The Relationship Between Insomnia and Impaired Quality of Life in the United States

We touched base with Dr. Mark Olfson to discuss his team’s new research, “Insomnia and Impaired Quality of Life in the United States,” which was just published in the Journal of Clinical Psychiatry.

Dr. Olfson is a Professor of Psychiatry and Epidemiology at Columbia University Irving Medical Center (CUIMC) and a Research Psychiatrist at the New York State Psychiatric Institute (NYSPI). His research focuses on identifying gaps between clinical science and practice in the delivery of mental health care with a focus on the safety and effectiveness of treatments provided in routine practice.

The authors of “Insomnia and Impaired Quality of Life in the United States” are: Mark Olfson, MD, MPH (CUIMC and NYSPI); Melanie Wall, PhD (CUIMC and NYSPI); Shang-Min Liu, MS (CUIMC and NYSPI); Charles M. Morin, PhD (Laval University); and Carlos Blanco, MD, PhD (National Institute on Drug Abuse).

Columbia Psychiatry: What is/are the main finding(s) of your team’s new research, “Insomnia and Impaired Quality of Life in the United States”?

Dr. Olfson: We found that over one quarter of adults (27.3%) in the United States experience insomnia, which includes problems falling or staying asleep, in course of one year. Among adults with insomnia, only around a quarter (27.8%) reported that their condition was recognized by a health care professional. The national burden of insomnia on loss of quality of life exceeded any of the other 18 medical conditions that were assessed in this study. For some conditions, such as arthritis or fibromyalgia, problems with insomnia were explained by pain. To summarize, insomnia is common, often not recognized clinically, exacts a heavy burden on quality of life, and frequently related to co-occurring medical conditions. 

Columbia Psychiatry: The risk of insomnia has been linked to several specific medical conditions. What are some of the more common medical conditions that is linked to insomnia, and what is “comorbid insomnia”?

Dr. Olfson: Insomnia is linked to several medical conditions. For example, over half of adults with angina, peptic ulcer disease, or fibromyalgia reported insomnia and over of third of those with arthritis, chronic pulmonary disease, or cancer reported insomnia. In practice, it can be difficult to determine whether a concurrent medical condition causes insomnia or whether insomnia contributes to the risk of the medical condition. For this reason, the phrase “comorbid insomnia” is often used to describe the co-occurrence of insomnia with medical conditions.

Columbia Psychiatry: In the paper, your team examines the prevalence of insomnia in a nationally representative sample of US adults, estimates its national health burden in relation to other common medical conditions, and assesses patterns of comorbidity between insomnia and other conditions as well as dependence of these comorbidities on pain, stressful life events, and mental disorders. What are the key methods to this examination?

Dr. Olfson: This paper takes advantage of large nationally representative sampling of adults and wide-ranging mental health and health interview to evaluate the relative burden in terms of quality of life loss of various health conditions. In this context, insomnia, largely because of its high prevalence – over one quarter of US adults – emerges as having the largest associated loss in quality of life. One of the key methods in this paper is the use of measure of quality adjusted life years or QALYs which permits comparisons across people with different health conditions.

Columbia Psychiatry: How is insomnia detected and assessed? Are there treatments for it?

Dr. Olfson: In general practice, insomnia is usually assessed by history or a screening tool, sometimes with the aid of a sleep diary. There are several treatments for insomnia. For many people, simple measures will be sufficient to help restore their sleep such as limiting daytime naps; avoiding caffeine, nicotine, and other stimulants near bedtime; lowering the noise level in the sleeping environment; exercise; or ensuring adequate exposure to natural light during the day. Strong evidence also supports the sustained effectiveness of cognitive-behavioral therapy which can be delivered in person or over the Internet. More complex sleep conditions may require referral for a formal evaluation to a clinical sleep lab.

Columbia Psychiatry: What are the overall impacts of insomnia on self-assessed health? What can insomnia result in?

Dr. Olfson: Poor-quality sleep can have adverse effects on a person’s sense of well-being, their quality of life, and productivity at work and increase the risk of accidents. It can also increase your risk for common mental health problems such as anxiety and depression as well as high blood pression, heart disease, diabetes, obesity, and other medical conditions. 

Columbia Psychiatry: Did these findings surprise you and your team at all?

Dr. Olfson: We knew that insomnia was common and could interfere with quality of life, but we were surprised to discover that at a population level insomnia accounts for a significantly greater loss of quality of life than common medical conditions such as arthritis and obesity or mental health conditions such as depressive disorders or alcohol use disorder.

Columbia Psychiatry: What were some of the limitations that your team faced in doing this research?

Dr. Olfson: One of the limitations of this study is that we relied on self-report of insomnia rather than independent medical evaluations of insomnia. We also used a rather broad definition of insomnia that did not require specific nocturnal symptoms, such as difficulty maintaining sleep or early morning awakening. A stricter definition of insomnia would have likely identified a narrower group with insomnia.

Columbia Psychiatry: Where does the research go from here? 

Dr. Olfson: One of the important public health challenges is to be estimate the actual effects of improving insomnia management on the health, well-being, and productivity of the population.   Another key challenge is to help primary care physicians and patients reduce their long-term use of benzodiazepines and z-drug to manage insomnia because of their risks related to dependence, impaired cognitive function, and accidents, especially in older adults.