A Study of Factors Causing Sleep State Misperception in Patients with Depression

Abstract

Purpose

Sleep state misperception, which is the discrepancy between subjective and objective sleep, is often observed in patients with depression. This phenomenon may delay the remission of depression. Previous studies have focused on the total sleep time (TST) misperception, with many of these studies using actigraphy. Thus, our study investigated depressed patients with the exploratory aim of clarifying factors associated with the sleep state misperception including the wake after sleep onset (WASO) misperception, with their objective sleep additionally evaluated by polysomnography (PSG).

Patients and Methods

We conducted a cross-sectional study. Before undergoing overnight PSG monitoring, 40 patients with depression completed questionnaires that included the Beck Depression Inventory (BDI), Epworth sleepiness scale, Temperament and Character Inventory, and the Pittsburgh sleep quality index. Patients were also asked to estimate their subjective sleep duration after they woke up in the morning. Based on this data, we calculated the misperception using the following formula: subjective sleep duration minus objective sleep duration. We compared each factor between negative and positive misperception groups and the multiple regression analysis was performed for TST and WASO misperception, respectively.

Results

Although sleep architectures, age, severity of depression and obstructive sleep apnea (OSA) exhibited differences in underestimating or overestimating the WASO, only sex differences were associated with underestimating or overestimating their total sleep time (TST). Moreover, BDI, the severity of OSA, sleep architectures (N1% and N2%), and benzodiazepine (BZD) use were significantly correlated with WASO misperception, whereas only OSA severity was significantly correlated with TST misperception. A subsequent multiple regression analysis demonstrated the BDI was independently correlated with the WASO misperception (β=0.341, p=0.049).

Conclusion

In clinical practice, interventions especially for OSA, and the reduction of depressive symptoms are an important method for improving patient sleep perception. Moreover, current results suggest that BZD prescriptions should be avoided as well.

Keywords:

• insomnia
• personality
• sleep architectures
• discrepancy
• sleep disorders

Abbreviations

AHI, apnea-hypopnea index; BD, bipolar disorders; BDI, Beck Depression Inventory; BMI, body mass index; CP, chlorpromazine; DZP, diazepam; ESS, Epworth sleepiness index; HA, harm avoidance; HAM-D, Hamilton Rating Scale for Depression; IP, imipramine; MDD, major depressive disorders; PSG, polysomnography; CPAP, continuous positive airway pressure; SE, sleep efficacy; SOL, sleep onset latency; TST, total sleep time; WASO, wake after sleep onset latency; YMRS, Young Mania Rating Scale.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgment

This research was supported in part by research grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan, a Grant-in-Aid for Comprehensive Research on Disability Health and Welfare from the Ministry of Health, Labour and Welfare of Japan, a Grant-in-Aid for the center of Innovation Program by the Japan Science and Technology Agency, JSPS KAKENHI Grant No. 17K10272 and No. 20K11577, AMED under grant No. JP21dk0307103 and No. JP21dk0307099.

Disclosure

KI has received speakers’ honoraria from Eisai, Kyowa, Meiji Seika Pharma, Otsuka, Sumitomo Dainippon, Taisho, Takeda, and Towa. NO has received research support or speakers’ honoraria from, or has served as a consultant to, Sumitomo Dainippon, Eisai, Otsuka, KAITEKI, Mitsubishi Tanabe, Shionogi, Eli Lilly, Mochida, Daiichi Sankyo, Nihon Medi-Physics, Takeda, Boehringer Ingelheim, Meiji Seika Pharma, EA Pharma, Pfizer, MSD, Lundbeck Japan, Taisho Pharma, Kyowa Kirin, Janssen, UCB, Shionogi, Nihon Medi-Physics, Tsumura, Novartis, Astellas, Ono, Viatris, Medical Review, Yoshitomi Yakuhin, and Astellas. In addition, NO has a patent 19874599.4 with royalties paid to Woolsey; a patent 2020-552954 with royalties paid to Sumitomo Pharma co., Ltd. The authors report no other conflicts of interest in this work.