more related in regions with more than 100 000 inhabitants compared to small localities (fewer than 5 000 residents). Insomnia complaints, defined as the presence of at least one insomnia symptom accompanied by sleep dissatisfaction or use of a sleep medication, were reported by 18.6% of the sample. The prevalence was higher in women (22.4%) than in men (14.5%) and increased with age. However, the proportion of subjects dissatisfied with their sleep remained comparable for all age groups; it was the number of subjects using a sleep medication that increased with age. This was 3.2% in subjects 44 Years or younger, 13.3% in subjects between 45 and 64 Years, 22% of those between 65 and 74 Years and almost a third of individuals 75 Years or older (32%; p<0.001). However, insomnia symptoms remained present for most of these consumers: 80.4% of those between 15 and 44 Years, 87.9% of those between 45 and 64 Years, 81.4% of those between 65 and 74 Years and 78.8% of subjects of 75 Years or older. Compared to subjects in other epidemiological studies undertaken in England, Germany and Italy and using the same methodology, subjects in this study complained with their sleep more often. Insufficient sleep was found more often in the active population, which is subject to schedule constraints. Shift workers as well as evening or night workers were the most likely to have a sleep debt.
We studied the sleep of patients with insomnia during continuous and very long-term use of benzodiazepines (BZDs), and after withdrawal. A group of 25 patients (mean age 44.3+/-11.8 years) with persistent insomnia, who had been taking BZDs nightly for 6.8+/-5.4 years was selected. The control group was comprised of 18 age-matched healthy individuals. Sleep stage parameters were analyzed during Night 1 (while taking BZDs), Night 2 (first night after completing BZD withdrawal), and Night 3 (15 days after gradual BZD withdrawal). Sleep data for control subjects was monitored in parallel. Sleep EEGs of the patients were analyzed using Period Amplitude Analysis (PAA), during Nights 1 and 3 only. During BZD use, a significant reduction of Total Sleep Time (TST) and increased sleep latency were found in the insomniac group when compared to controls. We found an increase in stage 2 non-REM (NREM) sleep, and a reduction in Slow Wave Sleep (SWS) when comparing to night 3 (after withdrawal). Sleep EEGs analysis showed an increase in sigma band and decrease in delta count in stages 2, 3, 4 NREM and REM sleep in the BZD group when comparing to night 3 (after withdrawal). During the BZD withdrawal period, six out of nine subjects taking lorazepam failed withdrawal. In the remaining 19 subjects, gradual withdrawal of BZDs was associated with immediate worsening of nocturnal sleep, as indicated by sleep parameters. However, 15 days after withdrawal (Night 3), some of the sleep structure parameters of patients were not significantly different from baseline (while taking BZDs), except for a significant increase in SWS and in delta count throughout most sleep stages, and a decrease in stage 2 NREM sleep. These values were not different from those shown by control subjects. REM sleep parameters showed no significant variation across the experimental conditions. Subjective sleep quality was significantly improved on Night 3 compared with Night 1. Conclusions: Chronic intake of BZDs may be associated with poor sleep in this population. A progressive 15-day withdrawal did not avoid an immediate worsening of sleep parameters. But at the end of the protocol, SWS, delta count, and sleep quality were improved compared to those recorded during the chronic BZD intake, despite the lack of change in sleep efficiency.
BACKGROUND: Pain syndrome is thought to play a role in depression. This study assesses the prevalence of chronic (>or= 6 months' duration) painful physical conditions (CPPCs) (joint/articular, limb, or back pain, headaches, or gastrointestinal diseases) and their relationship with major depressive disorder. METHODS: We conducted a cross-sectional telephone survey of a random sample of 18 980 subjects from 15 to 100 years old representative of the generalpopulations of the United Kingdom, Germany, Italy, Portugal, and Spain. Answers provided during telephone interviews using the Sleep-EVAL system were the main outcome measure. Interviews included questions about mental disorders and medical conditions. Data on painful physical conditions were obtained through questions about medical treatment, consultations, and/or hospitalizations for medical conditions and a list of 42 diseases. RESULTS: Of all subjects interviewed, 17.1% reported having at least 1 CPPC (95% confidence interval [CI], 16.5%-17.6%). At least 1 depressive symptom (sadness, depression, hopelessness, loss of interest, or lack of pleasure) was present in 16.5% of subjects (95% CI, 16.0%-17.1%); 27.6% of these subjects had at least 1 CPPC. Major depressive disorder was diagnosed in 4.0% of subjects; 43.4% of these subjects had at least 1 CPPC, which was 4 times more often than in subjects without major depressive disorder (odds ratio [OR], 4.0; 95% CI, 3.5-4.7). In a logistic regression model, CPPC was strongly associated with major depressive disorder (OR: CPPC alone, 3.6; CPPC + nonpainful medical condition, 5.2); 24-hour presence of pain made an independent contribution to major depressive disorder diagnosis (OR, 1.6). CONCLUSIONS: The presence of CPPCs increases the duration of depressive mood. Patients seeking consultation for a CPPC should be systematically evaluated for depression.
BACKGROUND: Insomnia is frequent in the general population and is often related to a psychiatric illness. However, little is known about how the chronicity of insomnia affects this relation and how often subjects with chronic insomnia have antecedents of psychiatric disorders. METHODS: A total of 14,915 subjects aged from 15 to 100 years representative of the general population of the United Kingdom, Germany, Italy, and Portugal were interviewed by telephone using the Sleep-EVAL system. The questionnaire assessed current psychiatric disorders according to the DSM-IV classification and a series of questions assessed the psychiatric history. Insomnia was considered as chronic when it lasted for 6 months or more. RESULTS: The prevalence for insomnia accompanied with impaired daytime functioning was 19.1% and significantly increased with age. More than 90% of these subjects had a chronic insomnia. About 28% of subjects with insomnia had a current diagnosis of mental disorders and 25.6% had a psychiatric history. A DSM-IV insomnia disorder was found in 6.6% of the sample. Presence of severe insomnia, diagnosis of primary insomnia or insomnia related to a medical condition, and insomnia that lasted more than one year were predictors of a psychiatric history. In most cases of mood disorders, insomnia appeared before (> 40%) or in the same time (> 22%) than mood disorder symptoms. When anxiety disorders were involved, insomnia appeared mostly in the same time (>38%) or after (> 34%) the anxiety disorder. CONCLUSIONS: The study shows that psychiatric history is closely related to the severity and chronicity of current insomnia. Moreover, chronic insomnia can be a residual symptom of a previous mental disorder and put these subjects to a higher risk of relapse.
The purpose of this study is to assess the prevalence of insomnia symptoms and diagnoses in the general population of Finland. A total of 982 participants, aged 18 years or older and representative of the general population of Finland, were interviewed by telephone using the Sleep-EVAL system. The participation rate was 78%. The questionnaire included the assessment of sleep habits, insomnia symptomatology according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) and International Classification of Sleep Disorders (ICSD), associated and sleep/mental disorders and daytime consequences. The overall prevalence of insomnia symptoms occurring at least three nights per week was 37.6%. Difficulty initiating sleep were mentioned by 11.9% of the sample, difficulty maintaining sleep by 31.6%, early morning awakenings by 11.0% and non-restorative sleep by 7.9% of the sample. Global dissatisfaction with sleep was found in 11.9% of the sample. Daytime consequences (fatigue, mood changes, cognitive difficulties or daytime sleepiness) were reported by 39.9% of participants with insomnia symptoms and 87.6% of those with sleep dissatisfaction. A deterioration of sleep in summer or winter was associated with more complaints of sleep dissatisfaction. Prevalence of any DSM-IV insomnia diagnosis was 11.7%. More specifically, DSM-IV diagnosis of primary insomnia had a prevalence of 1.6% and DSM-IV diagnosis of insomnia related to another mental disorder was at 2.1%. Insomnia was a symptom of another sleep disorder in about 16% of cases and of a mental disorder in about 17% of cases. As reported in other Nordic studies, sleep quality was worse in summer. Insomnia symptomatology was common and was reported by more than a third of Finnish participants. Compared with other European countries studied with the same methodology (France, the UK, Germany, and Italy), the prevalence of DSM-IV insomnia diagnosis was 1.5 to two times higher in Finland.
OBJECTIVE: The study evaluated the prevalence of major depressive episodes with psychotic features in the general population and sought to determine which depressive symptoms are most frequently associated with psychotic features. METHOD: The sample was composed of 18,980 subjects aged 15-100 years who were representative of the general populations of the United Kingdom, Germany, Italy, Portugal, and Spain. The participants were interviewed by telephone by using the Sleep-EVAL system. The questionnaire included a series of questions about depressive disorders, delusions, and hallucinations. RESULTS: Overall, 16.5% of the sample reported at least one depressive symptom at the time of the interview. Among these subjects, 12.5% had either delusions or hallucinations. More than 10% of the subjects who reported feelings of worthlessness or guilt and suicidal thoughts also had delusions. Feelings of worthlessness or guilt were also associated with high rates of hallucinations (9.7%) and combinations of hallucinations and delusions (4.5%). The current prevalence of major depressive episode with psychotic features was 0.4% (95% CI=0.35%-0.54%), and the prevalence of a current major depressive episode without psychotic features was 2.0% (95% CI=1.9%-2.1%), with higher rates in women than in men. In all, 18.5% of the subjects who fulfilled the criteria for a major depressive episode had psychotic features. Past consultations for treatment of depression were more common in depressed subjects with psychotic features than in depressed subjects with no psychotic features. CONCLUSIONS: Major depressive episodes with psychotic features are relatively frequent in the general population, affecting four of 1,000 individuals. Feelings of worthlessness or guilt can be a good indicator of the presence of psychotic features.
Untreated insomnia often has repercussions on socio-professional or cognitive functioning of insomniacs. In industrialized countries, the prevalence of insomnia ranges between 10% and 48%, depending on the methodology and the measured time interval. However, few studies have examined the relationship between insomnia and mental disorder diagnoses. This epidemiological study on insomnia complaints was conducted on 5 622 subjects representative of the non-institutionalized French population aged 15 years or over. Sixteen interviewers using the Sleep-EVAL expert system performed telephone interviews. Insomnia complaints (defined as difficulty initiating or maintaining sleep, feeling unrefreshed at awakening accompanied by dissatisfaction with sleep quality or quantity, or use of sleep-promoting medication) were observed in 18.6% (95% confidence interval: 17.6% to 19.6%) of the sample. The median duration of insomnia complaints was five years. Regional variations in the prevalence of insomnia complaints were observed in France. In North 2 and Center 4 regions, the prevalence of insomnia complaints was higher compared to the rest of France with a relative risk of 1.4 (95% confidence interval: 1.1-1.6) time superior for the North region and 1.3 (95% CI: 1.0-1.6) for the Center 4 region. The lowest prevalence was registered in the Mediterranean area. In most regions, the prevalence of insomnia complaints was higher in women than in men with the exception of the South and West regions where the prevalence was similar. Subjects with insomnia complaints consulted more frequently compared to the rest of sample with an odds ratio of 3 to 1 [95% CI: 2.8 to 4.1]. Close to 20% of subjects were being treated for a physical disease at the time of the survey; subjects with insomnia complaints being twice more numerous (34.3%) than the rest of the sample (15.9%; p<0.001). To identify the main factors associated with insomnia complaints, socio-demographic and health variables were introduced in a multivariate model. Separated or divorced individuals (OR: 1.6); widowers (OR: 1.5); subjects aged between 45 and 65 years (OR: 1.4) or older than 65 (OR: 1.5); women (OR: 1.3); those with little or no education (OR: 1.4); and subjects living in the North region had higher reported insomnia complaints. Living in the East region (Mediterranean) was a protective factor (OR: 0.6). Furthermore, subjects with vascular diseases (OR: 2.0), musculo-skeletal diseases (OR: 2.0) or cardiac diseases (OR: 1.9) and those who had consulted a physician in the previous six months (OR: 2.7) had higher a probability of insomnia complaints. Subsequently, DSM IV insomnia diagnoses were examined in subjects who complained of insomnia. A diagnosis of primary insomnia was found in 7% of these subjects. A diagnosis of insomnia related to another mental disorder was found in 15.6% of insomnia complainers. A depressive disorder diagnosis was given in 10.8% of cases (mainly a major depressive disorder). This diagnosis was made more often among women and subjects of less than 65 years. An anxiety disorder diagnosis was given for 33.1% of insomnia complainers (an anxiety generalized disorder in about half the cases). About a quarter of insomnia complainers did not receive a diagnosis. This was the case more often for men and the subjects 65 years or older. If demographic and medical factors are relatively well documented at the epidemiological level, it is otherwise for psychiatric diagnosis associated with insomnia complaint. Very few studies in the general population have been done and still fewer of them have applied a positive and differential diagnosis process. In this study, we used the DSM IV classification to establish positive and differential diagnoses among subjects with insomnia complaints. Compared to other epidemiological studies, our study is distinguished by several aspects: 1) insomnia complaint had a narrower definition. It did not suffice that the subject reported insomnia symptoms, it was also necessary that the subject said s/he was dissatisfied with her/hr/his sleep or that s/he took measures to improve it (medication or sleep hygiene). This choice was motivated essentially by the fact that it is difficult, from a point of clinical point of view, to consider that an individual has insomnia solely based on the presence of symptoms, that, appreciated by a clinician, would resemble insomnia without that they make problem for the subject. 2) Several sleep habits were systematically collected. The majority of epidemiological studies are not centered on sleep problems, with the consequence that results do not allow a global view of factors that are associated with insomnia. 3) The various diagnostic categories of insomnia as well as elements of the differential diagnosis were applied. Thus, we can conclude that insomnia, as a diagnostic entity, including all its forms, is found in 5.6% of the French population. In the majority of cases, the insomnia complaint is part of the symptomatology of a mental disorder, mainly an anxiety disorder. This distinction is important since it helps the physician to determine therapeutic choices. To conclude, it is worthwhile to consider the number of insomnia complainers who had consulted a physician, mainly a general practitioner, in the six months prior to the study. This designates physicians as the first-line resource in the treatment and the prevention of sleep disorders.
BACKGROUND: The use of psychotropic medications and its association with sleep and psychiatric and physical illnesses were studied in the general population. METHOD: A cross-sectional telephone survey was carried out using the Sleep-EVAL knowledge-base system. A representative sample of the noninstitutionalized general populations of France, Germany, Italy, and the United Kingdom, aged 15 years or over, was interviewed (N = 18,679; participation rate: 78.8%; target population: 204,605,391 inhabitants). Questions were asked about psychotropic medication intake (name of medication, indication, dosage, duration of intake, prescriber), sociodemographics, physical illnesses, and DSM-IV mental disorders. RESULTS: At the time of the interview, 6.4% of the subjects took a psychotropic medication. Anxiolytics were reported by 4.3% of the sample, hypnotics by 1.5%, antidepressants by 1.0%, and neuroleptics and other psychotropics by less than 1.0%. Hypnotics and anxiolytics were mostly used as a sleep disorder treatment. Antidepressants were taken appropriately for a depressive illness in only 44.1% of cases. Low doses of hypnotics and anxiolytics were found in about 10% of cases and low doses of antidepressants in 31.7% of cases. Subjects with a psychiatric disorder received a psychotropic treatment only infrequently (between 10% to 40.4%, depending on the disorder). All psychiatric disorders, including mood disorders, were treated mainly with an anxiolytic. A concomitant physical illness increased the likelihood of using a psychotropic treatment and was a strong predictor of adequate psychotropic dosage. CONCLUSION: Psychiatric pathology and sleep disorders remained mostly untreated or inadequately managed in the general population. Depression is underdiagnosed by the physicians and is treated with antidepressant in only 7% of cases. By contrast, anxiolytics are extensively prescribed, especially in France and Italy. The co-occurrence of organic and psychiatry disorders increases the frequency of medical consultations and the likelihood of being given a prescription for the mental disorder.
INTRODUCTION: In Western countries, insomnia is associated with daytime impaired functioning, as well as physical and psychiatric illnesses. However, little information exists on insomnia in Asian countries. This study investigates the prevalence and correlates of insomnia in the general population of South Korea. METHODS: A representative sample of the South Korean general population composed of 3719 noninstitutionalized individuals aged 15 years or older were interviewed by telephone using the Sleep-EVAL system. The participation rate was 91.4%. The interviews covered sleep habits, sleep symptomatology, physical and psychiatric illnesses. DSM-IV sleep and psychiatric disorder diagnoses were also assessed. RESULTS: Insomnia symptoms occurring at least three nights per week were reported by 17.0% of the sample; difficulty initiating sleep (DIS) was mentioned by 4.0% of the sample, difficulty maintaining sleep (DMS) by 11.5%, early morning awakenings (EMA) by 1.8%, and nonrestorative sleep (NRS) by 4.7% of the sample. DSM-IV insomnia disorder diagnoses were found in 5% of the sample. Over 50% of subjects with insomnia symptoms reported important daytime consequences and another 20% reported mild or moderate consequences. However, the proportion of insomnia subjects seeking medical help for their sleep problems was very low (6.8%). CONCLUSIONS: As in Western countries, insomnia is widespread in South Korea, affecting nearly one in five individuals. Many of them would benefit from medical help; however, few insomnia subjects are consulting for this problem. An educational effort is needed for both the general population and the physicians.
INTRODUCTION: Irregular work schedules often results in a disruption of the normal circadian rhythm that can causes sleepiness when wakefulness is required and insomnia during the main sleep episode. METHOD: Two physicians using the Sleep-EVAL system interviewed 817 staff members of a psychiatric hospital. The interviews were done during the working hours. In addition to a series of questions to evaluate sleep and mental disorders, the evaluation included a standard questionnaire assessing work conditions, work schedule and their consequences. Three work schedules were assessed: (1) fixed daytime schedule (n=442), (2) rotating daytime shifts (n=323) and (3) shift or nighttime work (n=52). RESULTS: Subjects working on rotating daytime shifts were younger than the two other groups and had a higher proportion of women. Participants working on rotating daytime shifts reported more frequently than the fixed daytime schedule workers to have difficulty initiating sleep (20.1% vs. 12.0%). The sleep duration of shift or nighttime workers was shorter than that of the two other groups. Furthermore, subjects working rotating daytime schedule reported to have shorter sleep duration of about 20 min when they are assigned to the morning shift. Work-related accidents were two times more frequent among the rotating daytime workers (19.5%) compared with the fixed daytime schedule workers (8.8%) and the group of nighttime or shift workers (9.6%). Sick leaves in the previous 12 months were also more frequently reported in the rotating daytime schedule group (62.8%) as compared with the daytime group (38.5%, P<.001); 51.9% of nighttime or shift workers took sick leave. CONCLUSIONS: Working on a rotating daytime shifts causes significant sleep disturbances. As consequences, these workers are more likely to feel sleepy at work and are more likely to have work-related accidents and sick leaves.
BACKGROUND: Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) are two sleep disorders characterized by abnormal leg movements and are responsible for deterioration in sleep quality. However, the prevalence of these disorders is not well known in the general population. This study aims to document the prevalence of RLS and PLMD in the general population and to identify factors associated with these conditions. METHODS: Cross-sectional studies were performed in the UK, Germany, Italy, Portugal and Spain. Overall, 18,980 subjects aged 15 to 100 years old representative of the general population of these five European countries underwent telephone interviews with the Sleep-EVAL system. A section of the questionnaire assessed leg symptoms during sleep. The diagnoses of PLMD and RLS were based on the minimal criteria provided by the International Classification of Sleep Disorders. RESULTS: The prevalence of PLMD was 3.9% and RLS was 5.5%. RLS and PLMD were higher in women than in men. The prevalence of RLS significantly increased with age. In multivariate models, being a woman, the presence of musculoskeletal disease, heart disease, obstructive sleep apnea syndrome, cataplexy, doing physical activities close to bedtime and the presence of a mental disorder were significantly associated with both disorders. Factors specific to PLMD were: being a shift or night worker, snoring, daily coffee intake, use of hypnotics and stress. Factors solely associated with RLS were: advanced age, obesity, hypertension, loud snoring, drinking at least three alcoholic beverages per day, smoking more than 20 cigarettes per day and use of SSRI. CONCLUSIONS: PLMD and RLS are prevalent in the general population. Both conditions are associated with several physical and mental disorders and may negatively impact sleep. Greater recognition of these sleep disorders is needed.
The study of sleep disorders in the general population involves several methodological issues that need to be defined prior to proceeding to the epidemiological study. The rigor of the methodology is an important issue since it will determine the reliability of the data gathered. This paper describes the methodology used in an epidemiological study performed in the French general population using telephone interviews with the help of Sleep-EVAL, an expert system designed for this purpose. The study aimed to investigate the prevalence of insomnia disorders according to the DSM IV classification and the use of psychotropic medications in the general population. The methodological choices for this study were based on several considerations. First, the sample had to be representative of the French population. Second, the study had to be conducted in the shortest period of time. Third, the interviews had to be conducted with respect to a strict standardization and fourth, the realization costs had to be minimal for a maximum of data collected. The telephone interview procedure was chosen over postal and face-to-face interviews because it offered the possibility of conducting all the interviews from the same site. Supervision was easier. It also offered an absolute control in the application of the selection procedure. To draw the sample, a two-stage procedure was adopted. At the first stage, we pulled a random series of telephone numbers in each Nielsen region with respect to the size of the settlement. At the second stage, during the initial telephone contact, a household member was chosen using the Kish selection procedure. This method is based on the utilization of eight tables of selection that allows for the choice of the person to interview in a given household and keeps the representativeness of the sample. This technique is little used in telephone surveys because of its burden and its intrusive nature: the interviewer must collect the age and gender of all eligible subjects, to classify men from the oldest to youngest and then to classify women. However, it is the most rigorous selection method for epidemiological surveys. To reduce the refusal rates and to alleviate the work of interviewers, the Kish method was implanted in the computer software used for this study. For this study, the exclusion criteria were minimal. Only individuals younger than 15 years of age, those with a speech or hearing impairment and those who were too ill to perform the interview were not included. Subjects who refused to participate, those who hung up without speaking to the interviewer and those who hung up before completing at least half of the interview were tabulated as refusal. The participation rate was calculated by dividing the number of completed interviews by the number of eligible participants (completed interviews, refusals and telephone numbers where the interviewer was unable to determine if the individuals met an exclusion criterion). In this study, the participation rate was 80.8% (5 622 completed interviews/6 966 eligible households). The diagnostic tool used for this study was the Sleep-EVAL system, an expert system designed to conduct epidemiological studies in the general population. It is a level 2, non-monotonic system endowed with a causal reasoning able to provide sleep and mental disorders diagnoses according to the DSM IV classification for this study. Subsequent versions of Sleep-EVAL also included the International Classification of Sleep Disorders. System symbolic representation of the classifications was put in a compiled knowledge base. This knowledge base was read and interpreted by the inference engine at the beginning of the interview. During the interview, this interpretation changed as a function of the answers provided by the interviewee and by deductions made from the analysis of information the system already knew. All interviews began with a standard questionnaire about sociodemographic information and sleep habits. From these first answers, the Sleep-EVAL system emitted a series of diagnostic hypotheses that were confirmed or rejected with supplementary questions. The interview ended once all diagnostic possibilities were exhausted. The validity of the Sleep-EVAL system was demonstrated in different studies performed in sleep disorders clinics. There were several advantages in using such a tool to conduct epidemiological surveys. No special skills from the interviewers nor specific knowledge of sleep and mental disorders were required. All the questions were chosen and formulated by the Sleep-EVAL system. The interviewer had simply to read the questions as they appeared on the monitor screen and enter the interviewee's responses by clicking the appropriate answer or typing it on the keyboard. Missing answers were non-existent because there was no possibility of skipping a question or entering inconsistent answers. It also ensured the uniformity of the interviews. Furthermore, it allowed the exploration of infrequent diagnoses. In summary, the methodology used for this study allowed for the investigation of the sleep pathology of the French population in a short period of time: only three months were necessary to complete the 5 622 interviews. The use of a computerized tool greatly facilitated the training of the interviewers and also their work. Furthermore, it ensured a standardized administration of the interviews and the exploration of a broad range of disorders that could hardly be realized with traditional paper-pencil questionnaires.
OBJECTIVE: To determine the prevalence of narcolepsy in the general population of five European countries (target population 205,890,882 inhabitants). METHODS: Overall, 18,980 randomly selected subjects were interviewed (participation rate 80.4%). These subjects were representative of the general population of the UK, Germany, Italy, Portugal, and Spain. They were interviewed by telephone using the Sleep-EVAL expert system, which provided narcolepsy diagnosis according to the International Classification of Sleep Disorders (ICSD). RESULTS: Excessive daytime sleepiness was reported by 15% of the sample, with a higher prevalence in the UK and Germany. Napping two times or more in the same day was reported by 1.6% of the sample, with a significantly higher rate in Germany. Cataplexy (episodes of loss of muscle function related to a strong emotion), a cardinal symptom of narcolepsy, was found in 1.6% of the sample. An ICSD narcolepsy diagnosis was found in 0.047% of the sample: The narcolepsy was severe for 0.026% of the sample and moderate in 0.021%. CONCLUSION: This is the first epidemiologic study that estimates the prevalence of narcolepsy in the general population of these five European countries. The disorder affects 47 individuals/100,000 inhabitants.
OBJECTIVES: To assess the prevalence of insomnia disorders using DSM-IV classification, and the consequences of insomnia in the Italian general population. METHODS: A representative sample of the Italian general population composed of 3970 individuals aged 15 years or older were interviewed by telephone using the Sleep-EVAL system (participation rate: 89.4%). Participants were interviewed about their sleep habits and sleep disorders. DSM-IV classification was used by Sleep-EVAL to determine the sleep disorder diagnosis. RESULTS: Insomnia symptoms were reported by 27.6% of the sample. Sleep dissatisfaction was found in 10.1% and insomnia disorder diagnoses in 7% of the sample. The use of sleep-enhancing medication was reported by 5.7% of the sample. Most of these subjects were using anxiolytics. Dissatisfaction with sleep was associated with daytime sleepiness. Middle-aged drivers dissatisfied with their sleep were three times more likely to have had a road accident in the previous year compared to other drivers. However, fewer than 30% of subjects dissatisfied with their sleep or with an insomnia disorder diagnosis had consulted a physician about their sleep problem. CONCLUSIONS: As in other European and non-European countries, insomnia is widespread in Italy. The consequences are important. Appropriate recognition and treatment of insomnia should be part of an educational program for general practitioners everywhere.
BACKGROUND: Recent findings suggest that there may be a relationship between excessive daytime sleepiness (EDS) and cognitive deficits. This study aims to determine to what extent EDS is predictive of cognitive impairment in an elderly population. METHODS: A total of 1026 individuals 60 years or older representative of the general population living in the metropolitan area of Paris, France, were interviewed by telephone using the Sleep-EVAL expert system. To find these individuals, 7010 randomly selected households were called: 1269 had at least 1 household member in this age range (participation rate, 80.9%). In addition to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and International Classification of Sleep Disorders diagnoses, the system administered to participants the Psychological General Well-being Schedule, the Cognitive Difficulties Scale (MacNair-R), and an independent living scale. RESULTS: Excessive daytime sleepiness was reported by 13.6% of the sample, with no significant difference among age groups. Compared with nonsleepy participants, those with EDS were at increased risk of cognitive impairment on all the dimensions of the MacNair-R scale after controlling for age, sex, physical activity, occupation, organic diseases, use of sleep or anxiety medication, sleep duration, and psychological well-being. The odd ratios were 2.1 for attention-concentration deficits, 1.7 for praxis, 2.0 for delayed recall, 2.5 for difficulties in orientation for persons, 2.2 for difficulties in temporal orientation, and 1.8 for prospective memory. CONCLUSIONS: Among elderly individuals in the general population, EDS is an important risk factor for cognitive impairment. A complaint of EDS by an elderly patient should signal the possibility of an underlying cognitive impairment in need of evaluation.
STUDY OBJECTIVES: The use of diagnostic classifications to define sleep disorders is still unusual in epidemiological studies assessing the prevalence of sleep disorders in an adolescent population. DESIGN: Cross-sectional study. Representative samples of general populations in United Kingdom, Germany and Italy were selected and interviewed by telephone about their sleep habits, sleep and mental disorder diagnoses. Overall, 724 adolescents ages 15-18 years and 1447 young adults ages 19 to 24 years were interviewed. ICSD-90 and DSM-IV diagnoses provided by the Sleep-EVAL expert system were used for the comparisons. SETTING: N/A. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: 8% of the adolescents and 12.6% of the young adults had ICSD dyssomnia or sleep disturbances associated with a mental disorder. According to the DSM-IV classification, 5.7% of the adolescents and 8.1% of the young adults had a dyssomnia diagnosis. The comparison between the two classifications show that 73.2% of adolescents and young adults with a DSM-IV dyssomnia diagnosis also had similar ICSD diagnosis. The reverse comparison, ICSD vs. DSM-IV, shows that 39.8% of the subjects with an ICSD diagnosis had a DSM-IV diagnosis. DSM-IV primary insomnia was the most frequent diagnosis. Subjects with such a diagnosis were found in about 10 different ICSD diagnoses, mainly inadequate sleep hygiene, psychophysiological or idiopathic insomnia and insufficient sleep syndrome. CONCLUSIONS: ICSD-90 classification provided higher prevalence of sleep disorder diagnoses than the DSM-IV classification. In adolescents and young adults, DSM-IV primary insomnia is two times more often associated with ICSD inadequate sleep hygiene than with ICSD psychophysiological or idiopathic insomnia.
Lack of a systematic assessment of insomnia has led to large variations in its reported prevalence in the general population. This study aims to provide new guidelines to assess insomnia prevalence. A cross-sectional telephone survey using the Sleep-EVAL system was done with 24,600 general population-based subjects 15 years and older representative of general populations (France, the UK, Germany, Italy, Portugal, and Spain) consisting of 251,405,391 inhabitants. The overall participation rate was 81.0%. Within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptomatology for insomnia, 27.2% (95% confidence interval: 26.6-27.8%) of the sample reported difficulty initiating sleep (DIS) (10.1%) or maintaining sleep (DMS) (disrupted sleep (DS): 18.0%; early morning awakening (EMA): 10.9%) or nonrestorative sleep (NRS) (8.9%) at least three times per week; 48.5% of them were concomitantly suffering of a DSM-IV sleep/mental disorder. A factor analysis identified several variables strongly related to each of the major factors of insomnia allowing: (1) The narrowing of the definition of insomnia: the prevalence of insomnia decreased to 16.8% with 64.5% of insomnia subjects having a DSM-IV sleep/mental disorder; (2) The identification of a sleep-deprived (voluntary or not) group without insomnia symptoms, representing 2.1% (1.9-2.3%) of the sample. Interestingly, the latter group closely matched the definition of insufficient sleep syndrome as described by the International Classification of Sleep Disorders (ICSD). Using more delineated criteria to assess insomnia increases the recognition of subjects complaining about sleep. Classifications should be amended to improve the correct identification of insomnia. Sleep-deprived subjects should also not be neglected.
STUDY OBJECTIVES: Global sleep dissatisfaction (GSD) is not part of the habitual insomnia symptoms in epidemiological studies. Furthermore, none of these studies has examined the relative importance of the various factors correlated to sleep dissatisfaction. This study aims to examine the links between GSD and insomnia and to find the factors contributing to GSD. DESIGN: A cross-sectional telephone survey was conducted in Germany (66 million inhabitants 15 years of age or older) with a representative sample of 4,115 subjects aged 15 years or older. Interviewers used the Sleep-EVAL system. The questionnaire covered several topics that were grouped into six classes of variables identified as potential factors associated with sleep dissatisfaction: sociodemographic descriptors, environmental factors, life habits, health status, psychological factors, sleep/wake factors. SETTING: N/A. PARTICIPANTS: A representative sample of 4,115 subjects aged 15 years or older INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Overall, 7% of the subjects reported being GSD; 95.5% of them had at least one insomnia symptom. The duration of insomnia symptom(s) was 20 months longer in GSD subjects compared to insomnia subjects without GSD. The prevalence of GSD was higher in women than in men and increased with age. The most significant predictive factors for GSD were: 1) for sleep/wake schedule variables: night sleep duration less than 6 hours (OR: 4.0 and over) and sleep latency greater than 30 minutes. 2) for sociodemographic variables: age between 65 and 74 (OR: 6.7) 3) for health variables: Upper airway disease (OR: 7.1); 4) for mental health variables: anxiety symptoms (OR: 3.0); 5) for environmental factors: too hot bedroom (OR=2.5) 6) for life habit factors: the need of a particular object in order to fall asleep (OR: 2.4). CONCLUSIONS: This study confirms that GSD is a better indicator of an underlying pathology than the classical insomnia symptoms alone: compared to insomniac subjects without GSD, subjects with GSD were two times more likely to report excessive daytime sleepiness, and eight times more likely to have a diagnosis of sleep or mental disorder. Furthermore, in car drivers, road accidents in the previous year were two times more frequent with GSD drivers as compared to insomnia drivers without GSD. Subjects with GSD were more than 10 times more likely to seek help for their sleep problems and five times more likely to use a sleep medication than insomnia subjects without GSD.
OBJECTIVES: To determine the role of activity status and social life satisfaction on the report of insomnia symptoms and sleeping habits. DESIGN: Cross-sectional telephone survey using the Sleep-EVAL knowledge base system. SETTING: Representative samples of three general populations (United Kingdom, Germany, and Italy). PARTICIPANTS: 13,057 subjects age 15 and older: 4,972 in the United Kingdom, 4,115 in Germany, and 3,970 in Italy. These subjects were representative of 160 million inhabitants. MEASUREMENTS: Clinical questionnaire on insomnia and investigation of associated pathologies (psychiatric and neurological disorders). RESULTS: Insomnia symptoms were reported by more than one-third of the population age 65 and older. Multivariate models showed that age was not a predictive factor of insomnia symptoms when controlling for activity status and social life satisfaction. The level of activity and social interactions had no influence on napping, but age was found to have a significant positive effect on napping. CONCLUSIONS: These results indicate that the aging process per se is not responsible for the increase of insomnia often reported in older people. Instead, inactivity, dissatisfaction with social life, and the presence of organic diseases and mental disorders were the best predictors of insomnia, age being insignificant. Healthy older people (i.e., without organic or mental pathologies) have a prevalence of insomnia symptoms similar to that observed in younger people. Moreover, being active and satisfied with social life are protective factors against insomnia at any age.
Hallucinations are perceptual phenomena involved in many fields of pathology. Although clinically widely explored, studies in the general population of these phenomena are scant. This issue was investigated using representative samples of the non-institutionalized general population of the United Kingdom, Germany and Italy aged 15 years or over (N=13,057). These surveys were conducted by telephone and explored mental disorders and hallucinations (visual, auditory, olfactory, haptic and gustatory hallucinations, out-of-body experiences, hypnagogic and hypnopompic hallucinations). Overall, 38.7% of the sample reported hallucinatory experiences (19.6% less than once in a month; 6.4% monthly; 2.7% once a week; and 2.4% more than once a week). These hallucinations occurred, (1) At sleep onset (hypnagogic hallucinations 24.8%) and/or upon awakening (hypnopompic hallucinations 6.6%), without relationship to a specific pathology in more than half of the cases; frightening hallucinations were more often the expression of sleep or mental disorders such as narcolepsy, OSAS or anxiety disorders. (2) During the daytime and reported by 27% of the sample: visual (prevalence of 3.2%) and auditory (0.6%) hallucinations were strongly related to a psychotic pathology (respective OR of 6.6 and 5.1 with a conservative estimate of the lifetime prevalence of psychotic disorders in this sample of 0.5%); and to anxiety (respective OR of 5.0 and 9.1). Haptic hallucinations were reported by 3.1% with current use of drugs as the highest risk factor (OR=9.8). In conclusion, the prevalence of hallucinations in the general population is not negligible. Daytime visual and auditory hallucinations are associated with a greater risk of psychiatric disorders. The other daytime sensory hallucinations are more related to an organic or a toxic disorder.
OBJECTIVE: Sleep bruxism can have a significant effect on the patient's quality of life. It may also be associated with a number of disorders. However, little is known about the epidemiology of sleep bruxism and its risk factors in the general population. DESIGN: Cross-sectional telephone survey using the Sleep-EVAL knowledge based system. SETTINGS: Representative samples of three general populations (United Kingdom, Germany, and Italy) consisting of 158 million inhabitants. PARTICIPANTS: Thirteen thousand fifty-seven subjects aged > or = 15 years (United Kingdom, 4,972 subjects; Germany, 4,115 subjects; and Italy, 3,970 subjects). INTERVENTION: None. MEASUREMENTS: Clinical questionnaire on bruxism (using the International Classification of Sleep Disorders [ICSD] minimal set of criteria) with an investigation of associated pathologies (ie, sleep, breathing disorders, and psychiatric and neurologic pathologies). RESULTS: Grinding of teeth during sleep occurring at least weekly was reported by 8.2% of the subjects, and significant consequences from teeth grinding during sleep (ie, muscular discomfort on awakening, disturbing tooth grinding, or necessity of dental work) were found in half of these subjects. Moreover, 4.4% of the population fulfilled the criteria of ICSD sleep bruxism diagnosis. Finally, subjects with obstructive sleep apnea syndrome (odds ratio [OR], 1.8), loud snorers (OR, 1.4), subjects with moderate daytime sleepiness (OR, 1.3), heavy alcohol drinkers (OR, 1.8), caffeine drinkers (OR, 1.4), smokers (OR, 1.3), subjects with a highly stressful life (OR, 1.3), and those with anxiety (OR, 1.3) are at higher risk of reporting sleep bruxism. CONCLUSIONS: Sleep bruxism is common in the general population and represents the third most frequent parasomnia. It has numerous consequences, which are not limited to dental or muscular problems. Among the associated risk factors, patients with anxiety and sleep-disordered breathing have a higher number of risk factors for sleep bruxism, and this must raise concerns about the future of these individuals. An educational effort to raise the awareness of dentists and physicians about this pathology is necessary.
OBJECTIVE: Despite many constraints on time schedules among teenagers, epidemiological data on sleep complaints in adolescence remain limited and are nonexistent for sleep disorders. This study provides additional data on sleep habits and DSM-IV sleep disorders in late adolescence. METHOD: A representative sample of 1,125 adolescents aged 15 to 18 years was interviewed by telephone using the Sleep-EVAL system. These adolescents came from 4 European countries: France, Great Britain, Germany, and Italy. Information was collected about sociodemographic characteristics, sleep/wake schedule, sleep habits, and sleep disorders and was compared with information from 2,169 young adults (19-24 years of age). RESULTS: Compared with young adults, adolescents presented with a distinct sleep/wake schedule: they went to sleep earlier, they woke up later, and they slept longer than young adults did. On weekends and days off, they also slept more than young adults did. However, the prevalence rates of sleep symptoms and sleep disorders were comparable in both groups. Approximately 25% reported insomnia symptoms and approximately 4% had a DSM-IV insomnia disorder. Fewer than 0.5% had a circadian rhythm disorder. CONCLUSIONS: Prevalence of insomnia disorders is lower in the adolescent population than in middle-aged or elderly adults. However, a rate of 4% in this young population is important given their young age and the consequences for daytime functioning.
The aim of the study was to assess sleep disturbances in subjects with posttraumatic stress disorder (PTSD) from an urban general population and to identify associated psychiatric disorders in these subjects. The study was performed with a representative sample of 1,832 respondents aged 15 to 90 years living in the Metropolitan Toronto area who were surveyed by telephone (participation rate, 72.8%). Interviewers used Sleep-EVAL, an expert system specifically designed to conduct epidemiologic studies of sleep and mental disorders in the general population. Overall, 11.6% of the sample reported having experienced a traumatic event, with no difference in the proportion of men and women. Approximately 2% (1.8%) of the entire sample were diagnosed by the system as having PTSD at the time of interview. The rate was higher for women (2.6%) than for men (0.9%), which translated into an odds ratio (OR) of 2.8 (95% confidence interval [CI], 1.3 to 6.1). PTSD was strongly associated with other mental disorders: 75.7% of respondents with PTSD received at least one other diagnosis. Most concurrent disorders (80.7%) appeared after exposure to the traumatic event. Sleep disturbances also affected about 70% of the PTSD subjects. Violent or injurious behaviors during sleep, sleep paralysis, sleep talking, and hypnagogic and hypnopompic hallucinations were more frequently reported in respondents with PTSD. Considering the relatively high prevalence of PTSD and its important comorbidity with other sleep and psychiatric disorders, an assessment of the history of traumatic events should be part of a clinician's routine inquiry in order to limit chronicity and maladjustment following a traumatic exposure. Moreover, complaints of rapid eye movement (REM)-related sleep symptoms could be an indication of an underlying problem stemming from PTSD.
OBJECTIVES Sleep-disordered breathing has been hypothesized to have a close relationship with hypertension but previous studies have reported mixed results. This is an important health issue that requires further clarification because of the potential impact on the prevention and control of hypertension. METHODS: The relationship between hypertension and three forms of sleep-disordered breathing (chronic snoring, breathing pauses and obstructive sleep apnea syndrome (OSAS)) was assessed using representative samples of the non-institutionalized population of the UK, Germany and Italy (159 million inhabitants). The samples were comprised of 13,057 individuals aged 15-100 years who were interviewed about their sleeping habits and their sleep symptoms over the telephone using the Sleep-EVAL system. RESULTS: OSAS was found in 1.9% (95% CI: 1.2% to 2.3%) of the UK sample, 1.8% (95% CI: 1.4% to 2.2%) of the German sample and 1.1% (95% CI: 0.8% to 1.4%) of the Italian sample. OSAS was an independent risk factor (odds ratio (OR): 9.7) for hypertension after controlling for possible confounding effects of age, gender, obesity, smoking, alcohol consumption, life stress, and, heart and renal disease. CONCLUSIONS: Results from three of the most populated countries in Western Europe indicate that OSAS is an independent risk factor for hypertension. Snoring and breathing pauses during sleep appeared to be non-significant predictive factors.
Confusional arousals, or sleep drunkenness, occur upon awakening and remain unstudied in the general population. We selected a representative sample from t |
