Clinical and sociodemographic correlates of severe insomnia in psychotropic drug-free, Asian outpatients with major depressive disorder
Introduction
Insomnia is characterized by difficulty falling asleep (sleep onset disturbance), difficulty staying asleep (sleep maintenance disturbance), or poor quality (nonrestorative) sleep, leading to impairment of next-day functioning, including psychological distress (Walsh, 2004). For patients with major depressive disorder (MDD), it is common, difficult to treat, and associated with poor outcomes. Insomnia can be found in 80–90% of patients with MDD (Park et al., 2013, Soehner et al., 2014, Sunderajan et al., 2010, Sung et al., 2014). In spite of achieving remission with fluoxetine treatment, almost half of these patients still have insomnia symptoms (Iovieno et al., 2011). The residual symptom of insomnia is a key predictor of recurrence in major depression and a major contributor to the disability associated with depression (Dombrovski et al., 2008, Katz and McHorney, 2002). Although insomnia has tremendous impact on MDD, it is still underrecognized and undertreated (Sunderajan et al., 2010).
Across the severity spectrum of insomnia, the severe one should be a priority area of MDD research. First, limited evidence suggests that severe insomnia is common in MDD patients. By using the insomnia subscale score of Hamilton Depression Rating Scale (HDRS), the Clinical Research Center for Depression in South Korea (CRESCEND) study found that 59.1% of MDD patients had high insomnia (score of 4 or more) (Park et al., 2013). Using a scale of rating from 0 to 5 of the insomnia item of Schedule for Affective Disorders and Schizophrenia, O'Brien et al. (2011) found that 24.7% of adult outpatients with MDD had severe insomnia (score of 4 or 5). Second, it was found that increasing severity of sleep disturbance in depressed patients was associated with poorer psychosocial functioning (McCall et al., 2000). Third, severe insomnia is independently associated with worsened health-related quality of life to almost the same extent as chronic physical conditions, such as congestive heart failure (Katz and McHorney, 2002). Last, as hypnotic medications for severe insomnia may be unavoidable, pharmacological treatment for these patients may be more complicated than usual. Antidepressants commonly used in practice, for example, selective serotonin reuptake inhibitors, not only have limited benefit on insomnia but also can themselves cause insomnia (Papakostas, 2007). Although benzodiazepines are acceptable for the treatment of severe, disabling, or extremely distressed insomnia (Committee on Safety of Medicines, 1998), such treatments have to be balanced with their harmful effects, for example, motor incoordination, increased risk of falls, etc.
There have been many studies on insomnia in depression, but the evidence specific for severe insomnia in MDD is still limited. Based on the multivariate analysis, compared with mild insomnia in MDD, the more severe one is associated with increased age, gastrointestinal somatic symptoms, poor insight, high levels of anxiety, and more severe illness (Park et al., 2013). Univariate findings of another study also supported the association between severe insomnia and poorer psychosocial functioning (O'Brien et al., 2011). However, due to the statistical limitation that could not rule out the coincidence of depression and poorer psychosocial functioning, this later finding might only reflect the association between severe insomnia and depression. Another limitation of both the studies was that some participants might be taking psychotropic medications (e.g., hypnotic medications) during the assessment periods, which might affect the sleep results. In addition, it is not yet known if several factors associated with insomnia in MDD are also correlated with the severe one. Examples of those are being female (Sung et al., 2014), severe depression (Sunderajan et al., 2010), suicide ideation (McCall et al., 2010), and poorer physical health (Sunderajan et al., 2010). Due to these reasons, we proposed to examine the clinical and sociodemographic correlates of severe insomnia in psychotropic-free outpatients with MDD.
Section snippets
Methods
This is a post-hoc analysis of data obtained from the Study on Aspects of Asian Depression (SAAD). The SAAD was a multi-country, cross-sectional, observational, clinical study of depression, carried out between 2009 and 2010. Because its details have already been presented (Srisurapanont et al., 2013, Sulaiman et al., 2014), only the key methods are presented here. This study examined outpatients with depression who were attending psychiatric practices in China, Korea, Malaysia, Singapore,
Participants
Of the 556 participants in the SAAD, 547 met the DSM-IV diagnostic criteria for MDD, confirmed by using the MINI. Of these, 19 MDD patients did not complete the three items of SCL-90-R. This post-hoc analysis, therefore, included the data of 528 patients with MDD from China (n=113, 21.4%), Korea (n=97, 18.4%), Malaysia (n=88, 16.7%), Singapore (n=37, 7.0%), Taiwan (n=91, 17.2%), and Thailand (n=102, 19.3%). Their mean age was 39.5 (SD=13.26) years, and 339 of them (64.2%) were female.
Of the 528
Discussion
The present findings suggest that severe insomnia is common in patients with MDD. Severe insomnia could be found in 45.3% of psychotropic, drug-free outpatients with MDD. For the severe end, initial insomnia and restless sleep were more common than terminal insomnia. Low educational qualifications, higher levels of perceived depression and anxiety, and poorer physical health are independently correlated with severe insomnia in MDD.
The prevalent rate of severe insomnia in the present study of
Contributors
The member of Mood Disorders Research: Asian & Australian Network (MD-RAN), except RUSH, designed and collected the data of the original study (the Study on Aspects of Asian Depression). SRISURAPANONT and LIKHITSATHIAN conceived the research ideas, managed the literature searches, and analyzed the data. SRISURAPANONT prepared the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Role of funding source
The original study (the Study on Aspects of Asian Depression, SAAD) was supported by an unrestricted research grant from Lundbeck A/S. No funding support for the present study. Lundbeck A/S has not role for research conception, study design, data analysis, or study report.
Conflict of interest
The authors have no conflicts of interest to report.
Acknowledgments
The authors would like to thank the members of Mood Disorders Research: Asian & Australian Network (MD-RAN) and all study site personnel for contributing to the Study on Aspects of Asian Depression.
References (45)
- et al.
Gender and socio-economic patterning of self-reported sleep problems in Britain
Soc. Sci. Med.
(2009) - et al.
Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review
J. Nutr. Health Aging
(2013) - et al.
Depression and insomnia: questions of cause and effect
Sleep Med. Rev.
(2000) - et al.
Insomnia severity is an indicator of suicidal ideation during a depression clinical trial
Sleep Med.
(2010) - et al.
Severe insomnia is associated with more severe presentation and greater functional deficits in depression
J. Psychiatr. Res.
(2011) Epidemiology of insomnia: what we know and what we still need to learn
Sleep Med. Rev.
(2002)- et al.
The epidemiology of insomnia: associations with physical and mental health. The HUNT-2 study
J. Psychosom. Res.
(2009) - et al.
Prevalence and clinical correlates of co-occurring insomnia and hypersomnia symptoms in depression
J. Affect. Disord.
(2014) - et al.
Falls in a psychiatric unit
Appl. Nurs. Res.
(1998) Diagnostic and Statistical Manual of Mental Disorders
(2013)
Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes
J. Am. Geriatr. Soc.
Health correlates of insomnia symptoms and comorbid mental disorders in a nationally representative sample of US adolescents
Sleep
Insomnia and Anxiety (Series in Anxiety and Related Disorders)
Benzodiazepines, dependence and withdrawal symptoms
Curr. Probl.
A study of the safety and harms of antidepressant drugs for older people: a cohort study using a large primary care database
Health Technol. Assess.
Antidepressants and falls in the elderly
Drugs Aging
Patient-assessed versus physician-assessed disease severity and outcome in patients with nonspecific pain associated with major depressive disorder
Prim. Care Companion J. Clin. Psychiatry
SCL-90-R (Revised) Version Manual I. Clinical Psychometric Research Unit
Use of non-benzodiazepine sedative hypnotics and risk of falls in older men
J. Gerontol. Geriatr. Res.
Which symptoms predict recurrence of depression in women treated with maintenance interpersonal psychotherapy
Depress. Anxiety
Predicting falls among psychiatric inpatients: a case-control study at a state psychiatric facility
Psychiatr. Serv.
Predictors for occasional and recurrent falls in community-dwelling older people
Z. Gerontol. Geriatr.
Cited by (13)
A technology developed from concept of acupuncture and meridian system, the clinical effect of BIOCERAMIC resonance on psychological related sleep disturbance with findings on questionnaire, EEG and fMRI
2018, Journal of Traditional and Complementary MedicineCitation Excerpt :Sleep disorder may be related to disturbances of the autonomic nervous system, can affect mental and physical wellbeing and the ability to work and interact in social relationships.1,2 Insomnia may be a symptom of other diseases, but untreated insomnia can lead to psychological distress, it may also cause clinical conditions of anxiety and depression.3 Sleep disorder may also be a risk factor for cardiovascular disease and increased mortality.4
Severe insomnia is associated with hypertriglyceridemia in women with major depression treated in psychiatry settings
2017, Journal of Affective DisordersCitation Excerpt :Insomnia is a core symptom of MDE: it is found in 80 to 90% of patients with MDE (Srisurapanont et al., 2015). Severe insomnia is identified in 25 to 50% of patients with MDE (Srisurapanont et al., 2015) and could lead to a worsening of health-related quality of life to a similar extent as chronic physical conditions (Srisurapanont et al., 2015). Since MDE are associated with insomnia and an increased risk of cardiovascular disease, we investigated whether insomnia is associated with HTG in patients with a current MDE.
The non-linear association between low-level lead exposure and maternal stress among pregnant women
2017, NeuroToxicologyCitation Excerpt :Items were scored on a five-point scale ranging from “not at all” to “extremely”. The Chinese version has been validated and widely used in previous studies (Tan et al., 2015; Srisurapanont et al., 2015). We used our study sample to gather validity and reliability evidence, and found that the Cronbach’s alpha coefficient was 0.96, and the validity coefficients including goodness-of-fit index, relative fit index, normed fit index, incremental fit index, and comparative fit index were 0.72–0.95.
Effects of Japanese policies and novel hypnotics on long-term prescriptions of hypnotics
2023, Psychiatry and Clinical NeurosciencesWhat predicts unremitting suicidal ideation? A prospective examination of the role of subjective age in suicidal ideation among ex-prisoners of war.
2021, Psychological Trauma: Theory, Research, Practice, and PolicyEfficacy of electroacupuncture on treating depression-related insomnia: A randomized controlled trial
2020, Nature and Science of Sleep
- 1
Manit Srisurapanont and Surinporn Likhitsathian are joint first authors.