Insomnia and lost productivity among young adults: there is still much work to do

Insomnia, obstructive sleep apnoea, and restless legs syndrome are the most frequent sleep disorders in Australia, together affecting almost half of all middle‐aged people.1 These conditions cost the Australian economy an estimated $11 billion per year in lost work productivity, comprising both absenteeism (absence from work) and presenteeism (people present at work but not fully functional).2 Less is known about the impact of sleep disorders on productivity in younger adults. The study by Reynolds and colleagues in this issue of the Journal3 fills an important gap in understanding how sleep disorders affect the productivity of young working adults.

The Raine Study has provided a wealth of longitudinal information on the prevalence and effects of sleep disorders in a Western Australian community‐based sample; one of its unique features is that it includes polysomnography assessments of participants. Reynolds and colleagues reviewed laboratory sleep study data and questionnaire responses (Pittsburgh Sleep Symptom Questionnaire for Insomnia; International Restless Legs Syndrome Study Group criteria; WHO Health and Work Performance Questionnaire) for 554 22‐year‐old second generation Raine Study participants, whose mothers had been recruited during their respective pregnancies. The authors found that 21.7% of participants had at least one sleep disorder: insomnia, 90 people (17%); obstructive sleep apnoea, 30 (5.4%); restless legs syndrome, two (0.4%). Strikingly, only seventeen of these people (14%) had previously been diagnosed with a sleep disorder by a health professional. Young workers with sleep disorders reported 40% greater workplace productivity loss than those without these conditions, including 34% greater absenteeism and 52% greater presenteeism. Workplace productivity loss was predominantly related to insomnia (28730 hours/1000 workers/year). Restless legs syndrome also had a detrimental effect, but as only two participants had this condition, the finding needs to be interpreted with caution. Somewhat unexpectedly, obstructive sleep apnoea was associated with lower productivity loss, perhaps because participants with this condition did not report associated excessive daytime somnolence (obstructive sleep apnoea was diagnosed solely on the basis of apnoea–hypopnoea index of greater than 15 events per hour).3 A European questionnaire‐based study of obstructive sleep apnoea found that people with moderate excessive daytime somnolence reported increased presenteeism, while those in whom it was severe reported greater absenteeism than people without excessive daytime somnolence.4 The young people in the study by Reynolds and colleagues may therefore have been a largely asymptomatic cohort (a recognised clinical phenotype), or they may have sought treatment soon after their diagnosis (eg, continuous positive airway pressure).

Presenteeism is of particular importance for younger people. The recent COVID‐19 pandemic has shed light on the fact that adequate leave provision may not be available to some workers, causing people to attend work for financial reasons when not well. Young workers are even more at risk of this problem, as they more frequently have temporary or casual work contracts, particularly with the rise of the “gig” economy. Presenteeism has emerged as an important occupational risk, and is associated with increased risk of cardiovascular disease5 and future sickness absence, with a high economic cost.6 Presenteeism has been associated with health disorders, including depression, and evidence is growing for the association of insomnia with poor workplace productivity, particularly presenteeism, in middle‐aged people,7 and this is known to have a bi‐directional relationship with depression.8

The study by Reynolds and co‐authors3 adds to the large body of evidence that sleep disorders — in their study, particularly insomnia in young adults — are often underdiagnosed, undertreated, and have significant health consequences for society.9 Among the many barriers to the diagnosis and management of insomnia are public ignorance of sleep disorders and underreporting and insufficient training and clinic time for primary care practitioners and psychologists who encounter these people in clinical practice.10 A recent parliamentary inquiry into sleep health awareness in Australia clearly identified that public education and education programs for primary care practitioners are needed to improve the detection and management of sleep disorders.11 Policy makers have a responsibility to act on these recommendations, which could lead to significant health and economic benefits for the Australian community. It is important to note that government‐funded, evidence‐based, effective treatments for insomnia are available, such as cognitive behavioural therapy, but their delivery remains a huge challenge.10

In conclusion, Reynolds and colleagues have added to the evidence that insomnia reduces the workplace productivity of young adults. Further research is needed to determine whether treating insomnia in young people improves productivity overall.