PSQI-based severity-ordered sleep-quality strata and associated clinical and psychosocial factors among adults with untreated obstructive sleep apnea: a multicenter cross-sectional study.

BACKGROUND: Obstructive sleep apnea (OSA) is prevalent and is associated with impaired functioning, cardiometabolic morbidity, and mental health problems. Subjective sleep quality is an important patient-reported outcome in OSA, yet most studies rely on a single Pittsburgh Sleep Quality Index (PSQI) global score, potentially masking heterogeneity in domain-level complaints. We aimed to identify PSQI-based sleep-quality strata among adults with untreated OSA and to examine their clinical and psychosocial correlates.

METHODS: We conducted a multicenter cross-sectional study in two sleep monitoring centers in China (January-October 2025). Adults with newly diagnosed, untreated OSA completed the PSQI and questionnaires assessing depressive symptoms, anxiety symptoms, daytime sleepiness, perceived stress, and social support. Latent profile analysis using the seven PSQI component scores was used to summarize PSQI component patterns. Because the retained solution was expected to be graded rather than sharply separated, the resulting strata were ordered by increasing subjective sleep burden. Refit multinomial models based on most-likely stratum assignment were used descriptively to examine correlates, and a three-step classification-uncertainty-adjusted analysis was performed in parallel to account for uncertainty in latent stratum assignment. Recruitment center was included as a design-related covariate, and additional sensitivity analyses excluded participants with diabetes and restricted the analysis to men.

RESULTS: Four graded PSQI-based strata were identified and presented as minimal (22.0%), mild (27.1%), moderate (24.7%), and severe (26.2%) sleep disturbance. Their component means were largely parallel and differed mainly in overall level, indicating severity ordering rather than decisively distinct symptom structures. Individual-level violin and boxplot displays showed within-stratum heterogeneity and partial overlap between adjacent strata, reinforcing the need to interpret the retained strata as severity-ordered PSQI strata rather than discrete clinical phenotypes. Greater subjective disturbance co-occurred with higher depressive and anxiety symptom scores, greater daytime sleepiness and perceived stress, and lower social support. In the severe-versus-minimal comparison, severe OSA, higher depressive symptom scores, higher anxiety scores, and lower social-support scores showed the most consistent associations, but the per-point psychosocial odds ratios were modest and should be interpreted as exploratory correlational estimates rather than clinically actionable causal effects.

CONCLUSIONS: Among adults with untreated OSA referred for laboratory polysomnography, PSQI-based latent profile analysis identified four severity-ordered descriptive strata of subjective sleep disturbance. The study did not provide strong evidence for qualitatively distinct symptom architectures beyond a graded PSQI severity pattern. More severe subjective burden co-occurred particularly with severe OSA, higher depressive and anxiety symptom burden, and lower social support. These findings remained materially similar after accounting for recruitment center and under classification-uncertainty-adjusted three-step analysis, but they should be interpreted cautiously in light of multiple exploratory comparisons, modest effect sizes, and the clinic-based sample.