[REVIEW]

Quality of Life in Patients

Suffering from Insomnia
by WAGUIH W. ISHAK, MD, FAPA; KARA BAGOT, MD;
SHANNON THOMAS; NAIRA MAGAKIAN, MD; DINA BEDWANI, MD;
DAVID LARSON, MD; ALEXANDRA BROWNSTEIN;
and CHRISTINE ZAKY, MD
Dr. IsHak, Ms. Thomas, Dr. Magakian, Dr. Bedwani, and Dr. Zaky are rom Cedars-Sinai Medical
Center; Los Angeles, California; Dr. Bagot is from Yale University School of Medicine, Yale Child
FUNDING: Dr. IsHak has received grants in Study Center, New Haven, Connecticut; Dr. Larson is from University of Southern California Keck
associated research areas as listed below: School of Medicine; and Ms. Brownstein is from University of California Los Angeles.
NARSAD on Quality of Life in Major
Depression, Pfizer Monotherapy in Major Innov Clin Neurosci. 2012;9(10):13–26
Depression.

FINANCIAL DISCLOSURES: None of the

authors have a conflict of interest in the ABSTRACT Conclusion: Insomnia and its
conduct and reporting of this review. Objective: Systematic review of comorbidities negatively affect an
the literature pertaining to quality of individual’s quality of life, and
ADDRESS CORRESPONDENCE TO: Waguih life studies in adults suffering from different modalities of treatment can
William IsHak, MD, FAPA, Cedars-Sinai insomnia, by specifically addressing produce improvements in physical
Medical Center Department of Psychiatry the following questions: 1) What is and psychological wellbeing and
and Behavioral Neurosciences, David the impact of insomnia on quality of quality of life. More research is
Geffen School of Medicine at UCLA, 8730 life? 2) To what extent do comorbid needed to develop more
Alden Drive, Thalians W-157, Los Angeles, conditions affect quality of life in interventions that specifically focus
CA 90048; Phone: (310) 423-3515; Fax: patients with insomnia? 3) What is on improving quality of life in
(310) 423-3947; E-mail: the impact of insomnia treatment on patients suffering from insomnia.
Waguih.IsHak@cshs.org quality of life?
Design: Our search was INTRODUCTION
KEY WORDS: Insomnia, quality of life, sleep conducted using the The World Health Organization
disorder MEDLINE/PubMed and PsycINFO (WHO) defines quality of life (QOL),
databases from the past 25 years as individuals’ perception of their
(1987–2012), using the keywords position in life, in the context of
“Insomnia” AND “Quality of Life,” culture and value systems in which
“QOL,” “Health-related quality of they live, and in relation to their
life,” or “HRQOL.” Fifty-eight studies goals, expectations, standards, and
were selected for inclusion by two concerns.1 This conceptual
physicians who reached a consensus framework is translated into patient-
about the studies to include in this reported ratings of the degree of
review. satisfaction one has with health,
Results: The literature reveals social, occupational status, and other
that quality of life is severely life involvements. Hence, high QOL
impaired in individuals with insomnia, ratings are reflective not only of
comorbid conditions significantly symptom reduction but also an
affects quality of life negatively, and overall improvement in the self-
sleep restoration techniques, evaluation of one’s own health. This
including cognitive behavioral is especially important in assessing
therapy and medications, are whether interventions have
successful at improving quality of life. accomplished the goal of health
However, restoration of quality of life restoration and not merely
to community levels is still unclear. symptomatic treatment. Quality of

13 [VOLUME 9, NUMBER 10, OCTOBER 2012] Innovations in CLINICAL NEUROSCIENCE 13

life may be a more reflective lens research specifically devoted to the abstracts using the following
through which to view the subject of evaluating QOL in inclusion criteria: 1) articles in
consequences of insomnia; it allows insomnia.9 The goal of this review is English or with an available
one to understand the significant to examine QOL in patients with published English translation, 2)
impact this disorder can have on the insomnia through an in-depth review publication in a peer-reviewed
daily lives of the people it affects,2–5 of the topic’s published literature. journal, 3) studies of humans, 4)
as impairments in QOL typically are While recent reviews have focused studies (of any design) that focused
cited as the impetus for seeking on how insomnia affects some on insomnia (not other sleep
treatment.6 aspects of QOL, such as daytime symptoms), and 5) studies that used
Insomnia is defined as difficulty functioning, sleep quality, at least one QOL measure or
with sleep initiation or sleep neurocognitive functioning, and domains derived from QOL
maintenance, early morning societal burden,2 QOL generally,3 and measures. Both physicians then
awakenings or nonrestorative sleep, QOL within the context of economic conducted, independently, a focused
according to the Diagnostic and and public health consequences,4 review using the full text articles of
Statistical Manual of Mental information about the extent of the studies that met the above criteria.
Disorders, Fourth Edition, Text role of comorbidities as well as the The reviewers then reached a
Revision (DSM-IV-TR) criteria. Such impact of treatment of insomnia on consensus about the studies to
symptoms hold the potential to QOL remain largely unaddressed. include in this manuscript.
drastically affect the patient’s ability Additionally there is lack of Data extraction and yield. The
to maintain a sense of wellbeing and investigation of studies that compare study selection process yielded 58
perception of self-satisfaction with different treatment modalities and articles meeting the aforementioned
health, occupational, and social the differential impact on QOL. selection criteria. Research
functioning. Consequently, insomnia This paper aims to answer the methodology and key findings were
is commonly linked to a diminished following three questions: 1) What is derived from the full text and the
QOL status for both primary the impact of insomnia on QOL? 2) tables of the selected studies. The
(syndromic) and secondary To what extent do comorbid literature search and selection
(symptomatic) insomnia.5 Insomnia conditions affect QOL in patients methodology are depicted in
is highly prevalent in the general with insomnia? and 3) What is the Figure 1.
population. Research reveals a impact of insomnia treatment on QOL measures in insomnia.
prevalence of approximately 30 QOL? General QOL measures used in
percent of insomnia symptoms with This review will attempt to answer insomnia. The Medical Outcomes
a range of 10 to 40 percent, the above questions via a systematic Study Short Form-36 (SF-36) is a
depending on how insomnia is review of the published literature very widely used scale in evaluating
defined.7 Somewhere between 10 pertaining to QOL in insomnia. It will health-related QOL (HRQOL) in a
and 18 percent of these individuals also identify knowledge gaps in the variety of medical/psychiatric
consider their difficulties with sleep field and propose future areas of conditions and in insomnia.10–14 The
to be severe and chronic.8 Overall, research that may deepen our SF-36 is a 36-item generic QOL
insomnia is more common in women understanding of this topic. measure that assesses eight domains
than in men, and its prevalence specific to HRQOL: 1) physical
increases with age in both sexes.5 METHODS functioning, 2) role limitation due to
Insomnia may be a primary disorder Data sources. A systematic physical health problems (role
(a syndrome) or secondary to a literature search was conducted physical), 3) body pain, 4) general
variety of physical or psychiatric using the MEDLINE/PubMed and health perceptions, 5) vitality, 6)
illnesses (e.g., sleep apnea, PsycINFO databases for the past 25 social functioning, 7) role limitations
depression, anxiety), environmental years (1987–2012). We used the due to emotional health problems
factors (e.g., noise levels, keywords “insomnia” AND “quality of (role emotional), and 8) mental
temperature, seasonal changes) life,” “QOL,” “health-related quality health.15,16 All health measures are
and/or psychosocial issues (e.g., of life,” or “HRQOL.” The reference scored on scales of 0 to 100, with
current or upcoming stressors). list of identified papers and prior higher scores indicating better
Identifying and treating potential reviews were manually reviewed for health. Community norms are set at
underlying conditions are priorities additional studies. The initial search a mean score of 50 (SD=10) on each
in the management of insomnia. yielded 427 articles. The search was of its two components: physical
Insomnia is associated with a then narrowed to studies that only component score (PCS) and mental
number of adverse medical, social, included measurement of quality of component score (MCS). The SF-36
and psychological consequences life. This narrowed search yielded has two abbreviated versions: the 12-
leading to QOL impairments. 150 articles. item SF-12 and the eight-item SF-8.
The World Health Consensus Study selection criteria. Two There are several advantages to using
report on sleep found relatively little physicians reviewed the 150 the SF-36, such as the following:

14 Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 9, NUMBER 10, OCTOBER 2012]

Reliability and validity have been
extensively tested in many different
populations; norms have been
generated for disease-specific and
general population; it is easy to
complete; it allows for comparisons
across disease states; and it has been
shown to be sensitive to insomnia-
related changes.17–19 Limitations
associated with the SF-36 include
decreased sensitivity at extremes
(either good or bad) and its lack of
specificity to the illness it measures.19
The Quality of Life Enjoyment and
Satisfaction Questionnaire Short-
Form (Q-LES-Q)is a 16-item scale
with a total score ranging from 0
(lowest QOL) to 100 (highest QOL)
with established community norms
mean score of 78.3 (SD=11.3).20,21 The
Q-LES-Q has been used in a wide
variety of research studies of FIGURE 1. Quality of life in insomnia literature search results
psychiatric disorders including
insomnia.22
The World Health Organization may confound the association into clinical or research settings.
Quality of Life—Brief Form between QOL and insomnia and was Other QOL measures used in
(WHOQOL-BREF) is a 24-item constructed based on interviews with insomnia. The Nottingham Health
questionnaire covering four domains 20 patients with ‘severe’ insomnia Profile (NHP, 38-item covering 6
(physical health, psychological health, (two or more complaints of insomnia domains)27 and the Sickness Impact
social relationships, and in the past month) and validated by Profile (SIP, 136 items covering 12
environment)23 has been used more applying the scale to patients domains), both of which are generic
commonly to measure QOL in other classified as “good sleepers” (n=391), measures, have also been used to
disorders where insomnia is also “mild insomniacs” (n=422), and detect QOL changes associated with
present. “severe insomniacs” (n=240). Five insomnia.18,19 McCall et al22,28 used the
The EuroQol-5 (EQ-5D) is a five- dimensions (physical energy/the will daily living and role functioning
item QOL questionnaire covering five to carry out tasks, cognition, social, (DLRF) and relationship to self and
domains (mobility, self-care, usual and psychological) of QOL are others (RSO) subscales of the
activity, pain and anxiety/ depression) evaluated over 43 questions. While Behavior and Symptom Identification
and has been used in comorbidity this study has some limitations, Scale (BASIS-32) to assess QOL. The
studies.24 Other investigators also including nonspecificity of several DLRF and RSO subscales have been
used the QOL inventory, a 31-item items (i.e., evaluates symptomatology shown to differentiate depressed
questionnaire specifically designed for common to many other disease patients with insomnia from those
the study which includes questions states) and only one evaluated without insomnia.22
related to sleep, cognitive function, sample, thus the generalizability
daytime performance, social and remains unproven; the face validity of RESULTS WHAT IS THE IMPACT
family relationships, and health.4 the study appears sound. The authors OF INSOMNIA ON QOL?
Details of the psychometric concluded that an insomnia-specific Insomnia has a large impact on an
properties of the general QOL QOL measurement is better able to individual’s ability to maintain work,
measures appear in a previous article capture the deficits in functioning and physical, and social performance as
by the authors.25 QOL directly attributable to insomnia well as overall quality of life, as
Insomnia-specific QOL and may better evaluate treatment shown by the findings from reviewed
Measures. Léger et al19 developed a outcome. studies (Table 1).
measurement tool, the Hotel-Dieu-16 The Quality of Life of Insomniacs Studies using the SF-36 to assess
(HD-16), to specifically evaluate QOL questionnaire was developed by insomnia and its impact on QOL
in those with varying severity of Rombaut et al26 to specifically showed that individuals with
insomnia. Unlike the aforementioned evaluate QOL in insomnia. This insomnia reported poor QOL.10–13,16
instruments, the HD-16 was designed instrument has been used in a few Zamitt et al11 used several
to control for comorbid illness that studies, and it has not been expanded instruments to evaluate the impact

[VOLUME 9, NUMBER 10, OCTOBER 2012] Innovations in CLINICAL NEUROSCIENCE 15

of insomnia on QOL in a sample of In summary, insomnia negatively frequent complaint as it is reported
261 “insomniacs” compared to a affects individuals’ quality of life and by nearly 85 percent of depressed
control group of 101 good sleepers. could cause increasing impairment patients.40 Unfortunately, insomnia
Individuals with irregular sleep in QOL with increasing severity of remains the most commonly
patterns, sleep apnea, restless leg sleep disturbance.3,30–35 unresolved symptom of depression
syndrome, periodic limb movement even after mood improvement
disorders, a history of psychiatric WHAT IS THE IMPACT OF following selective serotonin
illness, alcohol and substance abuse, COMORBIDITIES ON QOL IN reuptake inhibitors (SSRIs)
epilepsy, and human INSOMNIA? treatment.22 Many depressed patients
immunodificiency virus infection Insomnia commonly exists in the attribute low daytime functioning,
were excluded from the study. To presence of medical, psychiatric, and including poor concentration and
evaluate QOL, Zamitt et al11 used the psychosocial stressors.36 Vallieres et memory, decreased reaction time
SF-36 and the QOL inventory. The al37 found that unemployment, and coordination, fatigue, mood
results showed a significant recent death of a friend/family disturbance, and anxiety to inability
difference between the two groups member, recent end of a to obtain an adequate amount of
(p<0.0001 MANOVA) on all eight SF- relationship, and personal illness are nighttime sleep or sub-par quality of
36 subclasses. In comparison to the most common precipitants for sleep.
“good sleepers,” individuals with short-term insomnia (less than one A study performed by McCall et
insomnia reported more health month). Underlying stress may be al22 was designed to measure the
concerns that limited physical one of the factors contributing to impact of insomnia on the quality of
activity, caused more body pain, and insomnia and could contribute life of inpatients with depression.
caused more emotional difficulties. independently to impairing an The results showed lower QOL
Léger17 explored the effect of individual’s quality of life.29 Stressors ratings in patients with comorbid
insomnia on daytime functioning may also exacerbate the severity of insomnia. This difference was
using the SF-36 to evaluate the QOL insomnia as well as other comorbid especially prominent in those using a
of three matched groups of 240 conditions, which in turn may have measure of self-report, the Beck
subjects with severe insomnia, 422 several downstream effects on QOL Depression Inventory (BDI), as
with mild insomnia, and 391 good and ability to function. Moreover, compared to the clinician-rated
sleepers. It was found that those studies show that individuals Hamilton Rating Scale for Depression
with severe insomnia had lower QOL suffering from insomnia have a (HRSD). In a study of residual
scores in the above eight dimensions greater chance of developing symptoms in depression,
of SF-36 than did those with mild depression and anxiety leading to approximately 40 percent of patients
insomnia and good sleep patterns. further QOL deterioration.62 receiving fluoxetine reported
Mental status and emotional state Research shows that insomnia was symptoms compatible with
were worse in both the severe and often comorbid with chronic nonrestorative sleep.41 Compared to
mild insomnia groups compared to illnesses or depression.31 sleep disturbances related to
the good sleepers.17 In a study of Psychiatric comorbidities. It is initiation or maintenance of sleep,
insomnia and quality of life, Katz and estimated that insomnia affects nonrestorative sleep is associated
McHorney29 examined 3,445 anywhere from 50 to 80 percent of with greater daytime functional
patients diagnosed with chronic the treatment-seeking psychiatric impairment. Therefore, targeting
medical and psychiatric conditions. population,38 highlighting the insomnia in depression may increase
The results showed that patients importance of psychiatric daytime performance and overall
with insomnia have lower quality of comorbidities and/or causes of QOL.
life, measured by the SF-36, psychopathology. Additionally, 30 to Anxiety disorders. Generalized
independent of the presence/absence 50 percent of the aforementioned anxiety disorder (GAD) and
of a comorbid chronic illness. population that suffers from chronic insomnia commonly coexist, with at
Furthermore, the study found that insomnia has one or more of the least 66 percent of patients with
the effect of insomnia on quality of following psychiatric disorders: GAD experiencing comorbid sleep
life is equal in severity to the effect major depressive disorder, mania/ disturbances.42 Similarly, GAD is the
of any chronic illness, such as hypomania, an anxiety disorder most common psychiatric disorder
congestive heart failure or clinical (phobias, obsessive-compulsive among patients with insomnia.42
depression. Similarly, decreased QOL disorder, panic disorder, generalized Brenes et al43 found that 90 percent
as a function of insomnia was shown anxiety disorder) and/or a substance of older adults with GAD reported
to be comparable to QOL impairment abuse/dependence disorder.39 moderate to severe insomnia.43
due to chronic medical conditions, Depression. Sleep disturbance is Individuals with significant insomnia
using the Nottingham Health Profile an important component in the often also experience somatic
(NHP)27 and the Sickness Impact clinical presentation of depressive manifestations of psychiatric illness,
Profile (SIP).18,19 disorders. Insomnia is a particularly such as elevated physiological

16 Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 9, NUMBER 10, OCTOBER 2012]

TABLE 1. Impact of insomnia on QOL

REFERENCE MEASURE N SUMMARY OF FINDINGS

261 insomnia
Zammit et al
SF-36 subjects, 101 Insomnia patients had significantly lower SF-36 scores compared to controls (p< 0.0001).
(1999)11
controls

In a population of older adults, 26% reported 1 insomnia symptom, 13% reported 2, and
Schubert et
SF-36 2,800 10% reported 3. SF-36 decreased on all 8 domains as the number of reported symptoms
al (2002)12
increased (p< 0.0001).

Chronic physical illness was associated with poorer HRQOL (p<0.0001). Psychotropic
Stein et al
SF-36 1,359 medications use was associated with lower scores on SF-36 MCS (p=0.0001) and SF-36
(2008)13
PCS (p=0.015) in women (controlling for age and number of comorbid illnesses).

This study compared good sleepers (GS) to patients with severe insomnia (SI)—Physician
240 insomnia visit with insomnia complaint: 0% GS v. 18% SI (p<0.0001); regularly taking sleeping pills:
Léger et al
SF-36 subjects and 391 0% GS v. 28% SI (p<0.0001); hospitalizations (past 12 mo.): 9% GS v. 18% SI
(2001)17
good sleepers (p=0.0017); on at least 1 medication: 44% GS v. 67% SI (OR=2.59); “Work error that could
have serious consequences:” 6% GS v. 15% SI (p<0.001).

34% had mild insomnia and 16% had severe insomnia at baseline. 59% (95% CI, 55%-
Katz and 63%) of patients’ with mild insomnia and 83% (95% CI, 78–88%) with severe insomnia at
McHorney SF-36 3,445 baseline still had problems at 2-year follow-up. Mild and severe insomnia were associated
(2002)29 with decreases in physical health perception (mild: OR=2.0; severe: OR=5.1), vitality (mild:
OR=2.4; severe: OR=7.4), and mental health (mild: OR=3.5; severe: OR=10.2) domains.

Sleep problems were found to be associated with physical (AOR=1.21, 95% CI=1.01–1.45)
and mental health problems (AOR=3.58, 95% CI=2.95–4.35) especially in those with
Stein et al comorbid physical health issues. The co-occurrence of insomnia was independently
SF-36 4,181
(2002)31 associated with poorer ratings on the SF-36 PCS (p< 0.001) and increased the odds of 1 or
more days taken off from work in the past 30 days due to physical problems (AOR=1.55,
95% CI=1.20–1.98) by 50%.

Insomnia with reported impairments in daytime functioning was associated with significant
QOL deficits across all domains (p<0.001). Compared to patients without insomnia,
Hatoum et al
SF-36 1,100 patients with problems with quality/quantity of sleep (no reported daytime symptoms)
(1998)32
demonstrated significantly lower scores on the PCS (p<0.001) and the body pain (p=0.01)
subscale.

Guereje et al 2,152 elderly Difficulty initiating or maintaining sleep and early AM awakening were associated with
WHOQOL-Bref
(2009)34 Nigerians physical, psychological, social, and environmental subscales and overall QOL (p<0.05).

Sleep disturbance and daytime fatigue were associated with increased likelihood of low
Lee et al scores on the following subscales: physical functioning, AOR=6.10; physical health
SF-36 397
(2009)35 problems, AOR=8.28; bodily pain, AOR=6.41; general health, AOR=5.88; vitality,
AOR=17.09; social functioning, AOR=5.46; and mental health, AOR=12.83.

QOL: quality of life; SF-36: Medical Outcomes Study Short Form-36; HRQOL: health-related quality of life; MCS: mental component score;
PCS: physical component score; OR: odds ratio; CI: confidence interval; AOR: adjusted odds ratio; WHOQOL-Bref: World Health Organization
Quality of Life—Brief Form

[VOLUME 9, NUMBER 10, OCTOBER 2012] Innovations in CLINICAL NEUROSCIENCE 17

symptoms of arousal (e.g., dizziness, of childhood abuse/neglect on QOL and perceived and actual
headache, weakness, fatigue, subjective feelings of sleep difficulty functioning. Further research needs
palpitations, and gastro-intestinal and the secondary effect that this to be done to study the individual
distress).44 Moreover, patients with has on perceived quality of life in impact of pain, fatigue and insomnia
insomnia report more attention adulthood. The authors postulated on QOL and functional status in this
disorders and memory complaints.45 that neglect and abuse in childhood unique population.55
This may lead to impaired promote a neural set-up for poor Neurological disorders. Insomnia
concentration and increase the risk attachment with hindrance of the may also exacerbate symptoms of
of traffic accidents as well as fatigue development of positive TBI possibly due to injury to the
and daytime sleepiness—symptoms interpersonal relationships later in neural circuitry that regulates sleep,
associated with poor QOL. life. The anxiety that this engenders side effects of medications used to
Veterans returning from combat in combination with heightened treat complications of TBI, or
have been shown to demonstrate stress reactivity can contribute to comorbid psychiatric, pain, or
high rates of posttraumatic stress insomnia secondary to the stress of medical disorders.49 Insomnia may
disorder (PTSD) and traumatic brain psychosocial issues. This could further contribute to worsening
injury (TBI),46,47 both of which are further impact QOL and the ability to symptoms of TBI by impeding the
associated with a high prevalence of cope with emotional strain as well as healing process that occurs during
insomnia.48 Additionally, all three diminish the ability to foster and sleep. The estimated prevalence of
diagnostic subcategories of PTSD, re- maintain social relationships. insomnia in those with TBI varies
experiencing, avoidance, and hyper- Parental emotional abuse is widely from 21 to 93 percent.57,58
arousal, may factor into the associated with adulthood sleep Comorbid insomnia is also a
development of PTSD as they are complaints, which is consistent with common problem in those with
associated with poor sleep hygiene indices of insomnia associated with neurodegenerative disorders, such as
and/or may be the impetus for emotional and interpersonal stress. Parkinson’s or Alzheimer’s disease. In
frequent awakenings or delayed Medical comorbidities. certain neurological conditions,
sleep initiation. In a study by Wallace Individuals with insomnia have 60- insomnia may be considered a direct
et al49 comparing the differential percent greater healthcare costs as result of the disease itself or
effects of PTSD with or without compared to the general population secondary to other factors associated
comorbid mild TBI (mTBI) on sleep due to over-utilization of the with it, such as pain, depression, or
and daytime functioning, the authors healthcare system.51 This is treatment medications.59 Caap-
compared characteristics of sleep evidenced by greater number of Ahlgren and Devlin60 investigated the
between healthy sleepers (control), visits to the emergency department impact of insomnia on QOL in a
individuals with insomnia plus PTSD and outpatient physicians, increased population of 102 patients with
plus TBI combined and individuals use of pharmacotherapy, and more comorbid Parkinson’s disease and
with insomnia plus PTSD alone. laboratory tests ordered,52 proving to found that they had lower scores on
Although those participants with be a great economic and healthcare each domain of QOL, as measured by
PTSD plus mTBI demonstrated burden.53 Of patients seen in primary SF-36, as compared to patients with
similarities in type of insomnia care settings, approximately 10 Parkinson’s disease with no
experienced, short duration of sleep, percent suffer from chronic insomnia.60
and severity as compared to PTSD insomnia.54 Patients admitted to the ICU.
alone participants, the PTSD plus Cancer. Insomnia affects up to 50 Insomnia is well recognized in the
mTBI group indicated greater percent of cancer patients, intensive care unit (ICU).61 Despite
daytime sleepiness although they contributing to feelings of fatigue, exhibiting normal duration of sleep,
spent more of the night sleeping.49 and possibly immunosuppression.55,56 patients usually demonstrate poor
This is an important finding as In a cross-sectional study of 120 quality and abnormal patterns of
insomnia due to decreased duration elderly patients with cancer, Cheng sleep. Poor sleep quality can continue
of sleep has been associated with and Lee55 found that those with a in patients after discharge.62 There is
poor HRQOL outcomes, such as symptom cluster of insomnia, pain, evidence that even the recollection of
increased use of the healthcare and fatigue reported the lowest QOL, the difficulties experienced while on
system, increased morbidity and based on Functional Assessment of an ICU can negatively impact sleep
mortality due to physical illness, and Cancer Therapy (FACT-G) scores six months after discharge.62 These
reduced work productivity.49 and experienced the greatest sleep disturbances have been found
Childhood-related psychiatric decrements in functioning. They to contribute to significant continuing
disorders. Psychiatric illness in concluded that as 5.5 to 18.8 percent decrements in HRQOL in all domains
childhood can also have lifelong of elderly cancer patients have co- of the EuroQol-5 and to the inability
consequences on sleep quality and occurrence of the aforementioned to return to prior functioning.62 Lack
quality of life. Poon and Knight50 symptom cluster, the combined of treatment may contribute to
investigated the downstream impact impact of the three serve to decrease impaired QOL.63

18 Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 9, NUMBER 10, OCTOBER 2012]

 Congestive heart failure (CHF). impact on QOL in a population of benzodiazepines, benzodiazepine
In a study conducted by Krakow et patients with OSA and comorbid receptor agonists, and melatonin
al,64 insomnia and sleep-disordered insomnia, Bjornsdottir et al66 receptor agonists.
breathing (SDB) were the most evaluated 824 patients with OSA and Benzodiazepines.
common causes of sleep 762 healthy controls. In regard to Benzodiazepines have been shown to
disturbances in patients with CHF. symptoms of insomnia, they found be efficacious in reducing sleep onset
Additionally, Johansson et al65 found that compared to their healthy latency and frequency/amount of
that in elderly patients with CHF, 42 counterparts, those with OSA nighttime awakenings. However,
percent demonstrated SDB as encountered greater difficulties with benzodiazepines have not been
compared to eight percent in those sleep maintenance. They also found formally studied for their impact on
without CHF (p=0.001). In regard to that women with OSA had greater QOL and their negative effects on
insomnia, of those with comorbid sleep onset latency as compared to next-day functioning (e.g., decreased
CHF, 72 percent had difficulty women without OSA. Additionally, memory and recall and daytime
maintaining sleep (as compared to increased difficulty initiating and/or sleepiness), as well as the risk of
50% in non-CHF patients; p=0.05), maintaining sleep was associated tolerance and/or dependence when
and 25 percent exhibited daytime with poorer QOL (SF-12). Individuals used long-term.68
fatigue (as compared to 8% in non- with OSA also demonstrated more Benzodiazepine receptor
CHF patients; p=0.05).65 The elderly impairment in physical and mental agonists (BRAs). BRAs, also known
patients that demonstrated domains of perceived QOL.66 as nonbenzodiazepine sedative-
symptoms of insomnia or SDB and hypnotics, have also shown efficacy
comorbid CHF had worse QOL WHAT IS THE IMPACT OF in treatment of insomnia. They
scores compared to those without TREATMENT OF INSOMNIA ON demonstrate the same hypnotic
CHF. Furthermore, decrements in QOL? effects as benzodiazepines without
the physical composite score of the As the impact of insomnia on the high propensity for dependence
SF-36 were associated with the health and wellbeing might be under- and development of tolerance.
following signs of insomnia (p<0.05): recognized, many patients do not There are also several
difficulty initiating or maintaining seek medical care early in the course randomized, controlled trials (RCTs)
sleep, early morning awakening, and of sleep disturbance, resulting in a that have been conducted to
nonrestorative sleep. Nonrestorative significant amount of under- evaluate the efficacy of these
sleep was also associated with a treatment and inadequate medications on insomnia and the
deficit in the mental health treatment.67 As 85 to 90 percent of effect they have on QOL. In a RCT of
composite score (p<0.05).65 A study chronic insomnia is attributable to 458 patients (231 randomized to
to evaluate the impact of nasal comorbidities, including circadian treatment, 227 randomized to
dilator strips (NDS) on sleep quality, rhythm disorders, physical and placebo) studying the impact of a 14-
SDB, and QOL was done in nonobese psychiatric illness, concurrent day standing zoplicone regimen with
adults with sleep disturbances. The substance abuse, and/or an additional six weeks of medication
participants consisted of 42 subjects pharmacotherapy for comorbid per patient request, the patients
in the treatment group and 38 illness,8 cessation of medication/drug randomized to zolpicone had similar
subjects in the control group. At four use and/or treatment of the primary improvement in the psychological
weeks follow-up, the treatment disorder may adequately address wellbeing component and global QOL
group reported significant sleep disturbances that would lead to of the QOLI as compared to the
improvements in insomnia severity a downstream impact on QOL. placebo group. But the treatment
and sleep quality and improvement Behavioral as well as pharmacological group demonstrated significantly
in Q-LES-Q (mean d=0.51), interventions play an important role greater improvement in the activity,
compared to small, statistically in treatment and improvement of sleep, social, and work domains.67
insignificant changes in the control daily functioning and one’s These improvements were
group.64 perception of QOL. The details of the maintained at two-month follow-up.
Comorbid sleep disorders. reviewed treatment studies are Walsh et al69 evaluated the efficacy
Although sleep disorders such as shown in Table 2. of eszopiclone on sleep disturbances
obstructive sleep apnea (OSA), SDB, Pharmacological treatments. It (latency of sleep initiation, time to
narcolepsy, snoring and restless leg has been shown that 5 to 8 percent waking after sleep onset, and total
syndrome/periodic limb movement of the general population use sleep time) and QOL impairments.
are considered separate disease medications to aid in better quality, After six months of study medication
entities from insomnia, the co- or greater duration of sleep.8 There consumption, the patients receiving
occurrence of the two and their are three United States Food and eszopiclone demonstrated greater
combined impact on QOL is Drug Administration (FDA)- improvement in bodily pain, physical
important to consider. To study approved drug classes for the and social functioning, and vitality as
characteristics of insomnia and their treatment of insomnia: measured by the SF-36, as compared

[VOLUME 9, NUMBER 10, OCTOBER 2012] Innovations in CLINICAL NEUROSCIENCE 19

 TABLE 2. Impact of treatment on QOL in insomnia

SUMMARY OF FINDINGS
REFERENCE MEASURE USED N INTERVENTION DURATION
(P VALUES, ODDS RATIOS, PERCENTAGES, OR EFFECT SIZES)

Patients receiving CBT had reductions in SF-36 domains: vitality at

3 mo. (p<0.01) and physical functioning (p<0.04) and mental
Byles et al 209 chronic Follow up at 3, 6, 12
SF-36 CBT vs. placebo health (p<0.02) at 6 mo. CBT group had reduced hypnotic use
(2003)16 insomniacs months
(p<0.001) and insomnia scores (p<0.01) at 12 mo. follow-up
compared to placebo.

The ESZ group demonstrated significantly greater improvement in

QOL (DLRF:p=0.01; RSO:p<0.05; Q-LES-Q:p=0.08) as compared
Open-label FLX,
1 week open label to the placebo group. Additionally, women demonstrated greater
BASIS-32 60 depressed followed by FLX
McCall et al FLX following by 8 improvement in QOL at the end of treatment (DLRF:p<0.01;
(subscales: DLRF, patients with combined with either
(2010)22 weeks of FLX + ESZ RSO:p<0.05; Q-LES-Q-:p<0.01) as compared to the men within the
RSO, Q-LES-Q insomnia ESZ 3mg or placebo
or placebo. same treatment group. Both subscales of the BASIS-32 had
at bedtime
moderate effect sizes (DLRF:0.62; RSO:0.44) and the Q-LES-Q had
a small effect size (0.38).

Difficulty sleeping at baseline was associated with the following

SF-36 domains: general health perceptions (p=0.03), emotional
role limitations (p=0.0007) and general mental health (p=0.0003)
Morin et al 10,430 Australian
SF-36 Pharmacotherapy 3 years and use of pharmacotherapy for sleep at baseline was associated
(2006)68 women
with: physical functioning (p=0.0005), bodily pain (p=0.02), vitality
(p=0.01), social functioning (p=0.01) and general mental health
(p=0.001).

ESZ group had significantly better scores on the SF-36 domains

vitality & social functioning and physical functioning and the Work
SF-36, Work Limitations Questionnaire (across all domains) as compared to
Walsh et al 830 with primary ESZ (3mg) vs. 6 months, 14 days
Limitations placebo (p<0.05). ESZ patients had higher SF-36 ratings on bodily
(2007)69 insomnia placebo post-treatment
Questionnaire pain, role physical, general health, and MCS at 6 mo. (p<0.05).
The vitality domain showed the greatest improvement at 6 mo.
(p<0.001).

ESZ 2mg group had greater QOL (p<0.05), daytime alertness, and
231 adults aged ESZ 1mg (n=72),
Scharf et al sense of well-being as compared to placebo on the following
Q-LES-Q 65–85 years with ESZ 2mg (n=79), or 2 weeks
(2005)70 domains: physical health, mood, household activities, and leisure
primary insomnia placebo (n=80)
time activities.

Patients with insomnia had lower MCS than good sleepers

(p<0.01). Use of sleep medications was correlated with PCS
Sasai et al 2,822 adults 20 (OR=1.36). Insomnia was associated with higher risk of low MCS
SF-8 None (survey) N/A
(2010)73 years and older (OR=2.29) and PCS (OR=1.69). MCS and PCS scores significantly
lower in patients with insomnia on sleep meds as compared to
good sleepers (p<0.01).

SF-36: Medical Outcomes Study Short Form-36; CBT: cognitive behavioral therapy; BASIS-32: Behavior and Symptom Identification Scale; DLRF: daily living and role functioning;
RSO: relation to self and others; Q-LES-Q: Quality of Life Enjoyment and Satisfaction Questionnaire Short-Form; FLX: fluoxetine; ESZ: eszopiclone; QOL: quality of life; MCS: mental
component score; PCS: physical component score; OR: odds ratio

to those receiving placebo. They also addition to the Q-LES-Q to assess within the same treatment group.
demonstrated decreased sleep onset QOL in a population of individuals Both subscales of the BASIS-32 had
latency, increased time to waking, with comorbid unipolar depression moderate effect sizes (DLRF: 0.62;
and total sleep time.69 Scharf et al70 and insomnia at baseline and RSO: 0.44) and the Q-LES-Q had a
corroborated these findings in an following treatment with a small effect size (0.38).
elderly population randomized to combination of fluoxetine and Melatonin and melatonin
placebo or eszopiclone. In this eszopiclone or placebo. Following receptor agonists. Melatonin is a
subset of the population, the above eight weeks of treatment with either hormone produced in humans by the
sleep parameters as well as QOL fluoxetine plus eszopiclone or pineal gland in the central part of
showed improvement in the fluoxetine plus placebo, the the cerebrum. Melatonin agonists
eszopiclone group on the following eszopiclone group demonstrated are safe, nonaddictive, sleep-
domains: household activities, significantly greater improvement in inducing drugs that eliminate
leisure activities, mood, medication, QOL as compared to the placebo changes in the circadian rhythm.
and physical health, as measured by group. Additionally, women They can regulate sleep-wake cycles
the Q-LES-Q.70 demonstrated significantly greater and re-adjust circadian rhythms.71 In
McCall et al22 used the DLRF and improvement in QOL at the end of a review evaluating the safety of
RSO subscales of the BASIS-32 in treatment compared to the men different pharmacotherapeutic

20 Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 9, NUMBER 10, OCTOBER 2012]

TABLE 2. Impact of treatment on QOL in insomnia, continued

SUMMARY OF FINDINGS
REFERENCE MEASURE USED N INTERVENTION DURATION
(P VALUES, ODDS RATIOS, PERCENTAGES, OR EFFECT SIZES)

CBT patients had significant reductions in sleep latency,

209 adults with
CBT “sleep clinic” improvements in sleep efficiency, and reductions in the frequency
chronic insomnia
Dixon et al group and a “no of hypnotic drug use (all P<0.01) at 3- and 6-month follow-ups.
SF-36 using hypnotic 3–6 month follow up
(2006)74 additional treatment” CBT patients showed an improvement in HRQOL scores at 6 mo
drugs for at least 1
control group on the following SF-36 domains: physical functioning (p=0.04),
month
emotional role limitation (p=0.01), mental health (p=0.02)

High severity of sleep disturbance at baseline was associated with

greater improvements in physical and mental HRQOL. Daytime
functioning impairment: 74% pre-treatment, 40% post-treatment,
Baseline, post-
Van Houdenhove SF-36, CIS-20, GHQ, 35% 6 mo follow-up. Physical HRQOL: moderate effect sizes from
138 with insomnia CBT treatment, 6 months
et al (2011)77 PANAS pre- to post-treatment (ES=0.582, p<0.001), and pre-treatment to
after treatment
follow-up (ES=0.739, p<0.001); Mental HRQOL: large effect sizes
from pre- to post-treatment (ES=0.761, p<0.001), and pre-
treatment to follow-up (ES=0.082, p<0.001)

150 adults 18 years

and older with
chronic insomnia CBT (five weekly 50 CBT was associated with improved QOL as compared to treatment
Baseline, 5 week
Espie et al FACT-G (cancer- and comorbid min sessions) vs. as usual in the following domains: physical (post-treatment
treatment, 6 month
(2008)79 related QOL) breast, treatment as usual p=0.004, follow-up p<0.001), social (post-treatment, p=0.036), and
follow-up
gynecological, (control) functional (post-treatment p<0.001, follow-up p<0.001).
prostate, or bowel
cancer

Self-administered
23-item
Insomnia patients
questionnaire
taking zoplicone for
developed by study
12 months or more
Leger et al sleep experts (5 167 with insomnia, No differences found in quality of life between subjects with
vs. good sleeper Cross-sectional
(1995)81 aspects of QOL- 381 good sleepers insomnia and good sleepers.
with no hypnotic use
Safety, Professional,
in the past 12
Leisure, Domestic,
months
Relational, and
Sentimental)

Zolpidem 10mg po 5
nights/week and
Both groups demonstrated improvement with treatment. The
Hajak et al 789 with insomnia, placebo 2
SF-36 14 days continuous group demonstrated a greater increase in mean MOS
(2002)82 aged 18–60 years nights/week vs.
score as compared to the discontinuous group (p=0.005).
Zolpidem 10mg po
continuously

Individual CBT v.
group CBT. CBT
Individual treatment: included
18 chronic primary psychoeducation, 6 consecutive weekly
Both groups demonstrated significant improvement in QOL on the
Verbeek et al insomnia. Group sleep hygiene, sessions and follow-
SF-36 SIP SIP: pre- to post-treatment (p=0.000) and from pre-treatment to
(2006)83 treatment: 40 stimulus control, up sessions 1, 3,
follow-up (p=0.025).
primary or sleep restriction, and 6 months
secondary insomnia. relaxation exercises,
and cognitive
restructuring.

SF-36: Medical Outcomes Study Short Form-36; CBT: cognitive behavioral therapy; CIS-20: Checklist Individual Strength; GHQ: General Health Questionnaire; PANAS: Positive Affect
Negative Affect Schedule; ES: effect size; BASIS-32: Behavior and Symptom Identification Scale; DLRF: daily living and role functioning; RSO: relation to self and others; Q-LES-Q:
Quality of Life Enjoyment and Satisfaction Questionnaire Short-Form; FLX: fluoxetine; ESZ: eszopiclone; QOL: quality of life; MCS: mental component score; PCS: physical component
score; OR: odds ratio; HRQOL: health-related quality of life; FACT-G: Functional Assessment of Cancer Therapy; MOS: Medical Outcomes Study sleep module; SIP: Sickness Impact
Profile

modalities in the elderly,72 the Other pharmacological lamotrigine, or carbamazepine) on

authors concluded that melatonin interventions used for insomnia. QOL in insomnia.
agonists are safer to use than the No information is available on the Potential negative effects of
traditional sedative-hypnotics that impact of sedating medications, such pharmacological interventions. In
work on GABA receptors. The as antidepressants (e.g., trazodone, contrast to the above findings, sleep
authors also found that melatonin mirtazapine, or tricyclics), medications might have negative
receptor agonists also help to antipsychotics (e.g., quetiapine, effects on QOL. In a survey of 2,822
improve mood and quality of sleep in olanzapine, or chlorpromazine), or individuals, Sasai et al73 investigated
this population. mood stabilizers (e.g., valproic acid, the impact of insomnia and use of

[VOLUME 9, NUMBER 10, OCTOBER 2012] Innovations in CLINICAL NEUROSCIENCE 21

any sleep medication on the mental quality of life during active CBT, but Behavioral therapy. In a study
health (MCS) and physical health also these reductions were comparing a three-component
(PCS) composite scores of the SF-8. maintained following the cessation of behavioral intervention (comprising
The authors divided their sample CBT.76 stimulus control, relaxation and sleep
into good sleepers, good sleepers In a RCT of 209 patients with hygiene) to sham biofeedback
taking sleep medication(s), chronic insomnia using hypnotics (placebo), Soeffing et al80 found no
individuals with insomnia, and those randomized to either CBT or control difference in SF-36 scores between
with insomnia taking sleep (care as usual in a general medical groups at the end of treatment. A
medication(s). Insomnia was found practice), Dixon et al74 found that limitation of this study was the
to be associated with poorer MCS over the course of six months, those evaluation of outcome measure QOL
and PCS (scores <50; 50 is the receiving CBT demonstrated relatively early after initiation of
population average). In regard to significant improvement on emotional treatment, such that effects of
both MCS and PCS, insomnia role limitation, mental health, and therapy on QOL may not have yet
individuals taking sleep medications physical functioning domains of the been apparent.
scored lower than insomnia SF-36 as compared to controls. Other nonpharmacological
individuals not taking sleep aids. Van Houdenhove et al77 treatments. No information is
Additionally, good sleepers taking investigated the impact of CBT for available on the effects of light
sleep medications demonstrated insomnia (CBT-i) on symptoms of therapy, exercise, or nutrition on the
significantly lower scores on the PCS insomnia and HRQL on 138 patients QOL of patients suffering from
as compared to insomnia individuals with primary insomnia. The authors insomnia.
not using sleep medications. As the found that CBT-i was effective in Treatment limitations. It is
authors found that the use of improving sleep disturbances, important to note that a small
pharmacotherapy to aid sleep was including sleep onset latency, such number of cross-sectional and
significantly associated with that percentage of daily use of noncontrolled studies demonstrated
decrements in perceived physical pharmacologic sleep aids decreased. equivocal results of the effect of
health QOL, they concluded that Additionally, daytime functioning treatment of insomnia on QOL in
sleep medication is independently improved and HRQOL improved, regard to both pharmacological and
associated with poorer physical QOL especially in the emotional domain behavioral treatments. These results
due to medication side effects.73 This such that scores approached were found in regard to “insomniacs”
is very important to keep in mind, normative scores. CBT-i appeared to versus “good sleepers” with
especially in patients who are taking have the greatest effect on HRQOL treatment with zolpiclone,81 insomnia
sleep medications on a long-term and daytime functioning in those with individuals treated continuously with
basis. greater pre-treatment impairment in nightly zolpidem or discontinuous
Non-pharmacological psychological QOL and daytime zolpidem treatment,82 and individual
treatments. Cognitive behavioral functioning and those with severe versus group CBT in insomnia
therapy (CBT). Several studies insomnia.77 individuals.83 As there were several
discuss the clinical efficacy and cost CBT has been also shown to limitations in the study design in the
effectiveness of providing CBT for effective in cancer patients with aforementioned trials, such as the use
insomnia to long-term hypnotic drug insomnia. In 1993, Espie et al78 of QOL domains instead of a well-
users in general practice.74,75 These highlighted practical behavioral and validated measure of QOL and lack of
studies concluded that CBT could cognitive techniques to manage control groups,82,83 the results of these
indeed improve the sleep quality of insomnia. Based on the same trials should be generalized with
long-term hypnotic users with techniques, the investigators caution.
chronic sleep disorders. evaluated the impact of treatment of Nonpharmacological approaches
Among these was an RCT with insomnia on QOL in 150 patients for insomnia management are
two treatment arms—a CBT-treated diagnosed with cancer who were not effective and can be first-line
‘sleep clinic’ group and a ‘no undergoing concurrent therapy.68 However, CBT and other
additional treatment’ control group— radiation/chemotherapy for greater similar behavioral interventions are
and post-treatment assessments at than one month of the study.79 The not readily available and that may
three and six months.75 Two-hundred authors found that the CBT group limit their use, thus necessitating
and nine patients aged 31 to 92 years demonstrated significant pharmacologic therapy.
with chronic sleep problems were improvements on various measures of Multimodal treatments combining
enrolled. Among CBT-treated sleep, including latency of sleep onset sleep hygiene and CBT with hypnotic
patients, SF-36 scores showed and waking after sleep onset, as well medications are helpful in relieving
significant improvements in vitality as on the physical and functional insomnia and improving their QOL.3
at three months (p<0.01). Not only domains of the FACT-G QOL More studies are needed to test the
was there a notable reduction in assessment tool as compared to the full effects of combined treatments
symptomatology and health-related treatment as usual group.79 on QOL in insomnia.

22 Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 9, NUMBER 10, OCTOBER 2012]

DISCUSSION conditions may improve the outcome 2010;14:379–389.
Insomnia produces clinically for insomnia, comorbidities, and QOL 5. Buysse DJ, Angst J, Gamma A, et
significant impairments in social and overall. Interventions that specifically al. Prevalence, course, and
occupational areas of functioning, as target QOL in insomnia are highly comorbidity of insomnia and
evidenced by reduction of work needed. Additionally, there remains a depression in young adults. Sleep.
productivity, frequent absenteeism, paucity of studies that specifically 2008;31:473–480.
decreased cognition and mood, and utilized QOL as primary outcome 6. Morin CM, LeBlanc M, Daley M, et
increased morbidity of psychological measure, thus further controlled al. Epidemiology of insomnia:
and physical illness, accompanied by trials needs to be done to address prevalence, self-help treatments,
a greater healthcare burden due to related gaps in knowledge. consultations, and determinants of
chronicity of illness and direct and help-seeking behaviors. Sleep
indirect costs to society. CONCLUSION Med. 2006;7:123–130.
Furthermore, insomnia may predict Quality of life in insomnia is 7. Mai E, Buysse DJ. Insomnia:
future episodes of psychiatric illness. significantly impaired affecting prevalence, impact, pathogenesis,
An individual’s perception of loss of overall subjective sense of physical differential diagnosis, and
or decrements in functioning may or psychological well-being. The evaluation. Sleep Med Clin.
provide the motivation to seek effect of insomnia on QOL may be 2008;3:167–174.
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