The American Journal on Addictions, 24: 515–522, 2015 Copyright © American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12243

Sleep Disturbances are Associated With Reduced Health-Related Quality of Life in Patients With Substance Use Disorders e, Msc,1,2 Gerdien H. de Weert-van Oene, PhD,2,3 Ellis H. B. Magne Toon A. G. M. Wijdeveld, MD,2 Anton M. L. Coenen, PhD,4 Cor A. J. de Jong, PhD2 1

Department of Addiction and Korsakov Care, Vincent van Gogh Institute, Oostrum, the Netherlands Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Radboud University, Nijmegen, the Netherlands 3 Victas, Addiction Treatment Center, Utrecht, the Netherlands 4 Donders Institute, Radboud University Nijmegen, Nijmegen, the Netherlands 2

Background and Objectives: Sleep problems and substance use are strongly linked. Sleep problems play a role in the etiology of substance use, but also may be a result of it. After detoxification, sleep problems may worsen leading to relapse. Nowadays, most substance dependence treatment programs aim at recovery rather than total abstinence, and in that view health-related quality of life (HRQL) is a relevant construct. This article describes the association between selfperceived sleep problems and HRQL in a naturalistic population of polydrug-using inpatients. Methods: At the start of treatment, 388 polydrug-using inpatients completed questionnaires concerning their sleep quality and HRQL. Three categories were established based on reported sleep problems: patients without sleep problems (21.6%), those with clinically relevant sleep problems (34.5%), and patients with sleep disorders (43.8%). Results: Mean grades for quality of sleep were M ¼ 7.3 (sd 1.7), M ¼ 6.6 (sd 1.7) and M ¼ 5.3 (sd 1.9) for the three categories, respectively. In addition, patients in the disorder category perceived a lower HRQL than those in the other categories. In the explanation of HRQL, both sleep problems and sleep disorders added significantly to the model when controlling for baseline characteristics. Discussion and Conclusions: Our findings stress the need for clinicians to pay attention to the quality of sleep of recovering polydrug users, since this may play an important role in the recovery process. Monitoring sleep during treatment is advocated. This study adds to the knowledge about the way HRQL and sleep are related in a naturalistic sample of substance-dependent patients. (Am J Addict 2015;24:515–522)

Received December 2, 2014; revised April 16, 2015; accepted April 26, 2015. Address correspondence to: Ellis HB Magnee, Department of Addiction and Korsakov Care, Vincent van Gogh Institute, PO Box 5, 5800 AA Venray, the Netherlands. E-mail: [email protected]

INTRODUCTION Overall it is estimated that between 50% and 80% of the treatment-seeking psychiatric population is affected by insomnia.1 People who suffer from substance use disorders (SUD) are at high risk of sleep problems, such as insomnia.2 Between 36% and 72% of alcohol-dependent patients in specialized substance dependence programs have clinically significant sleeping problems,3 and 69% of patients in early alcohol recovery have sleep disturbances.4 Patients with SUD may develop sleep problems due to the direct effects of substance use or as a result of withdrawal from substance use.5 For instance, sleep disturbances occur in the early stages of recovery from alcohol dependence and may persist for several months despite continued abstinence,4,6 and the same is true in recovery from cannabis dependence.7 The prevalence of alcohol withdrawal-related insomnia in patients with lifetime diagnosis of alcohol dependence is around 37%,8 whereas the prevalence of alcohol use disorders in insomniacs is about 13%.9 Sleep problems can influence treatment success,9 and may thereby increase the risk of relapse.10 In fact, among alcohol-dependent patients in early recovery, sleep problems are related to future alcohol use.11 Furthermore, the relationship between SUD and sleep disorders is complex and bidirectional, as is indicated by the fact that addiction also may develop as a result of pre-existing sleeping difficulties.12–15 Sleep problems caused by the withdrawal from substance use predominantly refer to initiating and maintaining sleep (insomnia), but also to physiological sleep disorders like restless legs and sleep apnea.12,16 In addition, it should be emphasized that, although many studies concerning sleep problems and SUD focus on alcohol dependency, sleep problems are prevalent in all patients with SUD, either during the period of use or during and after detoxification.7,10,16 515

Nowadays in SUD research, health-related quality of life (HRQL) has gained relevance as an outcome measure, related to the fact that recovery has become the main objective in many treatment programs. The association between insomnia and HRQL is well established in previous research.1 Reduced HRQL has been associated with insomnia in population-based samples,17 as well as in various patient populations. However, although patients with SUD suffer from reduced HRQL (eg, 18), the relationship between sleep problems and HRQL in these patients is still not fully understood. Several studies dealt with sleep problems in homogeneous populations of patients dependent on alcohol, cannabis or other substances4,7,19 but none addressed the relationship between sleep disorders and HRQL in a naturalistic sample of polydrug-using inpatients, who also suffer from co-occurring psychiatric disorders (COD). The HRQL of COD patients is even more affected than among patients who only suffer from SUD.20 The objective of the present study is to examine the association between self-reported sleep problems and psychiatric disorders, including SUD, and HRQL in substance-dependent inpatients at the start of detoxification treatment. We hypothesize the presence of sleep disorders to be associated with reduced HRQL in patients with SUD. Throughout this article, the term “sleep problems” is used as an umbrella term for all (perceived) problems with respect to sleeping. For sleep problems that fulfill DSM-IV criteria, we use the terms for defined sleep disorders, for example, primary insomnia.

METHODS A cross-sectional study was conducted among a consecutive series of patients entering an inpatient detoxification center for SUD. The study concerned a naturalistic population of patients with a mix of SUD, and with psychiatric comorbidity. All patients fulfilling inclusion criteria—voluntary admission to the clinic, between 18 and 65 years of age—were invited for participation in the study, totaling 811 patients in a 4.5 year period. Exclusion criteria were: suffering from florid psychosis or acute suicidality (n ¼ 16); an intended stay in treatment 5 (%) Sleep-50 (M, sd) Sleep apnea Insomnia Narcolepsy Restless legs Circadian rhythm sleep Sleepwalking Nightmares Factors influencing sleep Impact on daily functioning Total sleep (Sleep-50) (M, sd) Grade (M, sd) EQ5D utility score (M, sd) EQ5D VAS score (M, sd)

Sleep complaints (n ¼ 134)

Sleep disorder (n ¼ 170)

.83 (.8)

1.10 (.9)

1.82 (.9)

F ¼ 43.69; p < .001

.84 (.9) .53 (.8) .56 (1.0) .93 (.5) .40 (.9) .72 (.7) 4.74 (3.1) 45.0

1.13 (1.1) .62 (.8) .79 (1.2) 1.33 (.8) .84 (1.3) 1.03 (.9) 6.74 (3.6) 69.0

1.70 (1.2) .98 (.9) 1.32 (1.3) 1.74 (.8) 1.03 (1.3) 1.56 (.9) 10.19 (4.2) 89.4

F ¼ 19.72; p < .001 F ¼ 10.02; p < .001 F ¼ 13.04; p < .001 F ¼ 36.36; p < .001 F ¼ 7.27; p < .001 F ¼ 31.22; p < .001 F ¼ 62.14; p < .001 x2 ¼ 54.16; p < .001

14.91 20.33 7.69 6.69 6.08

F ¼ 52.02; F ¼ 83.83; F ¼ 59.80; F ¼ 17.36; F ¼ 35.74;

10.43 11.84 5.25 4.54 3.88

(1.6) (3.1) (.4) (.7) (1.1)

12.88 15.17 6.25 6.12 4.93

(3.4) (5.2) (1.5) (3.3) (2.1)

(3.7) (5.9) (2.2) (2.7) (2.2)

p < .001 p < .001 p < .001 p < .001 p < .001

3.08 (.3) — 11.56 (3.3)

3.45 (1.1) 11.42 (3.4) 13.27 (3.3)

3.62 (1.2) 12.78 (3.4) 15.99 (3.2)

F ¼ 7.51; p < .001 F ¼ 6.83; p ¼ .01 F ¼ 56.99; p < .001

10.51 (3.8)

11.33 (2.1)

19.39 (3.4)

F ¼ 347.04; p < .001

7.48 (1.9)

6.98 (2.2)

6.57 (2.7)

F ¼ 4.01; p ¼ .02

7.32 (1.7) .88 (1.1)

6.64 (1.7) .77 (.2)

5.28 (1.9) .56 (.3)

F ¼ 40.40; p < .001 F ¼ 55.34; p < .001

71.33 (17.4)

64.66 (18.7)

50.98 (21.6)

F ¼ 34.41; p < .001

PSQI, Pittsburg Sleep Quality Index; EQ5D, Euroqol-5D; VAS, Visual Analogue Scale.

518

Differences between subcategories

Sleep and Addiction

September 2015

TABLE 3. Correlations between PSQI, SLEEP50 and EQ5D scales (Pearson correlation coefficients)

PSQI! SLEEP50# Apnea Insomnia Narcolepsy Restless legs Circadian rhythm Sleepwalking Nightmares Factors influencing sleep Impact daily functioning Grade EQ5D utility EQ5D VAS

Sleep Daily quality latency duration efficiency disturbances medication functioning

PSQI total

EQ5D utility score

EQ5D VAS score

.33 .66 .26 .18 .20

.22 .59 .22 .14 .10

.22 .51 .11 .04 .22

.22 .51 .12 .13 .12

.47 .53 .33 .18 .14

.17 .21 .19 .15 .03

.28 .23 .33 .14 .16

.43 .76 .35 .22 .20

.32 .31 .38 .28 .11

.27 .30 .35 .20 .10

.09 .31 .30

.03 .17 .07

.06 .10 .16

.02 .23 .16

.20 .28 .24

.10 .14 .29

.15 .14 .41

.14 .33 .38

.08 .18 .48

.09 .14 .35

.52

.36

.25

.27

.37

.13

.43

.54

.44

.41

.70 .40 .24 .16 .27 .13

.40 .07 .10

.42 .18 .21

.43 .33 .27

.26 .35 .27

.63 .35 .34

.24

.28

.11 .19 .19

PSQI, Pittsburg Sleep Quality Index.  p < .05;  p < .01.

problems category had higher scores than patients with no sleeping problems. The categories were formed using SLEEP50 scores; therefore, it may come as no surprise that we found differences in scores on the SLEEP-50 scales. Since the

categories were based on the total SLEEP-50 score, it is still informative to present the scores on the different subscales in this table. The differences in scores for the Restless Legs scale, for instance, were less striking than those for Insomnia.

TABLE 4. Hierarchical linear regression model for quality of life (EQ5D Utility score)

b in final model Step 1. baseline characteristics gender age Step 2. substance use alcohol cannabis cocaine opiates amphetamines GHB Psychoactive medication Step 3. psychiatric disorders depressive disorder PTSS psychotic disorder suicidal risk Step 4. sleep quality PSQI total score SLEEP50 total score Total explained variance in final model

.09

T (p)

DF (p)

DR2

2.417 (.091)

.013

2.881 (.006)

.054

21.414 (.000)

.186

6.537 (.002)

.028

1.950 (.052)

.271 .129

5.377 (.000) 2.390 (.017)

.271

2.611 (.009)

.205

4.028 (.000) .263

PTSD, post-traumatic stress disorder.

e et al. Magne

September 2015

519

Furthermore, the table shows that the categories also differed with respect to PSQI scores, reflecting perceived sleep quality. Total PSQI scores were more than twice as high in the disorder category than in the “no problems” category. However, 45% of patients without sleep problems still reported to perceive a low sleep quality (PSQI >5.0), whereas in the sleep disorders group 11% reported to perceive a good sleep quality (PSQI .60) with SLEEP-50 insomnia and with the grading of sleep; moderately (Pearson’s R between .30 and .60) with apnea, narcolepsy, nightmares, factors influencing sleep and daily functioning, and weakly (R < .30) with restless legs, circadian rhythm sleep and sleepwalking. Table 3 also shows the correlations between the separate types of sleep problems of both sleep scales and HRQL. Correlation coefficients are low to moderately high and almost all had p < .05, with the exceptions of circadian rhythm sleep and nightmares. Correlations between the sleep problems of the SLEEP-50 and HRQL were stronger than those between PSQI and HRQL. The results of the hierarchical regression procedure are presented in Table 4. Thirty-four percent of variance of HRQL could be explained by the model that was built. Self-reported sleep quality added significantly to the explanation of HRQL. Individual items that contributed to the prediction of HRQL were (younger) age, use of GHB, (not) having a history of depression or suicidal risk, classification into the “sleep problems” category, and classification into the “sleep disorder” category. PSQI scores did not add significantly to the explanation of HRQL.

DISCUSSION The present study dealt with the association between selfreported sleep problems and HRQL in a population of substance-dependent inpatients at the beginning of detoxification treatment. We used a sample of 388 patients, with 82% being polydrug users. Co-occurring disorders on all axes of DSM-IV were present. In this selected population of patients, 44% had a sleep disorder according to the SLEEP-50 algorithm. Additionally, one in every three patients suffered from self-reported sleep problems, without having significant daily impairments. One in every five patients had no clinically relevant sleep problems. 520

Sleep and Addiction

These figures should not necessarily be considered to reflect absolute prevalences, because our study population was a selection of all patients admitted to treatment. Unintended selection did occur, because some patients (n ¼ 65) refused participation in the study since they did not suffer from sleeping problems at treatment entry. This may have led to an overestimation of the real prevalence. On the other hand, among those who were excluded from participation because of their mental health condition (n ¼ 16; 1.9% of the initial population), and/or because of (excessive) use of benzodiazepines (n ¼ 7; .9%) may have been patients who suffered from increased sleeping problems. In fact, some of the patients who refused participation indicated a lack of confidence that this would work, since they suffered from sleeping problems for an extended period of time and “already tried everything.” This may have led to an underestimation of prevalence. Thirty-nine percent of patients in the population had narcoleptic problems (category 2), and 28% had a narcoleptic disorder (category 3). These are extremely high percentages for this rare disorder, affecting no more than .05% of the general population.27 The wording of the items that form the narcolepsy scale in the SLEEP-50 may have attributed to this high percentage, since they may reflect more transient symptoms associated with substance use. The indication of the diagnosis of narcolepsy in these cases is more likely the direct result of substance use, than of a genuine primary diagnosis of narcolepsy. This may have led to an overestimation of the prevalence of sleeping disorders in this population. However, we performed separate analyses with the exclusion of the narcolepsy scale; these analyses led to the same conclusions about the association between sleep disorders and HRQL. Further limitations of the study include its cross-sectional nature. It is the first exploration of the nature and strength of the association between sleep and HRQL in an inpatient sample of polydrug using substance dependent patients known to the authors. Future studies with more prospective designs are indicated to further assess these relationships. In this analysis the association between sleep disorders and HRQL in this population was clearly established. The analyses showed that sleep disorders explain 34% of variance in HRQL. However, it should be stressed that these findings do not prove a causal relationship between the two domains. The relation may originally have been reciprocal in that reduced HRQL was the cause of sleep disorders. Therefore, in our study we make no statements on causality; we merely found strong explanatory relationships between sleep and HRQL. This relationship may be in fact more complicated, especially in view of the strong associations between psychopathology, sleep and HRQL. Due to this complexity, the true nature of these relations has to be further explored. In our study we used only a few sociodemographic characteristics, including gender and age. Other studies28 have indicated associations between poor sleep and other background variables as ethnicity and marital status. Furthermore, we used only perceived sleep complaints. Classifications of September 2015

patients were made based on self-report, and were not verified in objective assessments (eg, polysomnography) for practical reasons: full diagnosis of sleep disorders would have taken up too much time from the clinicians in a setting where detoxification is the first objective. However, in view of our findings we advocate more attention to be paid by clinicians in addiction treatment settings, and more specifically in detoxification treatment. If no full diagnostic procedures can be used, both PSQI and SLEEP-50 can be used as screeners, and patients with high scores are to be referred for further diagnosis. There were only minor associations with substance use between the categories during the month before admission, and most were not statistically significant. For instance, we found no association with opioid use—including methadone —whereas other researchers did.29 This may relate to the naturalistic nature of our study, including polydrug using patients. There was an association with cannabis use, which is also found in other studies.30 ASI severity scores were higher for drug-related problems in the disorder and problems categories. Furthermore, Axis I co-morbidity is strongly associated with sleep disorders. The study showed that HRQL is strongly affected by both sleep problems and sleep disorders in this population, independent of the impact on HRQL by pre-existing psychopathology, and leads to impairments in daily functioning. This is a confirmation of previous findings in other patient populations and in more homogeneous populations of substance dependent patients. Katz and McHorney31 found that the effect of insomnia on HRQL is equal in severity to the effect of any chronic illness in patients diagnosed with chronic medical and psychiatric conditions. These findings indicate the relevance for clinicians to pay attention to the quality of sleep in patients entering substance dependence treatment, since this may contribute significantly to the perceived HRQL. It is known that patients seek help, not because their illness worsens or their symptoms increase, but rather because they experience deteriorating HRQL and even demoralization.32 Attention by clinicians for this phenomenon is relevant for successful treatment. Another argument for the clinical relevance of self-reported sleep problems is that in some patients sleep problems may worsen during treatment as a result of withdrawal from substances.12 Kolla et al.4 found improvements in PSQI scores at discharge; however, mean scores were still above cut-off for sleep disturbance. Therefore, monitoring of sleep is important, especially during the first stages of treatment, since worsening of sleep and thereby further reduction of HRQL may cause patients exit early from treatment, and to relapse in to substance use. This study shows that in a polydrug using population entering in to an inpatient detoxification program, selfreported sleep problems are highly prevalent and in almost half of cases affect daily functioning. Sleep interventions should be offered. Since this population is prone to addiction and as sleep medication is independently associated with poorer HRQL due to side effects, physicians should be reluctant in e et al. Magne

prescribing sleep medication.33 Other non-pharmacological sleep interventions, like mindfulness, psycho-education, or cognitive behavioral therapy (CBT) seem to offer good results.34,35 Monitoring of sleep and sleep problems during treatment is indicated. Declaration of Interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

REFERENCES 1. Ishak WW, Bagot K, Thomas S, et al. Quality of life in patients suffering from insomnia. Innov Clin Neurosci 2012;9:13–26. 2. Landolt HP, Gillin JC. Sleep abnormalities during abstinence in alcohol dependent patients. Etiology and management. CNS Drugs 2001;15:413–425. 3. Arnedt JT, Conroy D, Brower KJ. Treatment options for sleep disturbances during alcohol recovery. J Addict Dis 2007;26:41–54. 4. Kolla BP, Schneekloth T, Biernacka J, et al. The course of sleep disturbances in early alcohol recovery: An observational cohort study. Am J Addict 2014;23:21–26. 5. Kupfer DJ, Reynolds CF. Management of insomnia. NEJM 1997;5: 341–346. 6. Arnedt JT, Conroy D, Rutt J, et al. An open trial of cognitive-behavioral treatment for insomnia comorbid with alcohol dependence. Sleep Med 2007;8:176–180. 7. Lee D, Schroeder JR, Karschner EL, et al. Cannabis withdrawal in chronic, frequent cannabis smokers during sustained abstinence within a closed residential environment. Am J Addict 2014;3:234–242. 8. Brower KJ, Perron BE. Prevalence and correlates of withdrawal-related insomnia among adults with alcohol dependence: Results from a national survey. Am J Addict 2010;3:238–244. 9. Teplin D, Raz B, Daiter J, et al. Screening for substance use patterns among patients referred for a variety of sleep complaints. Am J Drug Alcohol Abuse 2006;32:111–120. 10. Morgan PT, Malison RT. Cocaine and sleep: Early abstinence. ScientificWorldJournal 2007;7:223–230. 11. Conroy DA, Arnedt TJ, Brower KJ, et al. Perception of sleep in recovering alcohol-dependent patients with insomnia: Relationship with future drinking. Alcohol Clin Exp Res 2006;30:1992–1999. 12. Brower KJ. Insomnia alcoholism and relapse. Sleep Med Rev 2003;7: 523–539. 13. Crum RM, Storr CL, Chan Y, et al. Sleep disturbance and risk for alcoholrelated problems. Am J Psychiatry 2004;161:1197–1203. 14. Crum RM, Ford DE, Storr CL, et al. Association of sleep disturbance with chronicity and remission of alcohol dependence: Data from a populationbased prospective survey. Alcohol Clin Exp Res 2004;10:1533–1540. 15. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbance and psychiatric disorders. JAMA 1989;262:1479–1484. 16. Schierenbeck T, Riedmann D, Berger M, Hornyak M. Effect of illicit recreational drugs upon sleep: Cocaine, ecstasy and marijuana. Sleep Med Rev 2008;5:381–389. 17. Leger D, Scheuermaier K, Philip P, et al. SF-36: Evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosom Med 2001;63:49–55. 18. Pyne JM, Franch M, McCollister K, et al. Preference-weighted healthrelated quality of life measures and substance use disorder severity. Addiction 2008;103:1320–1329. 19. Fisk JE, Montgomery C. Sleep impairment in ecstasy/polydrug and cannabis-only users. Am J Addict 2009;5:430–437. 20. Benaiges I, Prat G, Adan A. Health-related quality of life in patients with dual diagnosis: Clinical correlates. Health Qual Life Outcomes 2012;10:106.

September 2015

521

21. Hendriks VM, Kaplan CD, Van Limbeek J, et al. The addiction severity index: reliability and validity in a Dutch addict population. J Subst Abuse Treat 1989;63:49–55. 22. McLellan AT, Luborsky L, Cacciola J, et al. New data from the addiction severity index. reliability and validity in three centers. J Nerv Ment Dis 1989;7:412–423. 23. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburg sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213. 24. De Niet GJ, Tiemens BG, Lendemeijer HH, et al. Perceived sleep quality of psychiatric patients. J Psychiatric Ment Health Nurs 2008;15:465–470. 25. Spoormaker VI, Verbeek I, Van den Bout J, et al. Initial validation of the SLEEP-50 Questionnaire. Behav Sleep Med 2005;3:227–246. 26. Van Vliet IM, de Beurs E. The MINI-international neuropsychiatric interview. A brief structured diagnostic psychiatric interview for DSM-IV en ICD-10 psychiatric disorders. Tijdschr Psychiatr 2007;49:393–397. 27. Ohayon MM. From wakefulness to excessive sleepiness: What we know and still need to know. Sleep Med Rev 2008;12:129–141. 28. Chakravorty S, Gradner MA, Kranzler HR, et al. Insomnia in alcohol dependence: Predictors of symptoms in a sample of veterans referred from primary care. Am J Addict 2013;22:266270.

522

Sleep and Addiction

29. Peles E, Schreiber S, Adelson M. Variables associated with perceived sleep disorders in methadone maintenance treatment (MMT) patients. Drug Alcohol Depend 2006;2:103–110. 30. Bonn-Miller M, Babson K, Vujanovic A, et al. Sleep problems and PTSD symptoms interact to predict marijuana use coping motives. J Dual Diagn 2010;6:111–122. 31. Katz DA, McHorney CA. The relationship between insomnia and healthrelated quality of life in patients with chronic illness. J Fam Pract 2002;51:229–235. 32. De Jong CAJ, Kissane DW, Geessink RJ, et al. Demoralization in opioiddependent patients: A comparative study with cancer patients and community subjects. Open Addict J 2008;1:7–9. 33. Sasai T, Inoue Y, Komada Y, et al. Effects of insomnia and sleep medication on health-related quality of life. Sleep Med 2010;11: 452–457. 34. Brower K. Alcohol’s effects on sleep in alcoholics. Alcohol Res Health 2001;25:110–125. 35. Arnedt JT, Conroy DA, Armitage R, et al. Cognitive-behavioral therapy for insomnia in alcohol dependent patients: A randomized controlled pilot trial. Behav Res Ther 2011;49:227–233.

September 2015

Sleep disturbances are associated with reduced health-related quality of life in patients with substance use disorders.

Sleep problems and substance use are strongly linked. Sleep problems play a role in the etiology of substance use, but also may be a result of it. Aft...
114KB Sizes 3 Downloads 9 Views