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Psychosomatic Medicine 66:692-697 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Depression Predicts Self-reported Sleep Quality in Patients With Obstructive Sleep Apnea

Rachel D. Wells, MA, Ryan C. Day, PhD, Robert M. Carney, PhD, Kenneth E. Freedland, PhD and Stephen P. Duntley, MD

From the Departments of Psychology (R.D.W., R.C.D.), Psychiatry (R.M.C., K.E.F.), and Neurology (S.P.D.), Washington University, St. Louis, Missouri.

Address correspondence and reprint requests to Rachel D. Wells, MA, Department of Psychology, Washington University; One Brookings Drive, Campus Box 1125, St. Louis, MO 63130-4899. E-mail: rdwells{at}artsci.wustl.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: Depression is a common problem in patients with obstructive sleep apnea. The objective of this study was to examine whether depression is independently associated with lower self-reported sleep quality in patients with obstructive sleep apnea (OSA), after controlling for polysomnographic measures of sleep.

METHODS: The sample comprised 135 patients who had been referred to a university teaching hospital’s multidisciplinary sleep medicine center for polysomnographic evaluation of OSA. The median age of the subjects was 45 (mean age, 46 years) 55% were female, 69% were white, 31% were black, and their mean body mass index was 37.9 ± 11.2 kg/m2. Self-reported sleep quality during the past 2 weeks was assessed by the insomnia severity index. Polygraphic measures of sleep quality included the respiratory disturbance index, sleep onset latency, arousals for no apparent reason, sleep efficiency, and periodic leg movements associated with arousal. Depressive symptoms were assessed by the Beck Depression Inventory.

RESULTS: None of the polygraphic measures of sleep quality was related to self-reported sleep quality or depression. Oxygen desaturation was correlated with self-reported sleep quality (r = 0.21, p = .02). Depression correlated with self-reported sleep quality (r = 0.55, p < .0001). In a multiple regression analysis, depression remained a significant predictor of self-reported sleep quality after controlling for all of the polysomnographic measures of sleep quality (F = 9.65, partial r2 = 0.28 p = .0001).

CONCLUSION: Depression is a better predictor of self-reported sleep quality than are polysomnographic measures of sleep in patients with OSA.

Key Words: sleep apnea syndromes, • sleep apnea, • obstructive, • depression, • mood disorders, • sleep, • polysomnography.

Abbreviations: AFNAR = arousals for no apparent reason;; BDI = Beck Depression Inventory;; BMI = body mass index;; CPAP = continuous positive air pressure;; HSC = Human Studies Committee;; ISI = Insomnia Severity Index;; OSA = obstructive sleep apnea;; PLMA = periodic limb movements associated with arousal;; PSG = polysomnography;; RDI = Respiratory Disturbance Index;; REM = rapid eye movement;; SOL = sleep onset latency.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Obstructive sleep apnea (OSA) is characterized by repeated interruptions of respiration, resulting in sleep fragmentation and excessive daytime sleepiness (1). The prevalence of OSA in middle-aged adults is estimated to be 2% in women and 4% in men (2). OSA is associated with reduced quality of life (3–5), cardiovascular morbidity and mortality (6), and increased risk of automobile accidents (7,8).

Polysomnography (PSG) provides objective measures of respiration and sleep parameters that are essential to the diagnosis of OSA but which are often inconsistent with self-reported sleep quality. This discrepancy has been observed in several populations. For example, self-reports of sleep onset latency and arousal frequency from healthy individuals are not correlated with polysomnographic recordings of the same variables (9). Self-reports of total sleep time from depressed patients are uncorrelated with electroencephalographic measures of sleep (10). Individuals reporting insomnia tend to overestimate sleep onset latency (SOL), underestimate total sleep time, and underestimate arousal frequency (11). Similarly, individuals reporting hypersomnolence overestimate nocturnal sleep latency by an average of 26 minutes (12).

Discrepancies between polysomnographic and self-reported sleep quality extend to patients with OSA. Polysomnographic and self-report measures of total sleep time and sleep onset latency were compared in a study of 84 individuals being evaluated for OSA. Patients with confirmed OSA underestimated their total sleep time compared with those without OSA, and both groups overestimated their SOL. Apneic patients made larger errors in estimating SOL (13). Chervin and Guilleminault (12) found that patients’ estimates of SOL were uncorrelated with polysomnographic SOL.

Despite its poor correlation with polygraphic measures of sleep quality, self-reported sleep quality has been found to predict quality of life and the course of major depression (3,14–18). The determinants of perceived sleep quality are not well understood. Several variables have been associated with self-reported sleep quality, including perception of sleep latency (19,20), total sleep time, agitation (20), amount of REM sleep, arousal frequency (19), and sleep continuity (21). There is also some evidence that depression may influence self-reported sleep quality (22). For example, individuals diagnosed with major depression make larger errors in their estimates of sleep duration and arousal frequency than nondepressed individuals (23).

Further indication that depression may be an important factor in self-reported sleep quality comes from trials of antidepressants. In several controlled clinical trials of antidepressants, patients showed simultaneous improvements in depression and self-reported sleep quality, while polygraphic measures of sleep quality worsened (24–29). Depression also appears to be independently associated with the severity of self-reported fatigue in OSA, after controlling for OSA severity (30).

Several studies have shown that the prevalence of depressive symptoms is elevated among patients with OSA (eg, 32–35). To date, however, no studies have examined the association between depressive symptoms and self-reported sleep quality in patients with OSA. The aim of the current study is to examine whether depressive symptoms are independently associated with lower self-reported sleep quality in patients with OSA, after controlling for polysomnographic measures of sleep.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Subjects
Patients who were referred to the sleep disorders center at a university teaching hospital for polysomnographic evaluation of OSA were recruited for this study. The Washington University School of Medicine Human Studies Committee approved the study, and all subjects gave written informed consent on an HSC-approved consent form.

A total of 135 subjects were recruited from a series of 960 patients who were seen at the WUMSL between July 2001 and February 2002. Age ranged from 17 to 79 years, with a median of 45 years. Females composed 55% of the sample; 69% of the subjects were white, and the rest were black. Split night PSG was performed on 40% of the sample; the rest had full-night PSG. Antidepressants had been prescribed to 30% of the subjects. Antidepressant prescriptions included selective serotonin reuptake inhibitors (20 subjects) bupropion (8 subjects), trazodone (7 subjects), venlaxafine (5 subjects), nefazadone (1 subject), imipramine (1 subject), and amitriptyline (1 subject). Table 1 summarizes demographic and medical characteristics of the sample.


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  		TABLE 1. Correlations Between Demographic Variables and Sleep Quality and Depressive Symptoms
 
Measures
Polygraphic Measures of Sleep Quality
Polygraphic measurements of sleep included respiratory disturbance index, SOL, periodic limb movements associated with arousals, arousals for no apparent reason, and sleep efficiency (the percentage of time in bed that was spent asleep). These data were derived from polysomnographic recordings, which consisted of an electrooculogram, electroencephalogram, electrocardiogram, electromyogram, airflow and respiratory effort monitors, and recordings of oxygen saturation. These data were electronically recorded and an analysis of sleep stages was carried out in accordance with the guidelines of Rechtsaffen and Kales (36). Epoch length was 30 seconds. The PSG data were scored by registered polysomnographic technologists. The data were interpreted by a physician who is a diplomate of the American Board of Sleep Medicine (SPD). The physician did not have access to the patients’ responses on the Beck Depression Inventory (BDI) or Insomnia Severity Index (ISI).

Apnea was defined as a cessation in airflow of at least 10 seconds. Hypopnea was defined as a reduction in the amplitude of the airflow of at least 50%, lasting at least 10 seconds, followed by either a decrease in oxygen saturation of 4%, or signs of physiological arousal (at least three seconds of alpha activity). The Respiratory Disturbance Index (RDI) was defined as the total number of apneas plus hypopneas divided by the hours of sleep. The diagnostic criterion for OSA used in this investigation was an RDI ≥ 10, consistent with current guidelines (37). Analyses of periodic limb movements and arousals were performed using the American Sleep Disorders Association criteria (38,39).

Self-reported Sleep Quality
The ISI was used to assess self-reported sleep quality (40,41). The ISI is particularly well suited to capture the full spectrum of symptoms experienced by patients with OSA, including insomnia. Although most patients with OSA do not complain of insomnia, some do (42). The 7 ISI items provide information about satisfaction with sleep, perceived severity of initial insomnia, maintenance insomnia, and early morning awakenings, interference in functioning due to sleep problems, worry about sleep problems, and beliefs about how noticeable the sleep problems are to others. ISI scores can range from 0 to 28, with higher scores indicating greater dissatisfaction with sleep. When the ISI is used to evaluate patients with insomnia, scores greater than 14 indicate significant insomnia (41). The ISI has been shown to have adequate concurrent validity; it is significantly correlated to self-reports of sleep onset latency, waking after sleep onset, and early morning awakenings (41). It has adequate internal consistency and is sensitive to changes in symptom severity following insomnia treatment (41). For example, in a behavioral and pharmacological treatment trial for insomnia in older adults, mean ISI scores declined from 15.4 to 8.9 following treatment (41). The Sleep Impairment Index, which includes the same items but uses a slightly different scoring scale, is also sensitive to changes in symptoms of insomnia (43,44).

Patients were instructed to complete the ISI based on the quality of their sleep in the past 2 weeks.

Depressive Symptoms
The BDI is a 21-item questionnaire used to measure self-reported depressive symptoms (45). Although the BDI is not sufficient to diagnose depressive disorders, the BDI has been widely used to measure depressive symptoms and has been shown to be sensitive and moderately specific in identifying depressive disorders, both in otherwise healthy individuals and in patients with comorbid medical illnesses (46,47).

Procedure
Subjects underwent one night of standard PSG at an outpatient sleep medicine center. Patients were asked to refrain from napping or consuming caffeine or other stimulants on the day of the PSG study. In some cases, "split-night" polysomnographic sessions were performed. These included an initial diagnostic period and a subsequent period devoted to titrating the continuous positive air pressure treatment. In these cases, only the data from the diagnostic period were included in the analysis. Subjects were instructed to complete the BDI and the ISI on the morning following the sleep study. Data on the subjects’ comorbid diagnoses, prescription medications, age, gender, and body mass index (BMI) were obtained from their medical records.

Statistical Analysis
SPSS version 12.0 (SPSS Inc.; Chicago, IL) was used for the analyses. Correlation coefficients were used to characterize the univariate relationships between self-reported sleep quality and polygraphic sleep characteristics, BMI, age, and depressive symptoms. Backward elimination multiple regression analysis was used to determine whether depressive symptoms are an independent predictor of self-reported sleep quality, after controlling for relevant sleep characteristics. RDI, AFNAR, periodic limb movements associated with arousal (PLMA), SOL, BMI, and age were chosen as covariates on an a priori basis and were forced to remain in the regression model. Other covariates, such as comorbid disorders and medication use, were included in the model if present in at least 20% of the sample and if there was a plausible mechanism by which they might affect self-reported sleep quality. Sleep efficiency and oxygen desaturation were included in the model because of their potential influence on self-reported sleep quality. Oxygen desaturation was strongly correlated with RDI, however, making it inappropriate to include both variables in the same regression model. Therefore, we ran separate analyses adjusting for RDI and oxygen desaturation. Alpha was set at 0.05 for all analyses.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
There were no significant racial differences in sleep or depressive symptoms. Females reported poorer self-reported sleep quality (t = 2.5; p = .01) and had significantly more depressive symptoms than males (t = 2.6; p = .01).

A summary of the polysomnographic measures of sleep quality is given in Table 2. Because the RDI, SOL, and PLMA distributions were highly skewed, these scores were transformed into quartiles for the correlation and regression analyses. The mean RDI was 33.0 ± 38.1. and 49 patients had an RDI < 10. These patients were younger (t = –2.5, p = .01) and had a lower BMI (t = –3.04, p = .003) than subjects with RDI ≥ 10. However, there were no significant differences between these groups in depressive symptoms (t = –0.178, p = .86) or self-reported sleep quality (t = –0.64, p = .52).


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  		TABLE 2. Summary of Polygraphic Sleep Data and Correlations With Self-reported Sleep Quality
 
The mean ISI score was 13.6 ± 6.5, which is nearly equal to the level of sleep-related symptoms reported by patients with significant insomnia (41). Univariate analyses were performed to determine which variables were significantly related to self-reported sleep quality. RDI, AFNAR, SOL, PLMA, and age were not associated with self-reported sleep quality, but oxygen desaturation was associated with self-reported sleep quality (Table 2).

The mean BDI score was 12.0 ± 8.9, which is consistent with mild depression. None of the polysomnographic measures of sleep quality was significantly related to depressive symptoms (Table 2). Depressive symptoms were significantly correlated with greater dissatisfaction with sleep, as predicted (r = 0.60, p = .0001).

Of the subject characteristics that could influence self-reported sleep quality, use of antidepressants, gender, split versus full-night PSG, sleep efficiency, and cardiovascular disease were sufficiently frequent to be included as covariates in subsequent analyses. A backward elimination regression analysis was performed to determine whether depressive symptoms and/or these subject characteristics accounted for a significant portion of the variance in self-reported sleep quality, after controlling for relevant sleep characteristics. Depressive symptoms remained an independent predictor of self-reported sleep quality after controlling for polysomnographic measures of sleep disruption, age, BMI, antidepressant use, gender, type of PSG, sleep efficiency, and cardiovascular disease (F = 9.65, partial r2 = 0.28; p = .0001) (Table 3). Although poorer self-reported sleep quality was associated with higher BMI (r = 0.30, p = .001), BMI did not predict ISI scores after controlling for depression.


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  		TABLE 3. Summary of Backwards Regression Analysis for Variables Predicting Subjective Sleep Quality
 
Since the BDI contains two items related to fatigue and insomnia, a secondary analysis was performed to determine if the correlation between depressive symptoms and self-reported sleep quality was due to these items. Depressive symptoms remained an independent predictor of self-reported sleep quality after omitting these two items (F = 8.2, partial r2 = 0.21; p = .0001).

Another secondary analysis was performed to determine if oxygen desaturation during sleep predicted self-reported sleep quality. RDI and oxygen desaturation levels were correlated (r = –0.61, p = .0001), which made it inappropriate to include both variables in the regression model. When RDI was removed from the model and replaced with oxygen desaturation levels, both depression and oxygen desaturation levels predicted self-reported sleep quality (F = 9.3, partial r2 for BDI = 0.30, partial r2 for desaturation = –0.20, p = .0001).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
These findings show that in patients undergoing polysomnographic evaluation for suspected OSA, self-reported sleep quality is not related to polygraphic measures of sleep quality but is strongly related to depressive symptoms. Depressive symptoms were not significantly associated with polygraphic sleep quality, but they were strongly correlated with dissatisfaction with sleep after controlling for variables that are generally assumed to influence sleep quality, including RDI, AFNAR, PLMA, SOL, age, sleep efficiency, and BMI.

The mean RDI in our sample was 33.0, a level that is indicative of clinically significant OSA. Depressive symptoms remained a significant predictor of sleep complaints after adjusting for polysomnographic indices of sleep OSA. Excluding items on the BDI that assess fatigue and insomnia did not change this finding. This relationship between depressive symptoms and self-reported sleep quality is similar to that seen in clinical trials of antidepressants. In several of these trials, self-reported sleep quality and depressive symptoms improved concurrently, even though polygraphic sleep disturbances often worsened in patients taking antidepressants (24–29,31). Our results are also similar to a recent finding that the fatigue reported by patients with OSA is independently associated with depressive symptoms, after controlling for OSA severity (30).

These findings have important implications for the diagnosis and treatment of sleep disorders. Physicians often use self-reports of poor sleep quality to make referral decisions. This study suggests that patients who are experiencing high levels of depressive symptoms may report that their sleep problems are more severe than do individuals without depressive symptoms. It is possible that the perception of more severe sleep disturbances could prompt patients to seek treatment for long-standing sleep problems. This would be consistent with evidence that poorer psychosocial adjustment is correlated with earlier treatment seeking in patients diagnosed with myocardial infarction (48).

The purpose of this study was to identify correlates of patient complaints about sleep. The measure of self-reported sleep quality that we used, the ISI, does not provide self-report estimates of specific aspects of sleep, such as SOL or total sleep time. Instead, it focuses on the subjective experience of sleep problems and the amount of distress and impairment the individual attributes to their sleep problems. Medical care providers are often faced with the dilemma of how to reduce a patient’s distress about his or her sleep problems, when no diagnosable sleep disorder is present. Our study suggests that dissatisfaction with sleep is associated with depressive symptoms but may not be associated with polygraphic measures of sleep, with the exception of oxygen desaturation. When RDI was replaced with oxygen desaturation in the regression analysis, oxygen desaturation predicted self-reported sleep quality. This is not surprising, since it was expected that severity of OSA would predict self-reported sleep quality, and oxygen desaturation is a measure of the severity of OSA.

This study has several limitations. This study is based on a convenience sample, so that selection bias may have influenced the sample characteristics. The proportion of women in our sample is higher than expected. Women typically report more depressive symptoms on the BDI than men (49), and the women in our sample reported significantly more depressive symptoms and poorer self-reported sleep quality than the men. Gender failed to account for a significant portion of the variance in self-reported sleep quality, however.

Additionally, patients completed the self-report questionnaires without supervision, which raises the possibility that they may have completed them in a manner that compromises the validity of the results. The strong consistency of the results argues against this, but additional studies performed on random samples and under more carefully controlled conditions are needed.

Our sample included patients who had comorbid illnesses and who were taking prescription medications. Although this is typical of patients seen in sleep clinics, it is possible that comorbid diagnoses or medications may have influenced patients’ self-reported sleep quality. However, we included prevalent comorbid disorders and medications in the analyses, when possible, and they failed to explain a significant portion of the variance in perceived sleep quality. This makes it unlikely that comorbidities or medications were responsible for our results. Additional studies are needed to confirm these findings, however.

Some aspects of sleep, such as REM latency, are altered by both sleep apnea and depression. It is possible that self-reported sleep quality is related to these variables (19). The relationship between these variables, daytime fatigue, sleepiness, feelings of refreshment after waking, and other sleep parameters in patients with both OSA and depression should be examined in future studies.

In summary, we found that self-reported sleep quality is unrelated to RDI, SOL, PLMA, AFNAR, sleep efficiency, BMI, type of PSG, gender, use of antidepressants, cardiovascular disease, and age in patients referred for polysomnographic evaluation for OSA. Instead, self-reported sleep quality was independently associated with the severity of depressive symptoms, after controlling for polysomnographic measures of sleep quality and relevant subject characteristics. This indicates that individuals with depressive symptoms may report poorer sleep quality, independent of the actual quality of their sleep. This has implications for the use of self-report in diagnostic evaluations for sleep disorders and also highlights the importance of screening for depression in populations with sleep disorders.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
The authors thank the staff at the Washington University Multidisciplinary Sleep Medicine Center for their generous help.

Received for publication June 3, 2003.


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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