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Original Article

Relationship among Sleep Quality, Heart Rate Variability, Fatigue, Depression, and Anxiety in Adults

Ju Ah Kim, MSN, RN1, Seung Wan Kang, Ph.D., MD2
Korean Journal of Adult Nursing 2017;29(1):87-97.
Published online: February 28, 2017

1Doctoral Student, College of Nursing, Seoul National University, Seoul

2Assistant Professor, College of Nursing, Seoul National University, Seoul, Korea

Corresponding author: Kang, Seung Wan College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-747-7422, Fax: +82-2-745-7422, E-mail: drdemian@snu.ac.kr
• Received: January 16, 2017   • Accepted: February 26, 2017

Copyright © 2017 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The purpose of this study was to investigate the relationship among sleep quality, heart rate variability (HRV), fatigue, depression, and anxiety reported by Korean adults.
  • Methods
    A cross-sectional study of 208 adults aged 20~60 years was conducted using a short-term HRV analysis and self-reported questionnaires of Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale, Beck Depression Inventory, and State Trait Anxiety Inventory.
  • Results
    Subjects with good sleep quality (PSQI score≤5) had higher HRV total power (t=2.03, p=.043) and high-frequency (t=2.04, p=.043) with lower fatigue (t=-4.08, p<.001), depressive mood (t=-3.66, p<.001), and trait anxiety (t=-3.84, p<.001) than subjects with poor sleep quality. Poor sleep quality was negatively correlated with HRV total power (r=-.17, p=.016), high-frequency (r=-.14, p=.049), and positively fatigue (r=.39, p<.001), depression (r=.44, p<.001), state anxiety (r=.23, p=.001) and trait anxiety (r=.34, p<.001).
  • Conclusion
    The results indicated that sleep quality is correlated with HRV which reflects the activities of the autonomic nerve system, fatigue, depression, and anxiety in adults.
  • Key Words: Sleep; Heart rate; Fatigue; Depression; Anxiety
Figure 1.
Correlations between total power, high-frequency and sleep quality, depression.
kjan-29-87f1.jpg
Table 1.
Comparisons of General Characteristics by Sleep Quality (N=208)
Variables Categories Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) x2 or t p
n (%) or M±SD n (%) or M±SD n (%) or M±SD
Gender Male 63 (30.3) 38 (33.0) 25 (26.9) 0.93 .336
Female 145 (69.7) 77 (67.0) 68 (73.1)
Age (year) 20~29 51 (24.5) 30 (26.1) 10 (10.8) 0.38 .998
30~39 52 (25.0) 26 (22.6) 23 (24.7)
40~49 52 (25.0) 30 (26.1) 34 (36.6)
50~60 53 (25.5) 29 (25.2) 26 (28.0)
  40.56±11.72 40.52±11.60 40.61±11.94 -0.05 .959
Education level completed ≥High school 192 (92.3) 105 (91.3) 87 (93.5) 0.30 .582
＜High school 16 (7.7) 10 (8.7) 6 (6.5)
Job Employed 144 (69.2) 80 (69.6) 64 (68.8) 0.10 .761
Unemployed 64 (30.8) 35 (30.4) 29 (31.2)
Living status Live alone 51 (24.5) 27 (23.5) 24 (25.8) 0.50 .823
Live with family 157 (75.5) 88 (76.5) 69 (74.2)
Economic status High 6 (2.9) 2 (1.7) 4 (4.3) 0.73 .833
Middle 190 (91.3) 106 (92.2) 84 (90.3)
Low 12 (5.8) 7 (6.1) 5 (5.4)
Presence of chronic disease Yes 57 (27.4) 27 (23.5) 30 (32.3) 2.14 .144
No 151 (72.6) 88 (76.5) 63 (67.7)
BMI (kg/m2)   23.39±3.33 23.54±3.69 23.22±2.83 0.71 .476
Body fat mass (%)   27.33±7.09 27.53±7.54 27.07±6.52 0.47 .643

Good sleepers=Pittsburgh sleep quality index score ≤5; Bad sleeper=Pittsburgh sleep quality index score＞5; BMI=body mass index.

Table 2.
Comparisons of Sleep Quality (N=208)
PSQI Subcategories Range Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) x2 or t p
n (%) or M±SD n (%) or M±SD n (%) or M±SD
Total PSQI score 0~21 5.65±3.15 3.46±1.32 8.35±2.60 -16.50 ＜.001
Subjective sleep quality 0~3 1.20±0.74 0.83±0.53 1.65±0.72 -9.09 ＜.001
Sleep latency (minute) 0 (≤15) 120 (57.7) 85 (73.9) 35 (37.6) 52.58 ＜.001
1 (16~30) 60 (28.8) 29 (25.2) 31 (33.3)
2 (31~59) 20 (9.6) 1 (0.9) 19 (20.4)
3 (≥60) 8 (3.8) ․ 8 (8.6)
0~3 1.03±0.95 0.54±0.61 1.65±0.93 -9.99 ＜.001
Sleep duration (hour) 0 (≥7) 64 (30.8) 54 (47.0) 10 (10.8) 21.12 ＜.001
1 (6~7) 71 (34.1) 48 (41.7) 23 (24.7)
2 (5~6) 44 (21.2) 10 (8.7) 34 (36.6)
3 (＜5) 29 (13.9) 3 (2.6) 26 (28.0)
0~3 1.18±1.02 0.67±0.75 1.82±0.97 -9.40 ＜.001
Habitual sleep efficiency 0~3 0.46±0.85 0.06±0.24 0.95±1.06 -7.92 ＜.001
Sleep disturbance 0~3 1.11±1.08 0.73±0.85 1.58±1.16 -5.92 ＜.001
Frequency of taking sleeping pill 0 (0) 203 (97.6) 115 (100.0) 88 (94.6) 584.65 ＜.001
1 (≤1/week) 1 (0.5) ․ 1 (1.1)
2 (1~2/week) 2 (1.0) ․ 2 (2.2)
3 (≥3/week) 2 (1.0) ․ 2 (2.2)
0~3 0.05±0.36 0.00±0.00 0.12±0.53 -2.16 .034
Daytime dysfunction 0~3 0.52±0.80 0.30±0.58 0.81±0.95 -4.56 ＜.001

PSQI=PittsburGh Sleep Quality Index.

Table 3.
Heart Rate Variability, Fatigue, Depression, and State Trait Anxiety by Sleep Quality (N=208)
Variables Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) t p
M±SD M±SD M±SD
Total power (ms2) 1,295.38±1,133.08 1,432.50±1,294.56 1125.83±871.49 2.03 .043
LF (ms2) 433.01±593.08 486.59±662.37 366.74±489.65 1.45 .148
HF (ms2) 304.57±395.88 351.97±467.80 245.96±274.19 2.04 .043
LF/HF ratio 2.72±3.94 2.56±3.44 2.93±4.50 -0.67 .501
FSS 2.94±1.41 2.59±1.23 3.37±1.50 -4.08 ＜.001
BDI 6.45±6.12 5.06±5.34 8.16±6.61 -3.66 ＜.001
S-STAI 36.78±8.89 35.75±8.89 38.07±8.78 -1.88 .062
T-STAI 39.62±10.43 37.20±9.55 42.61±10.74 -3.84 ＜.001

LF=low frequency; HF=high frequency; LF/HF ratio=low frequency/ high frequency ratio; FSS=fatigue severity scale; BDI=beck depression inventory; S–STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.

Table 4.
Correlations of Sleep Quality, Fatigue, Depression, and Anxiety
Variables PSQI FSS BDI S-STAI T-STAI
PSQI 1        
FSS .39 (＜.001) 1      
BDI .44 (＜.001) .37 (＜.001) 1    
S-STAI .23 (.001) .28 (＜.001) .59 (＜.001) 1  
T-STAI .34 (＜.001) .41 (＜.001) .69 (＜.001) .72 (＜.001) 1

PSQI=Pittsburgh sleep quality index; FSS=fatigue severity scale; BDI=beck depression inventory; S-STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.

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    Relationship among Sleep Quality, Heart Rate Variability, Fatigue, Depression, and Anxiety in Adults
    Korean J Adult Nurs. 2017;29(1):87-97.   Published online February 28, 2017
    DOI: https://doi.org/10.7475/kjan.2017.29.1.87
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    Relationship among Sleep Quality, Heart Rate Variability, Fatigue, Depression, and Anxiety in Adults
    Image
    Figure 1. Correlations between total power, high-frequency and sleep quality, depression.

    Figure 1.

    Relationship among Sleep Quality, Heart Rate Variability, Fatigue, Depression, and Anxiety in Adults

    Comparisons of General Characteristics by Sleep Quality (N=208)

    Variables Categories Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) x2 or t p
    n (%) or M±SD n (%) or M±SD n (%) or M±SD
    Gender Male 63 (30.3) 38 (33.0) 25 (26.9) 0.93 .336
    Female 145 (69.7) 77 (67.0) 68 (73.1)
    Age (year) 20~29 51 (24.5) 30 (26.1) 10 (10.8) 0.38 .998
    30~39 52 (25.0) 26 (22.6) 23 (24.7)
    40~49 52 (25.0) 30 (26.1) 34 (36.6)
    50~60 53 (25.5) 29 (25.2) 26 (28.0)
      40.56±11.72 40.52±11.60 40.61±11.94 -0.05 .959
    Education level completed ≥High school 192 (92.3) 105 (91.3) 87 (93.5) 0.30 .582
    ＜High school 16 (7.7) 10 (8.7) 6 (6.5)
    Job Employed 144 (69.2) 80 (69.6) 64 (68.8) 0.10 .761
    Unemployed 64 (30.8) 35 (30.4) 29 (31.2)
    Living status Live alone 51 (24.5) 27 (23.5) 24 (25.8) 0.50 .823
    Live with family 157 (75.5) 88 (76.5) 69 (74.2)
    Economic status High 6 (2.9) 2 (1.7) 4 (4.3) 0.73 .833
    Middle 190 (91.3) 106 (92.2) 84 (90.3)
    Low 12 (5.8) 7 (6.1) 5 (5.4)
    Presence of chronic disease Yes 57 (27.4) 27 (23.5) 30 (32.3) 2.14 .144
    No 151 (72.6) 88 (76.5) 63 (67.7)
    BMI (kg/m2)   23.39±3.33 23.54±3.69 23.22±2.83 0.71 .476
    Body fat mass (%)   27.33±7.09 27.53±7.54 27.07±6.52 0.47 .643

    Good sleepers=Pittsburgh sleep quality index score ≤5; Bad sleeper=Pittsburgh sleep quality index score＞5; BMI=body mass index.

    Comparisons of Sleep Quality (N=208)

    PSQI Subcategories Range Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) x2 or t p
    n (%) or M±SD n (%) or M±SD n (%) or M±SD
    Total PSQI score 0~21 5.65±3.15 3.46±1.32 8.35±2.60 -16.50 ＜.001
    Subjective sleep quality 0~3 1.20±0.74 0.83±0.53 1.65±0.72 -9.09 ＜.001
    Sleep latency (minute) 0 (≤15) 120 (57.7) 85 (73.9) 35 (37.6) 52.58 ＜.001
    1 (16~30) 60 (28.8) 29 (25.2) 31 (33.3)
    2 (31~59) 20 (9.6) 1 (0.9) 19 (20.4)
    3 (≥60) 8 (3.8) ․ 8 (8.6)
    0~3 1.03±0.95 0.54±0.61 1.65±0.93 -9.99 ＜.001
    Sleep duration (hour) 0 (≥7) 64 (30.8) 54 (47.0) 10 (10.8) 21.12 ＜.001
    1 (6~7) 71 (34.1) 48 (41.7) 23 (24.7)
    2 (5~6) 44 (21.2) 10 (8.7) 34 (36.6)
    3 (＜5) 29 (13.9) 3 (2.6) 26 (28.0)
    0~3 1.18±1.02 0.67±0.75 1.82±0.97 -9.40 ＜.001
    Habitual sleep efficiency 0~3 0.46±0.85 0.06±0.24 0.95±1.06 -7.92 ＜.001
    Sleep disturbance 0~3 1.11±1.08 0.73±0.85 1.58±1.16 -5.92 ＜.001
    Frequency of taking sleeping pill 0 (0) 203 (97.6) 115 (100.0) 88 (94.6) 584.65 ＜.001
    1 (≤1/week) 1 (0.5) ․ 1 (1.1)
    2 (1~2/week) 2 (1.0) ․ 2 (2.2)
    3 (≥3/week) 2 (1.0) ․ 2 (2.2)
    0~3 0.05±0.36 0.00±0.00 0.12±0.53 -2.16 .034
    Daytime dysfunction 0~3 0.52±0.80 0.30±0.58 0.81±0.95 -4.56 ＜.001

    PSQI=PittsburGh Sleep Quality Index.

    Heart Rate Variability, Fatigue, Depression, and State Trait Anxiety by Sleep Quality (N=208)

    Variables Total (N=208) Good sleepers (n=115) Bad sleepers (n=93) t p
    M±SD M±SD M±SD
    Total power (ms2) 1,295.38±1,133.08 1,432.50±1,294.56 1125.83±871.49 2.03 .043
    LF (ms2) 433.01±593.08 486.59±662.37 366.74±489.65 1.45 .148
    HF (ms2) 304.57±395.88 351.97±467.80 245.96±274.19 2.04 .043
    LF/HF ratio 2.72±3.94 2.56±3.44 2.93±4.50 -0.67 .501
    FSS 2.94±1.41 2.59±1.23 3.37±1.50 -4.08 ＜.001
    BDI 6.45±6.12 5.06±5.34 8.16±6.61 -3.66 ＜.001
    S-STAI 36.78±8.89 35.75±8.89 38.07±8.78 -1.88 .062
    T-STAI 39.62±10.43 37.20±9.55 42.61±10.74 -3.84 ＜.001

    LF=low frequency; HF=high frequency; LF/HF ratio=low frequency/ high frequency ratio; FSS=fatigue severity scale; BDI=beck depression inventory; S–STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.

    Correlations of Sleep Quality, Fatigue, Depression, and Anxiety

    Variables PSQI FSS BDI S-STAI T-STAI
    PSQI 1        
    FSS .39 (＜.001) 1      
    BDI .44 (＜.001) .37 (＜.001) 1    
    S-STAI .23 (.001) .28 (＜.001) .59 (＜.001) 1  
    T-STAI .34 (＜.001) .41 (＜.001) .69 (＜.001) .72 (＜.001) 1

    PSQI=Pittsburgh sleep quality index; FSS=fatigue severity scale; BDI=beck depression inventory; S-STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.
    Table 1. Comparisons of General Characteristics by Sleep Quality (N=208)

    Good sleepers=Pittsburgh sleep quality index score ≤5; Bad sleeper=Pittsburgh sleep quality index score＞5; BMI=body mass index.

    Table 2. Comparisons of Sleep Quality (N=208)

    PSQI=PittsburGh Sleep Quality Index.

    Table 3. Heart Rate Variability, Fatigue, Depression, and State Trait Anxiety by Sleep Quality (N=208)

    LF=low frequency; HF=high frequency; LF/HF ratio=low frequency/ high frequency ratio; FSS=fatigue severity scale; BDI=beck depression inventory; S–STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.

    Table 4. Correlations of Sleep Quality, Fatigue, Depression, and Anxiety

    PSQI=Pittsburgh sleep quality index; FSS=fatigue severity scale; BDI=beck depression inventory; S-STAI=state-state trait anxiety inventory; T-STAI=trait-state trait anxiety inventory.

    Table 1.

    Table 2.

    Table 3.

    Table 4.

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