Assessment of physical activity in middle-aged and older adults with schizophrenia

BACKGROUND: Regular physical activity (PA) decreases morbidity in the general population; yet, information about the amount and effects of PA in persons with schizophrenia is scant. To develop interventions to increase PA and to assess its potential benefits in this group, accurate measurement of PA is needed. The purpose of this study was to characterize PA and determine the test-retest reliability and concurrent validity of the Yale Physical Activity Scale (YPAS), a self-report measure, in persons with schizophrenia. METHODS: PA was assessed with the YPAS, a scale of motivational readiness for PA, and accelerometry in middle-aged and older persons with a diagnosis of schizophrenia (n=54) and in a comparison group with no known psychiatric diagnosis (n=27). RESULTS: On the YPAS measures, persons with schizophrenia reported on average 11 h per week of PA, whereas the non-psychiatric comparison group reported about 32 h per week. Only about 30% of schizophrenia subjects were classified as being regularly active relative to 62% of the comparison group on PA motivational stages of readiness. On the accelerometry measures, the schizophrenia group had lower levels of light activity than the comparison group, but there were no differences in moderate and vigorous activity or sedentary behavior. Only in the comparison group were there significant associations between YPAS and accelerometer variables. Several YPAS scores demonstrated high test-retest reliability in both groups, and concurrent validity was supported between the YPAS and PA motivational stages of readiness. CONCLUSIONS: We found that the YPAS is a reliable measure of PA in schizophrenia for some indices. Although the YPAS demonstrated concurrent validity with other self-report measures, it did not demonstrate concurrent validity when compared to PA measured by accelerometry in persons with schizophrenia. Use of multiple measures, both subjective and objective, is recommended when assessing PA in schizophrenia.     

A functional neuropeptide Y Leu7Pro polymorphism associated with alcohol dependence in a large population sample from the United States

BACKGROUND: Quantitative trait locus studies, and observations in animals manipulated for the neuropeptide Y (NPY) gene suggest that variation within this gene may contribute to alcoholism. A recent population study suggested that the Pro7 allele of a functional NPY polymorphism (Leu7Pro) may be associated with increased alcohol consumption. We tested whether the Pro7 allele is associated with alcohol dependence in European Americans (EA). METHODS: The design was a population study comparing the Leu7Pro allele frequencies in alcohol-dependent subjects and controls. Population stratification potential and diagnostic specificity was studied by genotyping individuals from additional populations and psychiatric diagnostic classes. We studied 2 independently collected samples of EA alcohol-dependent subjects (sample 1, n = 307; sample 2, n = 160) and a sample of psychiatrically screened EA controls (n = 202); 8 population samples, including African Americans and European Americans (total n = 551); and 4 samples of individuals with Alzheimer disease, schizophrenia, posttraumatic stress disorder, and major depression (total n = 502). The main outcome measure was the difference in Leu7Pro allele frequencies between alcohol-dependent subjects and controls. RESULTS: The frequency of the Pro7 allele was higher in the alcohol-dependent subjects (sample 1, 5.5%; sample 2, 5.0%) compared with the screened EA controls (2.0%) (sample 1 vs controls, P=.006; sample 2 vs controls, P=.03). The attributable fraction (excess morbidity) in similarly affected populations, owing to the Pro7 allele, was estimated to be 7.3%. The frequency of the Pro7 allele was equal or lower in the population samples, as compared with the screened EA controls (0%-2.2%), with 1 exception (Bedouins). We found no significant evidence that the association of the Pro7 allele with alcohol dependence was due to an association with a comorbid psychiatric disorder. CONCLUSIONS: These results suggest that the NPY Pro7 allele is a risk factor for alcohol dependence. This is only the second specific genetic mechanism ever identified that modulates risk for alcohol dependence.     

Cognitive functioning in severe psychiatric disorders: a general population study

In clinical samples, patients with severe psychiatric disorders are found to have cognitive impairments. Less is known whether this applies to samples derived from the general population. We aimed to study cognitive functioning in a population-based sample comprising individuals with schizophrenia, other non-affective psychoses, bipolar disorders, major depressive disorder, and controls derived from the same population. The current analysis was based on 148 persons with severe mental disorders and 66 control subjects, derived from the Psychoses in Finland study. All subjects were interviewed with SCID, and a neuropsychological test battery was administered. Subjects with schizophrenia had a generalized cognitive impairment (d = 0.43–1.07), while those with other non-affective psychoses were impaired in verbal memory and processing speed (d = 0.43–0.59). Subjects with bipolar disorders were not impaired. Unipolar major depressive disorder associated with slowed processing speed (d = 0.64). Our findings on cognitive impairments in subjects with schizophrenia and other non-affective psychoses derived from the general population support previous findings of a generalized cognitive dysfunction in these subjects. However, our results suggest that subjects with bipolar disorders from non-clinical populations may not have significant cognitive impairments. Our results emphasize the importance of using control samples derived from the same population and studied similarly as those with disorders in evaluating cognitive functioning of subjects with severe mental disorders.     

Stages of change in smokers with schizophrenia or schizoaffective disorder and in the general population

This study compared smoking behavior and motivation to quit smoking, assessed with a "stages of change" questionnaire, in outpatients with schizophrenia or schizoaffective disorder and in a representative sample of the general population. We conducted a mail survey in a representative sample of the general population of Geneva, Switzerland, in 1996 (n = 742); and a survey of 151 patients with schizophrenia (84%) or schizoaffective disorder (16%) who attended a Geneva ambulatory psychiatric clinic in 2000. There were more smokers (70% vs. 28%, p < 0.001) in patients with schizophrenia or schizoaffective disorder than in the general population, and fewer ex-smokers (15% vs. 52%, p < 0.001). Patients with schizophrenia or schizoaffective disorder smoked more than smokers in the general population (22 vs. 16 cigarettes per day, p < 0.001). Among current smokers, the distribution of stages of change was similar in patients with schizophrenia or schizoaffective disorder (precontemplation 79%, contemplation 18%, preparation 3%) and in the general population sample (74%, 22%, and 4%, p = 0.6). In both samples, similar proportions of smokers had made an attempt to quit in the previous year (27% vs. 22%, p = 0.3). These results suggest that a substantial minority of smokers with schizophrenia or schizoaffective disorder are motivated to quit smoking, try to quit, and succeed in quitting.     

Assessing Readiness for Change Among Persons with Severe Mental Illness

Studies focusing on the readiness of persons to change have burgeoned in recent years. Assessing readiness for change is viewed as important for interventions aimed at promoting health behaviors, such as smoking cessation and substance abuse programs. This study is the first to examine readiness for change, as conceived by Prochaska and his colleagues, among a sample of persons with severe mental illness who were about to participate in a vocational rehabilitation program. We examined the reliability, validity, and other psychometric properties of the Change Assessment Scale and its ability to predict attrition and actual change.     

Prevalence of narcolepsy symptomatology and diagnosis in the European general population

OBJECTIVE: To determine the prevalence of narcolepsy in the general population of five European countries (target population 205,890,882 inhabitants). METHODS: Overall, 18,980 randomly selected subjects were interviewed (participation rate 80.4%). These subjects were representative of the general population of the UK, Germany, Italy, Portugal, and Spain. They were interviewed by telephone using the Sleep-EVAL expert system, which provided narcolepsy diagnosis according to the International Classification of Sleep Disorders (ICSD). RESULTS: Excessive daytime sleepiness was reported by 15% of the sample, with a higher prevalence in the UK and Germany. Napping two times or more in the same day was reported by 1.6% of the sample, with a significantly higher rate in Germany. Cataplexy (episodes of loss of muscle function related to a strong emotion), a cardinal symptom of narcolepsy, was found in 1.6% of the sample. An ICSD narcolepsy diagnosis was found in 0.047% of the sample: The narcolepsy was severe for 0.026% of the sample and moderate in 0.021%. CONCLUSION: This is the first epidemiologic study that estimates the prevalence of narcolepsy in the general population of these five European countries. The disorder affects 47 individuals/100,000 inhabitants.     

The course of dissociation in the general population: a 3-year follow-up study

OBJECTIVE: There have been no previous general population studies on the stability of dissociative symptoms. The aim of this study was to examine the course of and the changes in dissociative symptoms and factors associated with these changes during a 3-year follow-up of a Finnish general population sample. METHODS: The general population sample included a cohort of 1497 subjects. Dissociative symptoms were assessed with the Dissociative Experiences Scale (DES) and the DES-taxon (DES-T). Depressive symptoms and suicidal ideation were measured with the Beck Depression Inventory (BDI). The sample was categorized into low dissociators with DES scores less than 20 and high dissociators with DES scores of 20 or more. RESULTS: At baseline, 98 subjects were high dissociators. On follow-up, 28 of them were still high dissociators, whereas among 70 subjects, the DES score declined below the cutoff score. During the follow-up period, 28 of 1399 subjects became new high dissociators, and constantly low dissociators consisted of 1371 of 1399 subjects. Dissociative taxon membership was detected in 39 subjects either at baseline or at follow-up, but only 4 of them met the criteria at both assessments. Stable high dissociation was associated with an increase in the BDI score on follow-up, baseline suicidal ideation, a younger age, a reduced working ability, and smoking. Risk factors for becoming a new high dissociator were an increase in the BDI score, a younger age at baseline, and a reduced working ability. Among the baseline high dissociators, recovery from high dissociation was associated with a decline in the BDI score at follow-up and with no suicidal thoughts, older age, and a good working ability at baseline. CONCLUSIONS: Only a small proportion of the general population had constantly high levels of dissociative symptoms. The stability of dissociative taxon membership was weaker than the stability of the continuous variables of dissociation. The dissociative experiences had a tendency to change, and these changes were associated with changes in the BDI scores. Further studies are needed to reveal the factors associated with the changes in dissociative symptoms.     

Alarmingly large unemployment gap despite of above-average education in adults with ASD without intellectual disability in Germany: a cross-sectional study

For individuals with autism spectrum disorder (ASD), both getting access to as well as staying in the labor market are very challenging. However, the detailed educational, vocational, and employment characteristics of persons with ASD without intellectual disabilities are not yet studied. We conducted a retrospective study on a sample of 232 clinically late-diagnosed adults with ASD without intellectual disabilities. Data were compared to the general German population obtained from the public database of the German Federal Employment Agency. Results showed that the majority of persons with ASD graduated from high school and obtained a university entrance qualification (ASD: 50.4%; general population: 32.5%). Also, lower rates of basic secondary education were found in the ASD sample (ASD: 16.5%, general population: 29.6%). Significantly less individuals with ASD completed vocational training (40.1%) in comparison to the German population (56.3%). Despite the above-average level of education, the unemployment rate of the sample substantially exceeds that of the general population by the factor 5 (ASD: 25.2%; general population: 5.2%). Periods of unwanted unemployment of persons with ASD lasted on average 23 months with interpersonal problems being the main reason for contract termination. A higher level of educational qualification does not protect against a higher risk of unemployment for individuals with ASD presumably due to autism-specific interpersonal difficulties. Data emphasize the necessity to develop and spread both specific employment support activities for individuals with ASD as well as adequate awareness raising strategies. Funded by a public grant of the “Landschaftsverband Rheinland (LVR)”.

     

Exogenous corticosteroids and major depression in the general population

Objective: An existing literature suggests that corticosteroid exposures are associated with an elevated level of depressive symptoms in various clinical populations. The objective of this study was to evaluate this association in a general population sample. Methods: Data from a large-scale Canadian health survey were used in this analysis. The survey sample included 73,402 subjects over the age of 12 from the general Canadian population. The survey interview included a short-form version of the Composite International Diagnostic Interview (CIDI) section evaluating major depressive episodes. All estimates were weighted to account for unequal selection probabilities, and variance estimates were calculated using methods accounting for the survey design. Results: A statistically significant elevation in major depression prevalence was observed in corticosteroid-treated subjects. The estimated 12-month period prevalence of major depression was approximately three times as high in corticosteroid treated vs. non-treated subjects irrespective of age, gender and perceived health. Conclusions: In the general population, persons taking corticosteroids have a higher frequency of major depression than non-exposed subjects. Because this was an analysis of cross-sectional survey data, causal inference is not possible. However, the existence of an epidemiological association, in conjunction with information from the broader literature, suggests that corticosteroid exposure may be a determinant of depressive disorders in the general population.     

Epidemiology of depression and its treatment in the general population

This study examines the correlates of a major depressive disorder and its treatment in the general population. The sample was composed of 6694 individuals aged between 18 and 96 years, representative of the general population of the states of California and New York (48 million inhabitants aged 18 years or older). They were interviewed by telephone using the Sleep-EVAL system. The interviews included various sleep and health topics and the assessment of DSM-IV sleep and psychiatric disorders. The 1-month prevalence of a major depressive disorder was 5.2% in the sample, and was higher in women, middle-aged and non-Hispanic white individuals. Obesity (BMI > or =30kg/m(2)), poor health status and smoking were also strongly correlated with a major depressive disorder. A total of 57.7% of depressed subjects were receiving some forms of treatment for depression: 28.3% were taking antidepressants (alone or in combination with psychiatric health care) and 29.4% received psychiatric health care (without antidepressant medication). Severity of depression, ethnicity and weight (overweight or obese) were strongly associated with the presence of treatment. A major depressive disorder is frequent in the general population. Although its identification and treatment have improved over the years, some segments of the population, namely elderly and non-white individuals are less likely to receive appropriate care.     

The homeless mentally ill in the general hospital: a question of fit

The evolution of general hospital psychiatry and the growth of the homeless mentally ill population in the United States have coincided temporally. Although the two have many points of confluence, their interaction has largely been of a last-resort variety, sometimes occurring by default and rarely adequately planned. The general hospital psychiatric unit has an important role to play in serving the homeless mentally ill--a role that is consonant with its mission of providing care to individuals whose service needs include special treatment interventions in short-term settings. That role may be most effectively implemented in a pluralistic service system, where the general hospital psychiatric unit is one of many facilities responding appropriately, but differentially, to the needs of individual members of the homeless mentally ill population.     

Psychiatric comorbidity in epilepsy: a population-based analysis

PURPOSE: The estimated prevalence of mental health disorders in those with epilepsy in the general population varies owing to differences in study methods and heterogeneity of epilepsy syndromes. We assessed the population-based prevalence of various psychiatric conditions associated with epilepsy using a large Canadian national population health survey. METHODS: The Canadian Community Health Survey (CCHS 1.2) was used to explore numerous aspects of mental health in persons with epilepsy in the community compared with those without epilepsy. The CCHS includes administration of the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects. Age-specific prevalence of mental health conditions in epilepsy was assessed using logistic regression. RESULTS: The prevalence of epilepsy was 0.6%. Individuals with epilepsy were more likely than individuals without epilepsy to report lifetime anxiety disorders or suicidal thoughts with odds ratio of 2.4 (95% CI = 1.5-3.8) and 2.2 (1.4-3.3), respectively. In the crude analysis, the odds of lifetime major depression or panic disorder/agoraphobia were not greater in those with epilepsy than those without epilepsy, but the association with lifetime major depression became significant after adjustment for covariates. CONCLUSIONS: In the community, epilepsy is associated with an increased prevalence of mental health disorders compared with the general population. Epilepsy is also associated with a higher prevalence of suicidal ideation. Understanding the psychiatric correlates of epilepsy is important to adequately manage this patient population.     

Type 2 diabetes among persons with schizophrenia and other psychotic disorders in a general population survey

Schizophrenia and other psychotic disorders are associated with increased risk of developing type 2 diabetes. However, previous studies are mainly based on clinical samples where the comorbidity may be stronger. We investigated in a general population survey the prevalence of type 2 diabetes in persons with psychotic disorders and in users of antipsychotic medication. The study was based on a nationally representative two-stage cluster sample of 8,028 persons aged 30 or over from Finland. Diagnostic assessment of psychotic disorders combined SCID-I interview and case note data. Prevalences of type 2 diabetes, adjusting for age and sex, were estimated by calculating predicted marginals. The prevalence estimate of type 2 diabetes was 22.0% among subjects with schizophrenia, 13.4% among subjects with other nonaffective psychosis and 6.1% in subjects without psychotic disorders. Only two subjects (3.4%) with affective psychosis had type 2 diabetes. Users of all types of antipsychotic medication had increased prevalence of type 2 diabetes. Our results suggest that type 2 diabetes is a major health concern among persons with schizophrenia and other nonaffective psychotic disorders and also in users of antipsychotic medication, but persons with affective psychosis in the general population may not have increased prevalence of type 2 diabetes.     

Relevant dimensions of delusions: continuing the continuum versus category debate

Delusions and hallucinations are common among healthy individuals but may differ from the symptoms experienced by persons with schizophrenia. It is hypothesized that specific dimensions of delusions, such as the distress associated with them, preoccupation, conviction or their content might be more relevant in distinguishing persons with from persons without schizophrenia than the mere presence of delusional beliefs. Second, it is investigated whether delusional beliefs are as closely linked to hallucinations in a non-clinical population as in persons with schizophrenia. The Peters et al. Delusions Inventory and the Launay Slade Hallucination Scale - Revised were used to assess delusional ideation and hallucinatory experiences in a population sample that reflects the general population in age, education and gender (n=359) and in persons diagnosed with life-time schizophrenia in varying stages of remission (n=53). There was a strong association of delusional ideation and hallucinatory experiences in both groups. Stepwise discriminant function revealed the distress associated with delusions as well as beliefs involving persecution and loss of control to be the most relevant aspects in distinguishing persons with from persons without schizophrenia. It is concluded that delusions should be assessed multi-dimensionally, laying particular emphasis on distress and content of beliefs.     

Prevalence of sleep problems in individuals with multiple sclerosis

BackgroundSleep disturbance in multiple sclerosis has received little research attention despite the potential influence it may have on disease impact.ObjectiveTo estimate the prevalence of sleep disorders in a large community sample of individuals with multiple sclerosis.MethodsA cross-sectional self-report survey of 1063 persons with multiple sclerosis. Sleep was assessed using the Women's Health Initiative Insomnia Rating Scale and Medical Outcomes Study Sleep measure.ResultsThe prevalence of sleep problems in multiple sclerosis is significantly higher than in the general population or other chronic diseases and may affect women with multiple sclerosis more than men.ConclusionSleep disturbance should routinely be evaluated in patients with multiple sclerosis and new interventions developed.     

Alcohol problem drinking among general hospital inpatients in northeastern Germany

OBJECTIVE: To estimate proportions of alcohol problem drinking: alcohol use disorders (AUDs) and drinking above recommended levels among general hospital inpatients in northeastern Germany. METHOD: The sample includes consecutively admitted inpatients (n=14,332) between 18 and 64 years old. This study adopted a two-stage-sampling approach including screening and ascertainment of diagnosis based on DSM-IV criteria and a quantity-frequency index. RESULTS: In total, 20.4% of all inpatients screened positive. Nine percent of the total sample were identified with current problem drinking in the following descending order: 5.3% AUD and 3.6% drinking above recommended levels. In addition, 3.1% of persons were diagnosed with alcohol dependence in remission. Proportions differed significantly among men and women (P<.001). Higher proportions of problem drinking were found at rural sites compared to urban sites (13.7% vs. 7.5%, P<.001). CONCLUSIONS: In addition to AUDs, drinking above recommended levels is a common problem among general hospital inpatients. Thus, the implementation of systematic alcohol screening and brief interventions should be considered.     

The psychometric quality of the Nottingham Health Profile (NHP) in the general population

The Nottingham Health Profile (NHP) is a questionnaire that assesses health related quality of life. The aim of this paper is to test the psychometric quality of the instrument based on a subject sample which is representative for the German population. The sample consisted of 1996 persons with ages between 18 and 92 years. They were asked to fill in several questionnaires including the NHP. The results show that the NHP does not differentiate between subjects in the range of low and medium levels of complaints. Only one half of the subject sample agreed to at least one of the 38 items. All six subscales showed significant age and sex effects which were proved with nonlinear regression analyses. The validity was assessed through correlations with other health related questionnaires. It can be concluded that the use of the NHP cannot be recommended when studies in the general population are conducted.     

Hyperlipidemia in persons using antipsychotic medication: a general population-based birth cohort study

BACKGROUND: Shortly after phenothiazines were introduced, they were found to elevate serum triglyceride and total cholesterol levels. During the past decade, an increasing body of literature has also documented this effect in atypical antipsychotics. Previous studies of antipsychotic-associated hyperlipidemias are based on clinical samples, mostly from case series. We studied the prevalence of hyperlipidemia in subjects who did and did not take antipsychotic medication in a prospective, general population-based birth cohort. METHOD: The study sample consisted of 5654 members of the unselected Northern Finland 1966 Birth Cohort who participated in the 1997-1998 clinical examination at 31 years of age. Blood samples were taken after an overnight fast, and serum total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride levels were determined. Health habits and other possible correlates for hyperlipidemia were assessed using a questionnaire. The sample was analyzed in 4 categories according to use of antipsychotic medication: (1) atypical, (2) typical, (3) atypical and typical (for the 3 antipsychotic categories, total N = 45), and (4) no antipsychotic medication (N = 5609). Nonparametric tests and multiple logistic regression analysis were used to measure the effect of antipsychotics on serum lipids. RESULTS: High lipid levels were found in persons treated with both atypical and typical medication (mean total cholesterol = 233 mg/dL, mean triglycerides = 163 mg/dL). Mean total cholesterol and triglycerides were also high in subjects who used only typical medication (215 mg/dL and 148 mg/dL, respectively). The prevalence of hypercholesterolemia, high LDL cholesterol, and hypertriglyceridemia was high in persons using antipsychotic medication (31.1%, 20.0%, and 22.2%, respectively) compared with persons not using such medication (12.2%, 10.2%, and 7.0%, respectively). After we adjusted for risk factors for hyperlipidemia (sex, diet, waist circumference, physical exercise, smoking, and alcohol consumption), the results of logistic regression analysis showed that in persons treated with antipsychotic medication the risk of hypercholesterolemia was 2.8 (95% CI = 1.4 to 5.6); of hypertriglyceridemia, 2.3 (95% CI = 1.0 to 5.4); and of high LDL cholesterol, 1.6 (95% CI = 0.7 to 3.5). CONCLUSION: Lipid levels in subjects who used both atypical and typical medication and those who used only typical medication were high even in young age. As these persons are at special risk of hyperlipidemia, their lipid levels should be regularly monitored, and a cholesterol-lowering diet, as well as medication, should be considered. The results indicate an elevated risk of hyperlipidemia in persons using antipsychotic medication independent of the other risk factors assessed.     

Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population

OBJECTIVE: Somatization is related to elevated health care utilization (HCU) and high health care costs. However, it is unclear whether HCU in somatizers and nonsomatizers in the general population is determined by existing symptoms or by lower thresholds for doctor visits. METHOD: A representative sample of the German general population (N=2510) was screened for psychopathology and HCU in the prior 12 months. The sample was subdivided into somatizers (n=712) and controls (n=1796), using the Patient Health Questionnaire (PHQ-15). A general tendency to visit doctors even for minor reasons was assessed. Demographic and psychopathological variables were additionally entered into regression analyses to predict HCU for the whole investigated sample and the two subsamples. RESULTS: Higher somatization, unemployment or retirement, a lower decision threshold for doctor visits and higher posttraumatic symptomatology were consistent and unique positive predictors of HCU in the prior 12 months. CONCLUSION: Not only symptoms per se but also a lower decision threshold for doctor visits contribute to increased HCU. Psychopathological and demographic variables can further predict HCU in somatizing persons and controls. Although somatization and reduced thresholds for doctor visits are associated, they have to be distinguished from each other and contribute independently to increased costs.     

Prevalence and consequences of insomnia disorders in the general population of Italy

OBJECTIVES: To assess the prevalence of insomnia disorders using DSM-IV classification, and the consequences of insomnia in the Italian general population. METHODS: A representative sample of the Italian general population composed of 3970 individuals aged 15 years or older were interviewed by telephone using the Sleep-EVAL system (participation rate: 89.4%). Participants were interviewed about their sleep habits and sleep disorders. DSM-IV classification was used by Sleep-EVAL to determine the sleep disorder diagnosis. RESULTS: Insomnia symptoms were reported by 27.6% of the sample. Sleep dissatisfaction was found in 10.1% and insomnia disorder diagnoses in 7% of the sample. The use of sleep-enhancing medication was reported by 5.7% of the sample. Most of these subjects were using anxiolytics. Dissatisfaction with sleep was associated with daytime sleepiness. Middle-aged drivers dissatisfied with their sleep were three times more likely to have had a road accident in the previous year compared to other drivers. However, fewer than 30% of subjects dissatisfied with their sleep or with an insomnia disorder diagnosis had consulted a physician about their sleep problem. CONCLUSIONS: As in other European and non-European countries, insomnia is widespread in Italy. The consequences are important. Appropriate recognition and treatment of insomnia should be part of an educational program for general practitioners everywhere.