by Randy A. Sansone, MD; Howard C. Edwards, MD; and Jeremy S. Forbis, PhD
Dr. Sansone is a Professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. Edwards is a resident in the Department of Internal Medicine at Kettering Medical Center in Kettering, Ohio; and Dr. Forbis is an Assistant Professor in the Department of Sociology at the University of Dayton in Dayton, Ohio.

Psychiatry (Edgemont) 2010;7(7):44–46

Funding: There was no funding for the development and writing of this article.

Financial disclosure: The authors have no conflicts of interest relevant to the content of this article.

Key words: Pittsburgh Sleep Quality Index, PSQI, mental healthcare utilization, psychiatric disorders, sleep, sleep problems


Disturbances in sleep are empirically associated with a number of different psychiatric disorders. In this pilot study, we examined whether four general queries about mental healthcare utilization (“Have you ever been seen by a psychiatrist?,” “Have you ever been hospitalized in a psychiatric hospital?,” “Have you ever been in counseling?,” and “Have you ever been on medication for your nerves?”) would evidence correlations with various aspects of sleep disturbance as measured by the Pittsburgh Sleep Quality Index. In a cross-sectional sample of convenience, we surveyed 75 internal medicine outpatients. We asked participants about the four preceding mental healthcare variables as well as sleep experiences using the Pittsburgh Sleep Quality Index. Prior to statistical analyses, we assigned one point to each mental healthcare utilization variable endorsed and developed a composite score (0–4). In analyses, while the mental-healthcare-utilization composite score was not related to overall sleep quality (i.e., the Global Pittsburgh Sleep Quality Index Score), it was statistically significantly related to the Pittsburgh Sleep Quality Index component of Sleep Disturbance (p<.01). This suggests that while individuals with greater mental healthcare utilization do not evidence differences in overall sleep quality compared to those with low utilization, they do report more disturbances in sleep.


Comorbidity between sleep difficulties and various psychiatric disorders is reportedly high.[1] For example, a number of Axis I disorders have been associated with sleep disturbances, including attention-deficit hyperactivity disorder (ADHD);[2] depression;[3] bipolar disorder;[4] anxiety disorders,[5] including generalized anxiety disorder (GAD)[6] and panic disorder;[7] post-traumatic stress disorder (PTSD);[8] schizophrenia;[9] alcohol dependence;[10] and eating disorders.[11] Even personality characteristics have been associated with sleep disturbances.[12] Given the broad association between sleep disturbances and numerous psychiatric phenomena, we wondered whether a general inquiry about mental healthcare utilization, similar to that undertaken during a routine psychiatric interview, would evidence any correlations with sleep disturbance.


Participants. Participants in the study were male or female, were ages 18 years or older, and were being seen in an outpatient internal medicine facility that is predominantly staffed by resident physicians. The sample was one of convenience, and exclusion criteria were medical, cognitive, intellectual, or psychiatric illness that would preclude the successful completion of a survey booklet. During the study period (January 2009–September 2009), 149 patients were approached and 116 agreed to participate, for a response rate of 78 percent. However, only 76 participants completed all materials.
Of the 76 respondents included in our analyses, 74.6 percent were women and 25.4 percent were men, ranging in age from 18 to 70 years (M=41.6, SD=13.8). Sixty-six (84%) of the participants were white/Caucasian, six were African-American, two were Hispanic, and two were Native American. With regard to educational attainment, all but 6.6 percent of the participants had at least graduated from high school, and 26.6 percent had earned a college degree. One participant did not complete any demographic information.

Procedure. During assigned clinic times, one investigator (Dr. Edwards) approached candidates from his clinical caseload. Candidates were informed of the purpose of the study (i.e., to examine their overall sleep quality in the past month in relationship to a number of study variables), including potential risks (e.g., minimal anxiety) and benefits (i.e., no personal benefit, but perhaps a broader benefit to other patients), and informed that findings would be scientifically reported in group, not individual, format. This information was also clarified on the cover page of the research booklet, according to the guidelines of the two institutional review boards that approved the project. Those candidates who agreed to participate were then asked to complete a six-page survey booklet. The cover page of the survey booklet contained the elements of informed consent, and completion of the survey booklet was assumed to be implied consent.

Following an initial demographic query, we explored mental healthcare utilization through the following four general questions: “Have you ever been seen by a psychiatrist?,” “Have you ever been hospitalized in a psychiatric hospital?,” “Have you ever been in counseling?,” and “Have you ever been on medication for your nerves?” We elected these four mental healthcare inquiries because they reflect the questions that are typically asked of patients during a routine psychiatric interview. Finally, we explored each participant’s subjective sleep quality with the Pittsburgh Sleep Quality Index (PSQI).[13] The PSQI is a 19-item, self report questionnaire that explores subjective sleep quality over the past month. There are seven component scores (i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, daytime dysfunction) that may be coalesced into one global score, with higher global scores indicating poorer sleep quality. A global PSQI score of greater than 5 is considered to be a sensitive and specific measure of poor sleep quality.

This project was approved by the institutional review boards of the community hospital and the university.


The responses of participants to the queries regarding sleep quality are shown in Table 1. Of the respondents, 12 (15.79%) scored in the 75th percentile of the Global PSQI Score, indicating severe difficulties in all areas. Of the seven different sleep quality components, habitual sleep efficiency was the most commonly endorsed component score, with extreme difficulty reported by 36.84 percent of participants. Conversely, only nine (11.84%) respondents indicated extreme difficulty with regard to daytime dysfunction.

We next developed a composite score for each participant, consisting of the summed responses to each of the mental healthcare utilization items (one point for each endorsement), thereby creating an ordinal score (0–4). We then examined correlations between our mental healthcare utilization composite scores and PSQI scores. While the mental healthcare utilization composite score was not shown to be associated with the Global PSQI measure, it was significantly associated with sleep disturbance (p<0.01).


While there was no statistically significant correlation between our mental healthcare utilization composite score and the Global PSQI score, there was a statistically significant relationship between the mental health utilization composite score and sleep disturbance. The sleep disturbance score on the PSQI consists of eight sub-items. These sub-items are as follows: 1) wake up in the middle of the night or early morning; 2) have to get up to use the bathroom; 3) cannot breathe comfortably; 4) cough or snore loudly; 5) feel too cold; 6) feel too hot; 7) have bad dreams; and (8) have pain. Because there were no statistically significant differences in the overall Global PSQI scores, but statistically significant differences on the sleep disturbance score, we can tentatively conclude that while there are no overall differences in general sleep quality between those with lower versus with higher mental healthcare utilization, participants with a greater number of different types of mental healthcare utilization evidence more disturbed sleep. Note in Table 1 that there were no statistically significant correlations with the component “use of sleep medications,” indicating that there was no greater use of prescribed or over-the-counter hypnotics among the entire sample. In summary, these findings tell us that individuals with histories of mental healthcare utilization are likely to have sleep disturbances, but overall sleep quality is comparable to those without histories of mental healthcare utilization, including the use of hypnotics.

This pilot study has a number of potential limitations, including the use of self-report data, a sample of convenience, and a small sample size. However, this is one of the few studies to examine mental healthcare utilization in relationship to sleep quality. Importantly, mental healthcare utilization does not appear to be related to changes in overall sleep quality. However, individuals with greater mental healthcare utilization report more sleep disturbances. Only further research will tease out the nuances of this finding.

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