Sleep Disturbance and Short Sleep as Risk Factors for Depression and Perceived Medical Errors in First-Year Residents

Healthy working time arrangements for healthcare personnel and patients: a systematic literature review

BACKGROUND

A number of working time arrangements have been linked to negative consequences for both health personnel and their patients. A common hypothesis put forth to explain these findings suggests that certain working time arrangements lead to negative patient consequences due to the adverse impact they have on employee health. The purpose of this study is to use systematic reviews to investigate whether employee health explains the relationship between working time arrangements and patient safety.

METHODS

A systematic literature review was performed including published reviews and original studies from MEDLINE, PsycINFO, Cinahl and Web of Science investigating working time arrangements for healthcare personnel, employee health and patient safety. In addition, we screened reference lists of identified reviews. Two reviewers independently identified relevant publications according to inclusion criteria, extracted findings and assessed quality.

RESULTS

Six thousand nine hundred thirty papers were identified, of which 52 studies met our criteria. Articles were categorized into five groups according to how they approached the research question: 1) independent analyses of relationship between working time arrangements and employee health, and of working time arrangements and patient safety (5 studies); 2) relationship between working time arrangements on both employee health and patient safety (21 studies); 3) working time arrangements and employee health as two explanatory variables for patient safety (8 studies); 4) combinations of the above analyses (7 studies); 5) other relevant studies (5 studies). Studies that find that working time is detrimental to employee health, generally also find detrimental results for patient safety. This is particularly shown through increases in errors by health personnel. When controlling for employee health, the relationship between working time arrangements and patient safety is reduced, but still significant.

CONCLUSIONS

Results suggest that employee health partially (but not completely) mediates the relationship between working time arrangements and patient safety. However, there is a lack of studies directly investigating employee health as a mediator between working time arrangements and patient safety. Future studies should address this research gap.

Prevalence of sleep disturbances in Chinese healthcare professionals: a systematic review and meta-analysis

OBJECTIVE

The current review is a systematic, quantitative meta-analysis aimed at examining the pooled prevalence of sleep disturbances in Chinese healthcare professionals. Furthermore, we explore the possible causes of the inconsistencies in the current estimates.

METHODS

Systematic searches of databases were conducted for literature published on English (EMBASE, PubMed and Web of Science) and Chinese (Chinese National Knowledge Infrastructure, Wan Fang database and Chinese Science & Technology journal database) databases until 25 May 2018. Statistical analyses were performed using SPSS and R software, the prevalence of sleep disturbances was pooled using random-effects model.

RESULTS

A total of 52 studies with 31,749 participants were included. The pooled prevalence of sleep disturbances among Chinese healthcare professionals is 39.2% (95% CI: 36.0%-42.7%). Higher sleep disturbance rates are associated with being female, lower cut-off of Pittsburgh Sleep Quality Index (PSQI), later survey year, bigger sample size, the standardized assessment tool, being a nurse, and shift work. Sample size and cut-off of PSQI were significant moderators for heterogeneity.

CONCLUSION

Sleep disturbances are common in Chinese healthcare professionals, and their prevalence is much higher than the general population. Further research is needed to identify effective strategies for preventing and treating sleep disturbances among healthcare professionals.

Insomnia symptoms and short sleep predict anxiety and worry in response to stress exposure: a prospective cohort study of medical interns

STUDY OBJECTIVES

While anxiety rates are alarmingly high in short sleeping insomniacs, the relationship between insomnia and anxiety symptoms has not been extensively studied, especially in comparison to the relationship between insomnia and depressive symptoms. Using residency training as a naturalistic stress exposure, we prospectively assessed the role of sleep disturbance and duration on anxiety-risk in response to stress.

METHODS

Web-based survey data from 1336 first-year training physicians (interns) prior to and then quarterly across medical internship. Using mixed effects modeling, we examined how pre-internship sleep disturbance and internship sleep duration predicted symptoms of anxiety, using an established tool for quantifying symptom severity in generalized anxiety disorder (GAD).

RESULTS

Pre-internship poor sleepers are at more than twice the odds of having short sleep (≤6 h) during internship as good sleepers (OR = 2.38, 95% CI = 1.61, 3.57). Poor sleepers were also at twice the odds for screening positive for probable GAD diagnosis (OR = 2.08, 95% CI = 1.26, 3.45). Notably, sleep onset insomnia strongly predicted anxiety development under stress (OR = 3.55, 95% CI = 1.49, 8.45). During internship, short sleep associated with concurrent anxiety symptoms (b = -0.26, 95% CI = -0.38, -0.14) and predicted future anxiety symptoms even more strongly (b = -0.39, 95% CI = -0.76, -0.03).

CONCLUSIONS

Poor sleepers, particularly those with sleep onset insomnia symptoms, are vulnerable to short sleep and GAD anxiety and worry during chronic stress.

The Global Problem of Insufficient Sleep and Its Serious Public Health Implications

Good sleep is necessary for good physical and mental health and a good quality of life. Insufficient sleep is a pervasive and prominent problem in the modern 24-h society. A considerable body of evidence suggests that insufficient sleep causes hosts of adverse medical and mental dysfunctions. An extensive literature search was done in all the major databases for “insufficient sleep” and “public health implications” in this review. Globally, insufficient sleep is prevalent across various age groups, considered to be a public health epidemic that is often unrecognized, under-reported, and that has rather high economic costs. This paper addresses a brief overview on insufficient sleep, causes, and consequences, and how it adds to the existing burden of diseases. Insufficient sleep leads to the derailment of body systems, leading to increased incidences of cardiovascular morbidity, increased chances of diabetes mellitus, obesity, derailment of cognitive functions, vehicular accidents, and increased accidents at workplaces. The increased usage of smart phones and electronic devices is worsening the epidemic. Adolescents with insufficient sleep are likely to be overweight and may suffer from depressive symptoms. The paper concludes by emphasizing sleep quality assessments as an important early risk indicator, thereby reducing the incidence of a wide spectrum of morbidities.

Prevalence of and risk factors for poor sleep quality among residents in training in KSA

Objectives

This study aimed to identify the prevalence of and risk factors for poor sleep quality among medical residents in KSA.

Methods

A cross-sectional study was conducted on residents in programmes supervised by the Saudi Commission for Health Specialties. An anonymous, self-administered, web-based survey using the Pittsburgh Sleep Quality Index (PSQI) was done. The study received ethical approval from the institutional review board of the King Saud University College of Medicine, Riyadh, KSA.

Results

A total of 1205 residents responded to the survey. A high prevalence of 86.3% of poor sleep quality was recorded. When grouped by specialty, anaesthesia residents had the highest prevalence of poor sleep quality (96%), whereas pathology residents had the lowest prevalence (68.7%). Increased sleep latency was the most common contributor to poor sleep quality, observed in 68.4% of residents at least once a week. Poor sleep quality was further stratified based on median PSQI scores into stages 1 (46.9%) and 2 (39.4%). Using multivariate logistic regression, the age group of those between 27 and 29 years (p = 0.012) covering on-call cases (p ≤ 0.01) or working shifts (p < 0.001) was significantly associated with stage 2 poor sleep quality.

Conclusion

Poor sleep quality is highly prevalent among medical residents in KSA. Increased sleep latency and short sleep duration were the most reported sleep distractors. On-call scheduling and shift work were major risk factors for poor sleep quality. Training programmes should abide by the 80-hour weekly limit and integrate wellness programmes into the curriculum.

The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders

Sleep reactivity is the trait-like degree to which stress exposure disrupts sleep, resulting in difficulty falling and staying asleep. Individuals with highly reactive sleep systems experience drastic deterioration of sleep when stressed, whereas those with low sleep reactivity proceed largely unperturbed during stress. Research shows that genetics, familial history of insomnia, female gender and environmental stress influence how the sleep system responds to stress. Further work has identified neurobiological underpinnings for sleep reactivity involving disrupted cortical networks and dysregulation in the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Sleep reactivity is most pathologically and clinically pertinent when in excess, such that high sleep reactivity predicts risk for future insomnia disorder, with early evidence suggesting high sleep reactivity corresponds to severe insomnia phenotypes (sleep onset insomnia and short sleep insomnia). High sleep reactivity is also linked to risk of shift-work disorder, depression and anxiety. Importantly, stress-related worry and rumination may exploit sensitive sleep systems, thereby augmenting the pathogenicity of sleep reactivity. With the development of cost-effective assessment of sleep reactivity, we can now identify individuals at risk of future insomnia, shift-work disorder and mental illness, thus identifying a target population for preventive intervention. Given that insomniacs with high sleep reactivity tend to present with severe insomnia phenotypes, patient sleep reactivity may inform triaging to different levels of treatment. Future research on sleep reactivity is needed to clarify its neurobiology, characterize its long-term prospective associations with insomnia and shift-work disorder phenotypes, and establish its prognostic value for mental illness and other non-sleep disorders.

Sleep disorders, depression and anxiety are associated with adverse safety outcomes in healthcare workers: A prospective cohort study

The objective of the study was to determine if sleep disorder, depression or anxiety screening status was associated with safety outcomes in a diverse population of hospital workers. A sample of shift workers at four hospitals participated in a prospective cohort study. Participants were screened for five sleep disorders, depression and anxiety at baseline, then completed prospective monthly surveys for the next 6 months to capture motor vehicle crashes, near-miss crashes, occupational exposures and medical errors. We tested the associations between sleep disorders, depression and anxiety and adverse safety outcomes using incidence rate ratios adjusted for potentially confounding factors in a multivariable negative binomial regression model. Of the 416 hospital workers who participated, two in five (40.9%) screened positive for a sleep disorder and 21.6% screened positive for depression or anxiety. After multivariable adjustment, screening positive for a sleep disorder was associated with 83% increased incidence of adverse safety outcomes. Screening positive for depression or anxiety increased the risk by 63%. Sleep disorders and mood disorders were independently associated with adverse outcomes and contributed additively to risk. Our findings suggest that screening for sleep disorders and mental health screening can help identify individuals who are vulnerable to adverse safety outcomes. Future research should evaluate sleep and mental health screening, evaluation and treatment programmes that may improve safety.

Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis

IMPORTANCE

Physician burnout has taken the form of an epidemic that may affect core domains of health care delivery, including patient safety, quality of care, and patient satisfaction. However, this evidence has not been systematically quantified.

OBJECTIVE

To examine whether physician burnout is associated with an increased risk of patient safety incidents, suboptimal care outcomes due to low professionalism, and lower patient satisfaction.

DATA SOURCES

MEDLINE, EMBASE, PsycInfo, and CINAHL databases were searched until October 22, 2017, using combinations of the key terms physicians, burnout, and patient care. Detailed standardized searches with no language restriction were undertaken. The reference lists of eligible studies and other relevant systematic reviews were hand-searched.

STUDY SELECTION

Quantitative observational studies.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers were involved. The main meta-analysis was followed by subgroup and sensitivity analyses. All analyses were performed using random-effects models. Formal tests for heterogeneity (I2) and publication bias were performed.

MAIN OUTCOMES AND MEASURES

The core outcomes were the quantitative associations between burnout and patient safety, professionalism, and patient satisfaction reported as odds ratios (ORs) with their 95% CIs.

RESULTS

Of the 5234 records identified, 47 studies on 42 473 physicians (25 059 [59.0%] men; median age, 38 years [range, 27-53 years]) were included in the meta-analysis. Physician burnout was associated with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59-2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87-2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68). The heterogeneity was high and the study quality was low to moderate. The links between burnout and low professionalism were larger in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians (Cohen Q = 7.27; P = .003). The reporting method of patient safety incidents and professionalism (physician-reported vs system-recorded) significantly influenced the main results (Cohen Q = 8.14; P = .007).

CONCLUSIONS AND RELEVANCE

This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental health care policy goal across the globe. Health care organizations are encouraged to invest in efforts to improve physician wellness, particularly for early-career physicians. The methods of recording patient care quality and safety outcomes require improvements to concisely capture the outcome of burnout on the performance of health care organizations.

Poor sleep is linked to impeded recovery from traumatic brain injury

Study Objectives

While disruptions in sleep are common after mild traumatic brain injury (TBI), the longitudinal relationships between sleep problems and global functioning after injury are poorly understood. Here, we prospectively investigate risk for functional impairment during the first 6 months of TBI recovery based on sleep onset insomnia symptoms and short sleep.

Methods

Patients presenting to the Emergency Department (ED) at Johns Hopkins Hospital within 24 hours of head injury and evaluated for TBI were eligible for our study. Demographic and injury-related information were collected in the ED. Patients then completed in-person surveys and phone interviews to provide follow-up data on global functioning, sleep, and depressive symptoms at 1, 3, and 6 months post-injury. A total of 238 patients provided sufficient data for analysis, and hypotheses were tested using mixed effects modeling.

Results

Sleep quality and global functioning improved over the 6 months of TBI recovery, but patients were at increased risk for functional impairment when sleeping poorly (odds ratio [OR] = 7.69, p < .001). Sleep onset insomnia symptoms and short sleep both independently corresponded to poor global functioning. Functional impairment was highest among those with both insomnia and short sleep (43%-79%) compared to good sleepers (15%-25%) and those with short sleep (29%-33%) or insomnia alone (33%-64%). A bidirectional relationship between sleep quality and functioning was observed.

Conclusions

Functionally impaired patients diagnosed predominantly with mild TBI exhibit high rates of insomnia and short sleep, which may impede TBI recovery. Monitoring sleep after head injury may identify patients with poor prognoses and allow for early intervention to improve functional outcomes.

Impact of Poor Sleep on Physical and Mental Health in Older Women

Many aspects of sleep and circadian rhythms change as people age. Older adults usually experience decrease in sleep duration and efficiency, increase in sleep latency and fragmentation, high prevalence of sleep disorders, and weakened rest-activity rhythms. Research evidence suggests that women are more likely to report aging-related sleep problems. This review presents epidemiologic and clinical evidence on the relationships between sleep deficiency and physical and mental outcomes in older women, explores potential mechanisms underlying such relationships, points out gaps in the literature that warrant future investigations, and considers implications in clinical and public health settings.

Effects of Sleep, Physical Activity, and Shift Work on Daily Mood: a Prospective Mobile Monitoring Study of Medical Interns

BACKGROUND

Although short sleep, shift work, and physical inactivity are endemic to residency, a lack of objective, real-time information has limited our understanding of how these problems impact physician mental health.

OBJECTIVE

To understand how the residency experience affects sleep, physical activity, and mood, and to understand the directional relationships among these variables.

DESIGN

A prospective longitudinal study.

SUBJECTS

Thirty-three first-year residents (interns) provided data from 2 months pre-internship through the first 6 months of internship.

MAIN MEASURES

Objective real-time assessment of daily sleep and physical activity was assessed through accelerometry-based wearable devices. Mood scaled from 1 to 10 was recorded daily using SMS technology. Average compliance rates prior to internship for mood, sleep, and physical activity were 77.4, 80.2, and 93.7%, and were 78.8, 53.0, and 79.9% during internship.

KEY RESULTS

After beginning residency, interns lost an average of 2 h and 48 min of sleep per week (t = - 3.04, p < .01). Mood and physical activity decreased by 7.5% (t = - 3.67, p < .01) and 11.5% (t = - 3.15, p < .01), respectively. A bidirectional relationship emerged between sleep and mood during internship wherein short sleep augured worse mood the next day (b = .12, p < .001), which, in turn, presaged shorter sleep the next night (b = .06, p = .03). Importantly, the effect of short sleep on mood was twice as large as mood's effect on sleep. Lastly, substantial shifts in sleep timing during internship (sleeping ≥ 3 h earlier or later than pre-internship patterns) led to shorter sleep (earlier: b = - .36, p < .01; later: b = - 1.75, p < .001) and poorer mood (earlier: b = - .41, p < .001; later: b = - .41, p < .001).

CONCLUSIONS

Shift work, short sleep, and physical inactivity confer a challenging environment for physician mental health. Efforts to increase sleep opportunity through designing shift schedules to allow for adequate opportunity to resynchronize the circadian system and improving exercise compatibility of the work environment may improve mood in this depression-vulnerable population.

Nocturnal insomnia symptoms and stress-induced cognitive intrusions in risk for depression: A 2-year prospective study

Nearly half of US adults endorse insomnia symptoms. Sleep problems increase risk for depression during stress, but the mechanisms are unclear. During high stress, individuals having difficulty falling or staying asleep may be vulnerable to cognitive intrusions after stressful events, given that the inability to sleep creates a period of unstructured and socially isolated time in bed. We investigated the unique and combined effects of insomnia symptoms and stress-induced cognitive intrusions on risk for incident depression. 1126 non-depressed US adults with no history of DSM-5 insomnia disorder completed 3 annual web-based surveys on sleep, stress, and depression. We examined whether nocturnal insomnia symptoms and stress-induced cognitive intrusions predicted depression 1y and 2y later. Finally, we compared depression-risk across four groups: non-perseverators with good sleep, non-perseverators with insomnia symptoms, perseverators with good sleep, and perseverators with insomnia symptoms. Insomnia symptoms (β = .10-.13, p < .001) and cognitive intrusions (β = .19-.20, p < .001) predicted depression severity 1y and 2y later. Depression incidence across 2 years was 6.2%. Perseverators with insomnia had the highest rates of depression (13.0%), whereas good sleeping non-perseverators had the lowest rates (3.3%, Relative Risk = 3.94). Perseverators with sleep latency >30 m reported greater depression than good sleeping perseverators (t = 2.09, p < .04). Cognitive intrusions following stress creates a depressogenic mindset, and nocturnal wakefulness may augment the effects of cognitive arousal on depression development. Poor sleepers may be especially vulnerable to cognitive intrusions when having difficulty initiating sleep. As treatable behaviors, nighttime wakefulness and cognitive arousal may be targeted to reduce risk for depression in poor sleepers.