Association between Sleep Quality, PTSD, and Depression Among Patients in Conflict-Affected Regions

Background: Psychiatric disorders, particularly post‐traumatic stress disorder (PTSD) and depression, posed a significant public health challenge in conflict-affected regions. Recurrent exposure to traumatic events and adverse socioeconomic conditions considerably increased their prevalence. Recent evidence has suggested that sleep quality was a key modifiable factor influencing neuropsychological outcomes. Aims and Objectives: This study aimed to evaluate the association between sleep quality and the severity of PTSD and depression among 1700 patients from conflict zones in Syria. We also investigated the impact of demographic and clinical variables on these relationships to inform the development of targeted, multidisciplinary mental health interventions. Methods: A cross-sectional design was employed, and data were collected from April 1 to October 1, 2024, at Tishreen Military Hospital and its affiliated centers. Participants (aged 18–79 years) with documented conflict exposure completed standardized face-to-face questionnaires. Sleep quality was assessed using an adapted Pittsburgh Sleep Quality Index (PSQI) categorized into Poor, Average, and Good. PTSD severity was measured via a modified PCL‑5 (0–10 scale; Cronbach’s α=0.89), and depressive symptoms via an adapted PHQ‑9 (0–10 scale; Cronbach’s α=0.85). Statistical analyses were performed using R 4.4.2 and included one-way ANOVA with post‑hoc Tukey’s HSD tests, Pearson correlation, binary logistic regression, k‑means clustering, and SEM. Assumptions of normality and homogeneity of variances were verified using Shapiro–Wilk and Levene’s tests, and missing data (≤5%) were addressed via multiple imputation. Results: Patients with poor sleep quality exhibited significantly higher PTSD scores compared to average and good sleepers (F(2,1697)=195.6, p<0.001; post‑hoc Tukey’s HSD, all pairwise p<0.001; partial η²≈0.187). A weak but significant positive correlation was observed between PTSD and depression (r=0.148, p<0.001). Logistic regression showed that demographic factors (age, gender, residency) did not significantly predict PTSD or depression prevalence. K‑means clustering identified three symptom subgroups based on score similarity and internal variance, which justified the selection of k‑means over other clustering approaches. SEM revealed that sleep quality significantly predicted PTSD, and PTSD significantly predicted depression; however, the indirect effect of sleep quality on depression via PTSD was not significant (indirect effect=–0.030, p=0.280). Conclusion: Findings underscored sleep quality’s critical role as a modifiable therapeutic target to mitigate PTSD severity among conflict-affected patients. Although a weak association between PTSD and depression was observed, sleep quality’s overall impact was robust. Integrating sleep-targeted interventions into multidisciplinary mental health care could benefit such populations. Future longitudinal studies using objective sleep assessments are warranted.