Association of sleep problems with suicidal behaviors and healthcare utilization in adults with chronic diseases: the role of mental illness

doi:10.21203/rs.3.rs-4813928/v1

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Research Article

Association of sleep problems with suicidal behaviors and healthcare utilization in adults with chronic diseases: the role of mental illness

https://doi.org/10.21203/rs.3.rs-4813928/v1

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Objectives: This study aimed to examine the association between sleep problems and suicidal behaviors and healthcare utilization in Canadian adults with chronic diseases, and the mediating role of mental illness.

Methods: Data were drawn from the Canadian Community Health Survey, 2015-16, from Ontario, Manitoba, and Saskatchewan– the provinces that selected the survey module on sleep. A total of 22,700 participants aged ≥18 years () and diagnosed with chronic diseases were enrolled in the study. Sleep problems referred to extreme sleep durations (either <5 or ≥10 hours) and insomnia. Mental illness was defined as a self-reported mood or anxiety disorder.

Results: Of the 6,318,400 participants, higher prevalence of all suicidal behaviors and healthcare utilization outcomes were found in participants with extreme sleep durations (compared with 7 to <8 hours), and in participants with insomnia (compared with no insomnia). After multivariate adjustment, extreme sleep durations and insomnia were still independently associated with increased odds of suicidal behaviors and healthcare utilization. Mediation analyzes showed that mental illness partly mediated the associations of extreme sleep durations and insomnia with suicidal behaviors and healthcare utilization.

Conclusions:

In conclusion, both extreme sleep durations and insomnia were associated with increased odds of suicidal behaviors and healthcare utilization outcomes in adults with chronic diseases, whereas mental illness partially mediated the association.

There is no doubt that the emergence of chronic diseases is a major challenge to global health.^1,2 In Canada, chronic diseases affect more than half of the population, and the prevalence of chronic diseases is still increasing due to significant changes in lifestyle, advances in medical technology, and an aging population.³ Suicidal behaviors are common among adults with chronic illness. In fact, numerous evidence suggests that the existence of a chronic illness is a risk factor for s suicidal behaviors.^4–6 Moreover, studies have demonstrated that adults with chronic diseases, especially those with comorbid mental illness, had more healthcare utilization.^7–9 It makes sense to understand the related factors of suicidal behaviors and healthcare utilization.

Additionally, unhealthy sleeping habits have become a growing trend in modern society.^10,11 The close relationship between sleep problems and some chronic diseases (such as coronary heart disease, diabetes, cancer, and stroke) has been established by many studies.^12–15 Sleep problems are also an established risk factor for suicide.¹⁶ Nevertheless, it is uncertain whether the intervention should focus on sleep problems to alleviate suicidal behaviors and healthcare utilization in patients suffering from chronic diseases. At the same time, because mental illness is affected by sleep problems and has a causal effect on the suicidal behaviors and healthcare utilization,^7,16 whether mental illness is a potential explanation for the association of sleep problems with suicidal behaviors and healthcare utilization in adults with chronic diseases is a matter to be confirmed.

A representative Canadian data were used to: (1) examine whether sleep problems were related to the increased odds of suicidal behaviors and healthcare utilization in adults with chronic diseases; (2) estimate the mediating role of mental illness in the relationship of sleep problems with suicidal behaviors and healthcare utilization in adults with chronic diseases.

Data sources and sample

Data were drawn from the Canadian Community Health Survey, 2015-16. A detailed description of this survey can be found at the website of Statistics Canada.¹⁷ Briefly, this survey collected information on health status, healthcare utilization, and health determinants for the Canadian population, aged 12 years or older, living in the 10 provinces and 3 territories. Interviews were conducted in person using computer-assisted personal interviewing or computer-assisted telephone interviewing. All participants gave informed consent and ethical approval was obtained from the relevant policy committees at Statistics Canada.

We restricted this study to participants from three provinces (Ontario, Manitoba, and Saskatchewan) that selected the optional survey module on sleep. Inclusion criteria: 1) 18 years or older (because sleep patterns in adolescents and adults are very different); 2) diagnosed with one or more common chronic diseases, including diabetes, hypertension, hyperlipidemia, heart disease, stroke, cancer, arthritis, scoliosis, fibromyalgia, osteoporosis, back problems, asthma, chronic obstructive pulmonary disease, migraine headaches, chronic fatigue syndrome, multiple chemical sensitivities, and Alzheimer’s disease or any other dementia; and 3) had complete information on main study variables, including sleep problems, suicidal behaviors, healthcare utilization, and mental illness. Finally, 22,700 participants deemed eligible for the present study.

Sleep problems

Sleep problems comprised extreme sleep durations and insomnia. Sleep duration was assessed using the question “How long do you usually spend sleeping each night?” Participants were instructed not to include time spent resting, and responses were recorded at hourly intervals. To capture possible non-linear relationships, sleep duration was categorized into five groups: <5, 5 to < 7, 7 to < 8, 8 to < 10, and ≥ 10 hours, with 7 to < 8 hours as the reference group.^{18, 19} Extreme sleep durations were defined as either very short sleep (< 5 hours) or very long sleep duration (≥ 10 hours).

Insomnia was estimated through the question “How often do you have trouble going to sleep or staying asleep?” with response options: never, rarely, sometimes, most of the time, and all the time.^20,21 According to previous studies, participants were considered having insomnia if they answered most of the time or all of the time.²²

Suicidal behaviours, and healthcare utilization

Suicidal behaviors, including suicidal ideation, plans, and attempts, were assessed with a series of questions. Participants were asked whether he or she had ever seriously contemplated suicide (yes or no), and whether this experience happened in the past year (yes or no). Participants were asked whether he or she had ever made a plan to seriously attempt suicide (yes or no), and whether this experience happened in the past year (yes or no). Participants were also asked whether he or she had ever seriously attempted suicide (yes or no), but this was not included in the current analysis due to low occurrence.

Healthcare utilization was evaluated by comparing whether the participants had ≥ 2 emergency room visits (yes or no), ≥ 5 consultations with medical doctor (yes or no), or ≥ 5 consultations with nurse (yes or no) in the past year.

Mental illness

Mental illness was defined as a self-reported mood or anxiety disorder.^23,24 Participants were asked whether he or she had a mood disorder such as depression, bipolar disorder, mania or dysthymia (yes or no), and whether he or she had an anxiety disorder such as a phobia, obsessive–compulsive disorder or a panic disorder (yes or no). The definition was considered being reliable given its similarity with administrative data and has been widely adopted.^25,26

Covariates

Sociodemographic and lifestyle covariates included age, sex, visible minority, body mass index (BMI), marital status, education, household income, smoking status, physical activity, illicit drug use, number of chronic diseases, and province of residence.

Statistical analysis

All analyses were conducted using STATA 15.0 (Stata Corp., College Station, TX, USA). Sampling weights were applied to ensure that the estimates reflected the general Canadian population. Bootstrap methods were used to account for the complex survey design. Descriptive statistics were used to summarize the characteristics of participants. Comparisons of the prevalence across different sleep categories were assessed by Pearson’s χ2 test. Bonferroni method for multiple comparisons was applied in all Pearson’s χ2 tests. Logistic regression models were performed to examine the association of sleep problems with suicidal behaviours and healthcare utilization. Each sleep problem was entered into the models separately. Mediation analyses were conducted using the generalized structural equation modelling (gsem) command following the Baron and Kenny’s steps.²⁷ After generating the model with gsem, the indirect (mediating) effect and the proportion of main associations represented by indirect effect can be tested directly with a product-of-coefficients test using the nlcom (nonlinear combination of estimators) command.²⁸

Final analysis included 6,318,400 Canadian adults with chronic diseases, living in Ontario, Manitoba, and Saskatchewan, whereas46.4% (95% CI 45.6, 47.3) of participants were male, and 25.7% (95% CI 24.4, 27.0) identified themselves as visible minority. Table 1 depicts the detailed characteristics of the participants. The percentages of sleeping < 5, 5 to < 7, 7 to < 8, 8 to < 10, and ≥ 10 hours among these participants were 8.3% (95% CI 7.7, 9.0), 41.8% (95% CI 40.6, 43.0), 29.5% (95% CI 28.5, 30.5), 18.9% (95% CI 18.0, 19.7), and 1.5% (95% CI 1.3, 1.8), respectively; and the percentage of insomnia was 21.5% (95% CI 20.6, 22.4).

Table 2 shows the prevalence of each suicidal behavior and healthcare utilization outcome by sleep duration. When compared with sleeping 7 to < 8 hours, higher prevalence of all suicidal behaviors and healthcare utilization outcomes were observed in participants with extreme sleep durations (< 5 or ≥ 10 hours). When compared with no insomnia, higher prevalence of all suicidal behaviors and healthcare utilization outcomes were observed in participants with insomnia.

In model 1, adjusting for age, sex, and visible minority, extreme sleep durations were significantly associated with increased odds of all suicidal behaviors and healthcare utilization outcomes when compared to sleeping 7 to < 8 hours (Table 3). Even in model 2, further adjusting for all potential covariates, we found these associations remained significant (Table 3). Similar results were obtained in the comparison between participants with and without insomnia (Table 3).

Mediation analyses revealed that mental illness partially mediated the associations of extreme sleep durations and insomnia with all suicidal behaviours and healthcare utilization outcomes (P values of all indirect effects < 0.01; Table 4). The mediating proportion of mental illness varied from 9.2–39.0% (Table 4).

The major findings of this study are: 8.3% (95% CI 7.7, 9.0) Canadian adults with chronic diseases had less than 5 hours of sleep per night; 1.5% (95% CI 1.3, 1.8) had more than 10 hours of sleep per night; and 21.5% (95% CI 20.6, 22.4) had insomnia. Sleep problems(both extreme sleep durations and insomnia)were significantly associated with increased odds of all suicidal behaviors and healthcare utilization outcomes; mental illness partially mediated these associations.

The association between sleep problems and suicidal behaviors has been of concern. Becker et al.²⁹ found that poor sleep duration was associated with suicidal behaviors in a large sample of college students. Chakravorty et al.³⁰ stated that adults who reported sleep durations of < 5 hours and > 9 hours per day were at the highest risk of suicidal ideation. Bishop et al.³¹ found that insomnia was related to suicide attempts among veterans. Longitudinal studies conducted by Wong et al. have shown that insomnia seemed to predict the subsequent suicidal ideation, suicide attempt, and suicide death in adolescence.^32,33 However, few studies have explored the link between sleep problems and suicidal behaviors in adults with chronic diseases. Existing evidence is insufficient for development of guidelines for the management of chronic diseases. Therefore, more evidence from adults with chronic diseases is necessary. We utilized a large representative Canadian dataset which contained more detailed sleep duration categories and found a strong association between sleep problems(both extreme sleep durations and insomnia)and the likelihood of suicidal behaviors in adults with chronic diseases.

On the other hand, our research also established a strong relationship between sleep problems and healthcare utilization in adults with chronic diseases, which was a supplement to the current limited research.^34–36 For example, Banno and Kryger ³⁵ found insomnia would impact women’s healthcare utilization. Luyster et al.³⁶ found that short and long sleep durations (sleeping < 5 and > 9 h) were associated with greater healthcare utilization among adults with asthma. Consistent with this evidence, our research included a large representative sample of Canadian adults, adding more empirical data for chronic disease management.

It is still not clear enough how sleep problems are linked to suicidal behaviors and healthcare utilization outcomes. According to our knowledge, this may be the first attempt to explore whether mental illnesses mediate the relationships between sleep problems and suicidal behaviors and healthcare utilization. In accordance with our expectation, findings of this study indicated that interventions for mental illness may reduce the impact of sleep problems on suicidal behaviors and healthcare utilization in adults with chronic diseases.

There were three main limitations in this study. First, the sleep duration and insomnia were evaluated by only one item. Despite the fact that the approach has been utilized extensively, it is still believed to be less valid as compared to more extensive measures. Second, the results were self-reported rather than measured; however, the determination of chronic diseases and mental illness were based on the diagnosis of health professionals. Finally, our design was cross-sectional, examining data from a group of people at a single moment in time. Thus, we could not monitor and report changes in outcome variables longitudinally.

In conclusion, our study demonstrated that sleep problems, including extreme sleep durations and insomnia, could increase odds of all suicidal behaviors and healthcare utilization in Canadian adults with chronic diseases, whereas mental illness partially mediated the associations. The assessment and treatment of sleep problems and mental illnesses should be considered in the context of strategies to strengthen suicide prevention efforts and lower the healthcare utilization in adults with chronic diseases.³⁷ Especially the COVID-19 pandemic has taken a toll on people’s sleep and mental health.^38,39 Therefore, future research should focus on whether interventions for sleep problems and mental illnesses in adults with chronic diseases can lower the risk of suicide and reduce the burden on health care.

Author Contribution

CW, ZW, NLB, and SG conceived the manuscript. NC, WAW, JV, and NLB analyzed data. All authors drafted and reviewed the manuscript

Data Availability

Data is provided within the manuscript or supplementary information files

Funding Declaration.

No funding was received for this manuscript.

Human Ethics and Consent to Participate declarations

The present manuscript adheres to the principles outlined in the Declaration of Helsinki. A full ethical clearance was obtained as consent to participate was sought and obtained.

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Table 1

Characteristics of study participants
	% (95% CI)
Sample size ^a	22,700
Weighted population ^a	6,318,400
Age, years
18 to 44	29.8 (28.9, 30.8)
45 to 59	31.7 (30.7, 32.7)
60 to 74	29.0 (28.1, 29.9)
≥ 75	9.5 (9.0, 10.0)
Sex
Male	46.4 (45.6, 47.3)
Female	53.6 (52.8, 54.4)
Visible minority
Yes	25.7 (24.4, 27.0)
No	74.3 (73.0, 75.6)
Body mass index, kg/m²
< 18.5	1.9 (1.6, 2.2)
18.5 to < 25.0	36.4 (35.2, 37.6)
25.0 to < 30.0	35.9 (34.8, 37.0)
≥ 30.0	25.9 (24.9, 26.9)
Marital status
Married/common-law	66.2 (65.1, 67.4)
Separated/divorced/widowed	15.8 (15.0, 16.7)
Never married	17.9 (17.1, 18.9)
Education level
Less than secondary school grad	12.8 (12.0, 13.6)
Secondary school grad	24.5 (23.5, 25.5)
Post-secondary grad	62.7 (61.6, 63.9)
Household income, CAD$
≤29 999	14.2 (13.4, 15.1)
30 000 to 49 999	16.0 (15.2, 16.9)
50 000 to 79 999	22.6 (21.6, 23.5)
≥80 000	47.2 (46.0, 48.4)
Smoking status
Current smoker	19.2 (18.3, 20.1)
Former smoker	42.1 (41.0, 43.2)
Never	38.7 (37.6, 39.8)
Physical activity
At/above CPAG’s recommendations	55.7 (54.6, 56.9)
Below CPAG’s recommendations	23.1 (22.1, 24.1)
No physical activity minutes reported	21.2 (20.3, 22.1)
Illicit drug use
Yes	9.0 (8.4, 9.6)
No	91.0 (90.4, 91.6)
Number of chronic diseases
1	41.5 (40.3, 42.6)
2	25.2 (24.3, 26.2)
≥ 3	33.3 (32.3, 34.4)
Province of residence
Ontario	85.2 (84.8, 85.6)
Manitoba	8.1 (7.8, 8.4)
Saskatchewan	6.7 (6.5, 7.0)

CI, confidence intervals; CPAG, Canadian Physical Activity Guidelines. Percentages were based on weighted numbers.

^a Numbers were rounded to base 100 for confidentiality purposes according to Statistics Canada data release policies.

Table 2

Prevalence of suicidal behaviors and healthcare utilization, by sleep duration
	Sleep duration, % (95% CI) < 5 hours 5 to < 7 hours 7 to < 8 hours 8 to < 10 hours ≥10 hours					Insomnia, % (95% CI) No Yes
Suicidal behaviors (lifetime)
Suicidal ideation	20.9 (18.1–23.7) ^**	12.5 (11.4–13.6)	10.3 (9.1–11.5)	11.3 (10.0-12.6)	25.4 (18.0-32.8) ^**	9.5 (8.8–10.3)	23.5 (21.6–25.5) ^#
Suicidal plans	9.7 (7.6–11.9) ^**	4.2 (3.6–4.8)	3.1 (2.4–3.7)	3.9 (3.1–4.7)	10.9 (7.1–14.8) ^**	2.8 (2.5–3.2)	10.1 (8.8–11.5) ^#
Suicidal attempts	8.2 (6.2–10.3) ^**	3.1 (2.6–3.7)	2.3 (1.8–2.9)	3.0 (2.4–3.7)	10.4 (5.2–15.6) ^**	2.3 (2.0-2.6)	7.5 (6.5–8.8) ^#
Suicidal behaviors (past-year)
Suicidal ideation	5.2 (3.4-7.0) ^**	2.7 (2.0-3.3)	2.1 (1.5–2.6)	1.9 (1.2–2.5)	8.5 (4.9–12.1) ^**	1.6 (1.2–1.9)	6.6 (5.4-8.0) ^#
Suicidal plans	1.7 (0.7–2.7)	0.7 (0.4-1.0)	0.4 (0.1–0.8)	0.5 (0.2–0.8)	3.9 (1.6–6.1) ^**	0.3 (0.2–0.5)	2.2 (1.6-3.0) ^#
Healthcare utilization (past-year)
≥2 emergency room visits	18.1 (15.0-21.2) ^**	11.2 (10.1–12.3) ^*	8.3 (7.2–9.3)	10.6 (9.2–12.0)	22.5 (16.1–28.9) ^**	9.2 (8.6–10.0)	17.3 (15.6–19.2) ^#
≥5 consultations with medical doctor	44.3 (40.6–48.0) ^**	31.2 (29.6–32.9)	28.9 (27.0-30.8)	29.8 (27.6–31.9)	42.7 (34.8–50.7) ^*	28.2 (27.0-29.3)	43.9 (41.6–46.2) ^#
≥5 consultations with nurse	4.3 (2.7-6.0) ^*	2.7 (2.1–3.2)	2.0 (1.6–2.4)	3.0 (2.1–3.9)	6.3 (3.2–9.4) ^**	2.1 (1.8–2.4)	5.1 (4.1–6.2) ^#

CI, confidence intervals. Percentages were based on weighted numbers.

^** P < 0.001 and ^* P < 0.05, in comparison with 7 to < 8 hours. P values were corrected using Bonferroni method due to multiple comparisons.

^# P < 0.001, in comparison with no insomnia.

Table 3

Associations between sleep duration and suicidal behaviors and healthcare utilization
	Sleep duration, OR (95% CI) < 5 hours 5 to < 7 hours 7 to < 8 hours 8 to < 10 hours ≥10 hours					Insomnia, OR (95% CI) No Yes
Suicidal behaviors (lifetime)
Suicidal ideation
Model 1	2.52 (2.04–3.12)	1.26 (1.07–1.48)	1.00 (Ref)	1.12 (0.92–1.35)	2.78 (1.75–4.43)	1.00 (Ref)	2.69 (2.34–3.09)
Model 2	1.84 (1.43–2.36)	1.14 (0.96–1.36)	1.00 (Ref)	1.09 (0.90–1.33)	2.04 (1.20–3.46)	1.00 (Ref)	2.26 (1.93–2.64)
Suicidal plans
Model 1	3.86 (2.77–5.40)	1.42 (1.07–1.88)	1.00 (Ref)	1.28 (0.93–1.77)	3.60 (2.15–6.03)	1.00 (Ref)	3.52 (2.87–4.33)
Model 2	2.61 (1.75–3.90)	1.27 (0.94–1.71)	1.00 (Ref)	1.33 (0.94–1.87)	2.45 (1.33–4.52)	1.00 (Ref)	2.76 (2.16–3.52)
Suicidal attempts
Model 1	4.20 (2.90–6.06)	1.37 (1.00-1.88)	1.00 (Ref)	1.31 (0.93–1.85)	4.40 (2.15–9.01)	1.00 (Ref)
Model 2	2.41 (1.53–3.78)	1.21 (0.87–1.67)	1.00 (Ref)	1.29 (0.91–1.83)	2.60 (1.09–6.20)	1.00 (Ref)
Suicidal behaviors (past-year)
Suicidal ideation
Model 1	3.04 (1.89–4.92)	1.31 (0.91–1.90)	1.00 (Ref)	0.91 (0.57–1.46)	3.95 (2.18–7.17)	1.00 (Ref)	4.10 (2.99–5.62)
Model 2	2.23 (1.26–3.94)	1.27 (0.87–1.86)	1.00 (Ref)	0.91 (0.55–1.49)	2.72 (1.36–5.43)	1.00 (Ref)	3.44 (2.39–4.96)
Suicidal plans
Model 1	4.58 (1.63–12.88)	1.68 (0.68–4.14)	1.00 (Ref)	1.22 (0.43–3.41)	7.81 (2.63–23.14)	1.00 (Ref)	6.25 (3.70-10.57)
Model 2	3.13 (1.07–9.12)	1.47 (0.60–3.60)	1.00 (Ref)	1.10 (0.38–3.16)	4.43 (1.30-15.07)	1.00 (Ref)	5.43 (2.98–9.88)
Healthcare utilization (past-year)
≥2 emergency room visits
Model 1	2.57 (2.00-3.30)	1.38 (1.15–1.65)	1.00 (Ref)	1.33 (1.08–1.64)	3.26 (2.16–4.93)	1.00 (Ref)	2.00 (1.73–2.32)
Model 2	1.94 (1.46–2.59)	1.28 (1.06–1.55)	1.00 (Ref)	1.32 (1.06–1.63)	2.22 (1.44–3.43)	1.00 (Ref)	1.65 (1.41–1.94)
≥5 consultations with medical doctor
Model 1	1.87 (1.56–2.24)	1.13 (1.00-1.27)	1.00 (Ref)	1.01 (0.87–1.17)	1.67 (1.17–2.39)	1.00 (Ref)	1.94 (1.74–2.17)
Model 2	1.58 (1.32–1.90)	1.06 (0.94–1.20)	1.00 (Ref)	0.98 (0.85–1.14)	1.49 (1.05–2.12)	1.00 (Ref)	1.68 (1.49–1.89)
≥5 consultations with nurse
Model 1	2.17 (1.37–3.43)	1.37 (1.00-1.87)	1.00 (Ref)	1.53 (1.05–2.23)	3.29 (1.84–5.90)	1.00 (Ref)	2.33 (1.74–3.13)
Model 2	1.71 (1.00-2.91)	1.21 (0.87–1.67)	1.00 (Ref)	1.32 (0.88–1.98)	2.63 (1.42–4.86)	1.00 (Ref)	2.13 (1.54–2.95)
Model 1: adjusted for age, sex, and visible minority;

Model 2: further adjusted for body mass index, marital status, education, household income, smoking status, physical activity, illicit drug use, number of chronic diseases, and province of residence.

Table 4

Indirect (mediating) effects of mental illness on the associations of sleep problems with suicidal behaviors and healthcare utilization
	Sleep duration < 5 hours vs. Normal ≥10 hours vs. Normal		Insomnia Yes vs. No
Suicidal behaviors (lifetime)
Suicidal ideation
Indirect effects	0.148 (0.092, 0.204)	0.309 (0.149, 0.469)	0.234 (0.189, 0.278)
P value	< 0.001	< 0.001	< 0.001
% mediated	20.4%	39.0%	29.1%
Suicidal plans
Indirect effects	0.161 (0.089, 0.234)	0.314 (0.137, 0.491)	0.254 (0.197, 0.311)
P value	< 0.001	0.001	< 0.001
% mediated	16.1%	34.3%	26.3%
Suicidal attempts
Indirect effects	0.165 (0.090, 0.239)	0.329 (0.134, 0.524)	0.274 (0.211, 0.337)
P value	< 0.001	0.001	< 0.001
% mediated	18.7%	34.0%	37.6%
Suicidal behaviors (past-year)
Suicidal ideation
Indirect effects	0.195 (0.106, 0.283)	0.393 (0.175, 0.611)	0.326 (0.253, 0.399)
P value	< 0.001	< 0.001	< 0.001
% mediated	18.3%	32.8%	28.1%
Suicidal plans
Indirect effects	0.250 (0.086, 0.413)	0.672 (0.218, 1.126)	0.411 (0.276, 0.547)
P value	0.003	0.004	< 0.001
% mediated	18.0%	34.4%	25.7%
Healthcare utilization (past-year)
≥2 emergency room visits
Indirect effects	0.067 (0.028, 0.105)	0.108 (0.027, 0.190)	0.081 (0.053, 0.109)
P value	0.001	0.009	< 0.001
% mediated	9.2%	12.8%	16.5%
≥5 consultations with medical doctor
Indirect effects	0.086 (0.048, 0.124)	0.151 (0.065, 0.237)	0.109 (0.081, 0.137)
P value	< 0.001	0.001	< 0.001
% mediated	18.7%	33.8%	20.8%
≥5 consultations with nurse
Indirect effects	0.103 (0.037, 0.168)	0.186 (0.060, 0.312)	0.124 (0.070, 0.178)
P value	0.002	0.004	< 0.001
% mediated	18.1%	21.9%	16.9%

Normal sleep duration referred to 7 to < 8 hours. Indirect effects were presented as coefficient (95% confidence interval). All analyses adjusted for age, sex, visible minority, body mass index, marital status, education, household income, smoking status, physical activity, illicit drug use, number of chronic diseases, and province of residence.

No competing interests reported.

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Editorial decision: Revision requested
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Association of sleep problems with suicidal behaviors and healthcare utilization in adults with chronic diseases: the role of mental illness

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Abstract

Introduction

Methods

Data sources and sample

Sleep problems

Suicidal behaviours, and healthcare utilization

Mental illness

Covariates

Statistical analysis

Results

Discussion

Declarations

Author Contribution

Data Availability

References

Tables

Additional Declarations

Status:

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