Elsevier

Journal of Affective Disorders

Volume 186, 1 November 2015, Pages 26-31
Journal of Affective Disorders

Clinical and sociodemographic correlates of severe insomnia in psychotropic drug-free, Asian outpatients with major depressive disorder

https://doi.org/10.1016/j.jad.2015.06.032Get rights and content

Highlights

  • We examined the correlates of severe insomnia in major depressive disorder (MDD).

  • Of 528 participants with MDD, 239 (45.3%) had severe insomnia.

  • Correlates were low education, depression, anxiety, and poorer physical health.

  • These correlates may implicate the treatment provided for this population.

Abstract

Background

Little has been known regarding the correlates of severe insomnia in major depressive disorder (MDD). This post-hoc analysis aimed to examine the sociodemographic and clinical correlates of severe insomnia in psychotropic drug-free, Asian adult outpatients with MDD.

Methods

Participants were psychotropic drug-free patients with MDD, aged 18–65 years. By using the Symptom Checklist-90 Items, Revised (SCL-90-R), a score of 4 (severe distress) on any one of three insomnia items was defined as severe insomnia. Other measures included the Montgomery–Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale (FSS), the nine psychopathology subscales of SCL-90-R, the Physical and Mental Component Summaries of Short Form Health Survey (SF-36 PCS and SF-36 MCS), and the Sheehan Disability Scale (SDS).

Results

Of 528 participants, their mean age being 39.5 (SD=13.26) years, 64.2% were females, and 239 (45.3%) had severe insomnia. The logistic regression model revealed that low educational qualifications (less than secondary school completion), high SCL-90- R Depression scores, high SCL-90-R Anxiety scores, and low SF-36 PCS scores were independently correlated with severe insomnia (p's<.05).

Limitations

Insomnia was determined only by the patient's distress. Middle insomnia was not assessed. Psychotropic drug-free patients with MDD are not commonly seen in psychiatric practice.

Conclusion

Severe insomnia is common in patients with MDD. It is closely related with low educational qualification, subjective depression and anxiety severity, and poor physical health. These findings may implicate the treatment of comorbid MDD and severe insomnia, for example, sleep hygiene education, pharmacological treatment.

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.

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