Sleep and Breathing

, Volume 18, Issue 1, pp 111–117 | Cite as

Gender differences in the effect of comorbid insomnia symptom on depression, anxiety, fatigue, and daytime sleepiness in patients with obstructive sleep apnea

  • Min-hwan Lee
  • Sang-Ahm LeeEmail author
  • Gha-hyun Lee
  • Ho-Sung Ryu
  • Seockhoon Chung
  • Yoo-Sam Chung
  • Woo Sung Kim
Original Article



This study investigated gender differences in the effect of comorbid insomnia symptom on depression, anxiety, fatigue, daytime sleepiness, and quality of life in patients with obstructive sleep apnea. There are gender differences in the presentation of obstructive sleep apnea. However, the influence of gender on the presentation of comorbid insomnia symptom and obstructive sleep apnea is not known.


Allparticipantsperformed overnightpolysomnography and completed a battery of questionnaires including Beck Depression Inventory, State-Trait Anxiety Inventory, Multidimensional Fatigue Inventory, Epworth Sleepiness Scale, and Short Form-36 Health Survey. Insomnia symptom was defined as present if a patient had any insomnia complaints longer than 1 month and at least one time per week.


Six hundred fifty-five adult patients with obstructive sleep apnea were enrolled; 233 (35.5 %) reported comorbid insomnia symptom with obstructive sleep apnea. The severity of obstructive sleep apnea was not related to comorbid insomnia symptom. Based on linear regression, women had higher depression, fatigue, and daytime sleepiness and lower health-related quality of life than men (all, p < 0.05). The presence of insomnia symptom had negative effects on fatigue (p = 0.005) and quality of life only (p = 0.015) in men but not in women when taking gender-by-insomnia interaction into consideration. There were significant differences in polysomnography-based sleep architecture between the obstructive sleep apnea-only and obstructive sleep apnea–insomnia groups, but only in the subgroup of men.


Men are more prone to the negative impact of comorbid insomnia symptom and obstructive sleep apnea on their level of fatigue and quality of life than women.


Obstructive sleep apnea Insomnia Depression Quality of life Gender 


Conflict of interest

All the authors have no conflicts of interest to disclose.


  1. 1.
    Cho YW, Shin WC, Yun CH, Hong SB, Kim J, Earley CJ (2009) Epidemiology of insomnia in Korean adults: prevalence and associated factors. J Clin Neurol 5:20–23PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Punjabi NM (2008) The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5:136–143PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Chung KF (2005) Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea. Respiration 72:460–465PubMedCrossRefGoogle Scholar
  4. 4.
    Krakow B, Melendrez D, Ferreira E, Clark J, Warner TD, Sisley B, Sklar D (2001) Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest 120:1923–1929PubMedCrossRefGoogle Scholar
  5. 5.
    Smith S, Sullivan K, Hopkins W, Douglas J (2004) Frequency of insomnia report in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS). Sleep Med 5:449–456PubMedCrossRefGoogle Scholar
  6. 6.
    Buckley TM, Schatzberg AF (2005) On the interactions of the hypothalamic-pituitary-adrenal (HPA) axis and sleep: normal HPA axis activity and circadian rhythm, exemplary sleep disorders. J Clin Endocrinol Metab 90:3106–3114PubMedCrossRefGoogle Scholar
  7. 7.
    Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342:1378–1384PubMedCrossRefGoogle Scholar
  8. 8.
    Yun CH, Jung KH, Chu K, Kim SH, Ji KH, Park HK, Kim HC, Lee ST, Lee SK, Roh JK (2010) Increased circulating endothelial microparticles and carotid atherosclerosis in obstructive sleep apnea. J Clin Neurol 6:89–98PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Baldwin CM, Griffith KA, Nieto FJ, O'Connor GT, Walsleben JA, Redline S (2001) The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep 24:96–105PubMedGoogle Scholar
  10. 10.
    Noh HJ, Joo EY, Kim ST, Yoon SM, Koo DL, Kim D, Lee GH, Hong SB (2012) The relationship between hippocampal volume and cognition in patients with chronic primary insomnia. J Clin Neurol 8:130–138PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Luyster FS, Buysse DJ, Strollo PJ (2010) Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med 6:196–204PubMedCentralPubMedGoogle Scholar
  12. 12.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235PubMedCrossRefGoogle Scholar
  13. 13.
    Young T, Hutton R, Finn L, Badr S, Palta M (1996) The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms? Arch Intern Med 156:2445–2451PubMedCrossRefGoogle Scholar
  14. 14.
    Shepertycky MR, Banno K, Kryger MH (2005) Differences between men and women in the clinical presentation of patients diagnosed with obstructive sleep apnea syndrome. Sleep 28:309–314PubMedGoogle Scholar
  15. 15.
    Brostrom A, Johansson P, Stromberg A, Albers J, Martensson J, Svanborg E (2007) Obstructive sleep apnoea syndrome—patients’ perceptions of their sleep and its effects on their life situation. J Adv Nurs 57:318–327PubMedCrossRefGoogle Scholar
  16. 16.
    American Academy of Sleep Medicine (2007) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. American Academy of Sleep Medicine, Westchester. Accessed 15 Dec 2012
  17. 17.
    Lee YH, Song JY (1991) A study of the reliability and the validity of the BDI, SDS, and MMPI-D scales. J Korean Neuropsychiatr Assoc 10:93–113Google Scholar
  18. 18.
    Kim JT, Shin DK (1978) A study based on the standardization of the STAI for Korea. Recent Medicine 2:69–75Google Scholar
  19. 19.
    Smets EM, Garssen B, Bonke B, De Haes JC (1995) The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 39:315–325PubMedCrossRefGoogle Scholar
  20. 20.
    Cho YW, Lee JH, Son HK, Lee SH, Shin C, Johns MW (2011) The reliability and validity of the Korean version of the Epworth sleepiness scale. Sleep Breath 15:377–384PubMedCrossRefGoogle Scholar
  21. 21.
    Han CW, Lee EJ, Iwaya T, Kataoka H, Kohzuki M (2004) Development of the Korean version of Short-Form 36-Item Health Survey: health related QOL of healthy elderly people and elderly patients in Korea. Tohoku J Exp Med 203:189–194PubMedCrossRefGoogle Scholar
  22. 22.
    Krell SB, Kapur VK (2005) Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath 9:104–110PubMedCrossRefGoogle Scholar
  23. 23.
    Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB (1993) Sex and depression in the National Comorbidity Survey. I: lifetime prevalence, chronicity and recurrence. J Affect Disord 29:85–96PubMedCrossRefGoogle Scholar
  24. 24.
    Shochat T, Umphress J, Israel AG, Ancoli-Israel S (1999) Insomnia in primary care patients. Sleep 22(Suppl 2):S359–365PubMedGoogle Scholar
  25. 25.
    Mohsenin V (2001) Gender differences in the expression of sleep-disordered breathing: role of upper airway dimensions. Chest 120:1442–1447PubMedCrossRefGoogle Scholar
  26. 26.
    O'Connor C, Thornley KS, Hanly PJ (2000) Gender differences in the polysomnographic features of obstructive sleep apnea. Am J Respir Crit Care Med 161:1465–1472PubMedCrossRefGoogle Scholar
  27. 27.
    Beneto A, Gomez-Siurana E, Rubio-Sanchez P (2009) Comorbidity between sleep apnea and insomnia. Sleep Med Rev 13:287–293PubMedCrossRefGoogle Scholar
  28. 28.
    Bixler EO, Vgontzas AN, Lin HM, Vela-Bueno A, Kales A (2002) Insomnia in central Pennsylvania. J Psychosom Res 53:589–592PubMedCrossRefGoogle Scholar
  29. 29.
    Bjornsdottir E, Janson C, Gislason T, Sigurdsson JF, Pack AI, Gehrman P, Benediktsdottir B (2012) Insomnia in untreated sleep apnea patients compared to controls. J Sleep Res 21:131–138PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Gooneratne NS, Gehrman PR, Nkwuo JE, Bellamy SL, Schutte-Rodin S, Dinges DF, Pack AI (2006) Consequences of comorbid insomnia symptoms and sleep-related breathing disorder in elderly subjects. Arch Intern Med 166:1732–1738PubMedCrossRefGoogle Scholar
  31. 31.
    Krakow B, Melendrez D, Lee SA, Warner TD, Clark JO, Sklar D (2004) Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath 8:15–29PubMedCrossRefGoogle Scholar
  32. 32.
    Krakow B, Melendrez D, Sisley B, Warner TD, Krakow J, Leahigh L, Lee S (2006) Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial. Sleep Breath 10:16–28PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Min-hwan Lee
    • 1
  • Sang-Ahm Lee
    • 1
    Email author
  • Gha-hyun Lee
    • 1
  • Ho-Sung Ryu
    • 1
  • Seockhoon Chung
    • 2
  • Yoo-Sam Chung
    • 3
  • Woo Sung Kim
    • 4
  1. 1.Department of Neurology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  2. 2.Department of Psychiatry, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  3. 3.Department of Otolaryngology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  4. 4.Department of Pulmonology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea

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