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Many medical undergrads experiencing daytime sleepiness

  • Researchers urge attention to sleep/psychiatric disorders and improving sleep hygiene

BY Ruwan Laknath Jayakody

A significant proportion of medical undergraduates in Sri Lanka are affected by poor sleep quality and excessive daytime sleepiness, a study conducted last year found.

This finding was made in a research article on the “Sleep quality and daytime sleepiness in medical students of a State University of Sri Lanka: A cross-sectional study” which was authored by M.R.K.M. Gunathilaka, R.M.S.I. Rajapakse, N.K. Senevirathne, B.A. Ekanayake, D. Chinthani, and S.P. Wickramage (all attached to the Rajarata University’s Medicine and Allied Sciences Faculty’s Physiology Department), M.G.R.S.S. Gunathilaka (attached to the same Faculty’s Microbiology Department), T.D. Ekanayaka (attached to the same Faculty’s Pathology Department), and J.N. Warnasekara (attached to the same Faculty’s Community Medicine Department) and published in the Anuradhapura Medical Journal’s 14th Volume’s Second Issue on 31 December 2020.

Undergraduate medical students undergo changes of a psychological and social nature when transitioning from school education to university education, a period which involves separation from one’s family, the establishment of new social relationships and autonomy, and the acquisition of individual and social responsibilities (as noted in “Our future: A Lancet commission on adolescent health and well-being” by G.C. Patton, S.M. Sawyer, J.S. Santelli, D.A. Ross, R. Afifi, N.B. Allen, M. Arora, P. Azzopardi, W. Baldwin, C. Bonell, R. Kakuma, E. Kennedy, J. Mahon, T. McGovern, A.H. Mokdad, V. Patel, S. Petroni, N. Reavley, K. Taiwo, J. Waldfogel, D. Wickremarathne, C. Barroso, Z. Bhutta, A.O. Fatusi, A. Mattoo, J. Diers, J. Fang, J. Ferguson, F. Ssewamala, and R.M. Viner). Moreover, since medical students have a comparatively high academic workload in terms of both study hours and examinations, they have been identified (“Sleep and somatic complaints in university students” by A.A. Schlarb, M. Classen, S.M. Hellmann, C. Vogele, and M.D. Gulewitsch) as a group with common and specific physical and psychosocial including non-psychiatric health issues which includes, among others, poor sleep quality, less actual sleep duration/sleep deprivation, and excessive daytime sleepiness. Poor sleep quality in medical students is in turn related to their poor academic achievement (“Excessive daytime sleepiness, poor sleep quality, and poor academic performance in medical students” by M.E. Machado-Duque, J.E.E. Chabur, and J.E. Machado-Alba). People with poor-quality sleep also reported considerably high levels of physical and psychological health-related problems including anxiety and depressive symptoms (as per R. Norbury and S. Evans’s “Time to think: Subjective sleep quality, trait anxiety, and university starting time”). 

In Sri Lanka, there are eight state medical faculties accommodating more than 5,000 students. 

Therefore, Gunathilaka et al., conducted a cross-sectional study in 2016 by recruiting all the undergraduate medical students (out of the 800, 662/82.7% responded and out of that, 649 were selected) in the Rajarata University’s Medicine and Allied Sciences Faculty. A self-administered questionnaire in English medium, comprising the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality and the Epworth Sleepiness Scale (ESS) to assess excessive daytime sleepiness, was used. Poor-quality sleep was defined as PSQI ≥5 while an abnormally high level of daytime sleepiness was defined as ESS ≥11.

Out of the sample of 649, the majority (460 – 70.9%) were females while the rest were males (189 – 29.1%). The ages ranged from 19 to 30 years, with a mean age of 23 years. The median duration of sleep per night was six hours (from a range of four to eight hours). The majority (approximately 76%) reported going to bed before 12 midnight. In total, 168 (25.9%) were having poor sleep quality. The academic year in which the student is in has shown a significant association with poor sleep quality where it was found that the proportion of final year students with poor-quality sleep had risen to a level roughly the same as students in the first two years with a gradual reduction from the third year up to the fourth year. Gunathilaka et al. observed that this could likely be due to the differences in the quantity of the academic workload. However, gender was not found to be a significant factor associated with the same. A total of 227 (34%) had shown abnormally high levels of daytime sleepiness. In this regard, the students’ academic year showed a statistically significant association with excessive daytime sleepiness, as seen in the gradual increase of those suffering from excessive daytime sleepiness parallel to the advancing academic year. It was final year students who constituted the highest percentage of students with excessive daytime sleepiness (46.8%). Among female medical students, 37.8% reported excessive daytime sleepiness along with 28.6% of male students reporting the same. That said, the time of going to sleep and the total hours of actual sleep did not show any statistically significant association with daytime sleepiness. With regard to the correlation between the quality of sleep and excessive daytime sleepiness, a weak but positive correlation was observed. The academic year affects the quality of sleep and excessive daytime sleepiness as the proportion of students having poor sleep was higher in the first two years which gradually reduced up to the fourth year but in the final year, rose again to a level that is roughly the same as that of the first two years. Conversely, the percentage of participants with excessive daytime sleepiness showed a gradual increase up to the final year.

As noted by Gunathilaka et al., the proportions of third and fourth year medical students with excessive daytime sleepiness were 40% despite the declining percentages of students with poor-quality sleep. Gunathilaka et al. explained that while a positive correlation exists between the PSQI score and the EDS score as depicted through a significant value, this finding of disproportionately higher excessive daytime sleepiness may be due to certain other factors affecting excessive daytime sleepiness such as the level of stress, the academic workload, and the presence of anaemia (Schlarb et al., “Sleep disturbances among medical students: A global perspective” by M.C. Azad, K. Fraser, N. Rumana, A.F. Abdullah, N. Shahana, P.J. Hanly, and T.C. Turin, “Sleep patterns and predictors of disturbed sleep in a large population of college students” by H.G. Lund, B.D. Reider, A.B. Whiting, and J.R. Prichard, and “Sleep in a large, multi university sample of college students: Sleep problems prevalence, sex differences, and mental health correlates” by S.P. Becker, M.A. Jarrett, A.M. Luebbe, A.A. Garner, G.L. Burns, and M.J. Kofler). Furthermore, though a statistically significant association was found between gender and excessive daytime sleepiness, there was no such association between gender and poor-quality sleep. 

Since approximately a quarter of medical students in the present study reported experiencing poor-quality sleep, Azad et al. have suggested looking into the presence of various sleep disorders and psychiatric disorders, so as to take necessary steps to improve sleep-related hygiene.