The Toronto Hospital Alertness Test scale: relationship to daytime sleepiness, fatigue, and symptoms of depression and anxiety

OBJECTIVE The Toronto Hospital Alertness Test (THAT) scale was designed to measure alertness, defined as the capacity of the mind to respond appropriately to external and internal stimuli. The present study's aim is to determine normative values of alertness on the THAT and to explore the relationship among excessive daytime sleepiness, fatigue, depressive symptoms, and alertness. METHODS Normative data were collected from 60 healthy males and females. To explore the relationship among alertness, daytime sleepiness, fatigue, depression, and anxiety, data were collected from charts of sleep clinic patients. All study subjects completed measures for fatigue, sleepiness, depressive symptoms, and anxiety. RESULTS The average score on the THAT was 34.9±7.2 (range 22-50) for the control group. The cutoff score for the THAT, indicative of clinically significant reduced alertness, was determined to be ≤20.5 (mean -2 SD). THAT alertness scores were found to be modestly, significantly, and negatively correlated with fatigue levels (r=-0.39, P<0.001), depressive symptoms (r=-0.53, P<0.001), and anxiety symptoms (r=-0.41, P<0.001). No correlations were found between alertness levels and daytime sleepiness. Regression analyses revealed a significant model (F=19.9, P<0.001, adjusted R (2)=0.35) with depressive symptoms (P<0.001) and fatigue (P=0.006) emerging as the only significant predictors of scores on the THAT. CONCLUSION The findings of this study support that sleepiness is not the same as poor alertness. Depressive symptoms and fatigue, but not sleepiness, were found to have a strong and significant impact on levels of alertness. This is the first study to link poor alertness to depressive symptoms.