Accepted Manuscript

Title: Schizophrenia and depression: The relation between

Sleep quality and working memory

Author: Maurits van den Noort Esli Struys Benot Perriard

Heike Staudte Sujung Yeo Sabina Lim Peggy Bosch

PII: S1876-2018(15)30077-0
DOI: http://dx.doi.org/doi:10.1016/j.ajp.2016.08.023
Reference: AJP 946

To appear in:

Received date: 24-11-2015

Revised date: 28-8-2016
Accepted date: 30-8-2016

Please cite this article as: Noort, Maurits van den, Struys, Esli, Perriard, Benot,
Staudte, Heike, Yeo, Sujung, Lim, Sabina, Bosch, Peggy, Schizophrenia and depression:
The relation between Sleep quality and working memory.Asian Journal of Psychiatry
http://dx.doi.org/10.1016/j.ajp.2016.08.023

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 1

Schizophrenia and Depression: The Relation between Sleep

Quality and Working Memory

Short title: Sleep and Memory in Psychiatric Patients (40 characters/maximum 40 letters and

spaces)

Maurits van den Noorta,b*, Esli Struysc, Benot Perriardd, Heike Staudtee, Sujung Yeoa, Sabina

Lima, and Peggy Boscha,e,f

a
Research Group of Pain and Neuroscience, Kyung Hee University, #47 Gyeonghuidae-Gil,

Dongdaemun-Gu, Seoul 130-701, Republic of Korea

b
Brussels Institute for Applied Linguistics, Vrije Universiteit Brussel, Pleinlaan 2, B-1050

Brussels, Belgium
c
Center of Linguistics, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Brussels, Belgium
d
Department of Psychology, Universit de Fribourg, Rue de Faucigny 2, 1700 Fribourg,

Switzerland
e
Psychiatric Research Institute, LVR-Klinik Bedburg-Hau, Nassauerallee 93-97, 47533 Kleve,

Germany
f
Donders Institute for Brain, Cognition, and Behaviour, Centre for Cognition, Radboud

University Nijmegen, Montessorilaan 3, 6525 HR Nijmegen, The Netherlands

E-mail addresses of the authors:

Maurits van den Noort, info@mauritsvandennoort.com

Esli Struys, estruys@vub.ac.be

 2

Benot Perriard, benoit.perriard@gmail.com

Heike Staudte, Heike.Staudte@lvr.de

Sujung Yeo, pinkteeth@daum.net

Sabina Lim, lims@khu.ac.kr

Peggy Bosch, p.bosch@donders.ru.nl

*Corresponding author: Prof. Dr. Maurits van den Noort, Research Group of Pain and

Neuroscience, Kyung Hee University, #47 Gyeonghuidae-Gil, Dongdaemun-Gu, Seoul 130-

701, Republic of Korea. Tel: ++491634317754; Fax: ++8229617831; E-mail:

info@mauritsvandennoort.com

Word count: 248 (maximum 250 words)

 3

Highlights.(3-5/max 85 characters)

Sleep problems are underestimated in patients with schizophrenia. (67 characters)

Decreased complex working memory performance in depression and schizophrenia. (79

characters)

Patients with schizophrenia show slower information processing. (65 characters)

A negative relationship exists between sleep quality and working memory. (74 characters)

Sleep needs more priority when treating patients with depression and schizophrenia. (85

characters)

Abstract

Sleep is known to be markedly disturbed in patients with depression, but in patients with

schizophrenia these problems are underestimated. This research aimed to determine if a

relationship existed between sleep problems in patients with schizophrenia and with

depression and their reduced working memory (WM) performance. Thirty outpatients with

schizophrenia, 30 outpatients with depression, and 30 healthy control participants were

enrolled in this study. All participants completed a sleep questionnaire (i.e., Pittsburgh Sleep

Quality Index (PSQI)), two simple WM tasks tapping only its storage component (i.e., digit

span forward and backward task), and two complex WM tasks tapping both its storage and

processing components (i.e., letter-number sequencing and reading span task). The results

showed that neither psychiatric group differed from the healthy controls on simple WM tasks.

Patients with schizophrenia did not differ from those with depression in the performance of

simple or complex WM tasks. However, patients with schizophrenia, and, to a lesser degree,

patients with depression performed significantly worse than the healthy control participants

on complex WM tasks, which was visible in lower WM scores for patients with depression

and in slower information processing, as well, for patients with schizophrenia. Finally, a
 4

significant negative relationship was found between the PSQI score and the reading span task

scores; thus, participants with worse performance tended to report more sleep problems. To

conclude, sleep needs to receive more priority when treating patients with depression and

especially patients with schizophrenia because better sleep improves (working) memory

performance and daily functioning.

Keywords: Schizophrenia; depression; sleep quality; working memory; reading span task.

1. INTRODUCTION

A well-known fact is that sleep problems are found in as many as 80% or more of patients

with depression (Reynolds and Kupfer, 1987). Less known to the general public is that 30% to

80% of patients with schizophrenia experience sleep problems (Cohrs, 2008). Given the

straightforward nature of the patients daytime complaints, for instance working memory

(WM) problems, one would expect extensive literature in favor of the hypothesis that patients

with sleep disorders experience serious cognitive problems. Surprisingly, however, data on

this issue are scarce (Drummond et al., 2013).

WM refers to a set of cognitive processes that provide temporary maintenance and

manipulation of information (Baddeley, 1986, 1992, 2000, 2007) required for the successful

completion of complex cognitive tasks, such as language, learning, and reasoning, in daily

functioning (Kim et al., 2004). According to Baddeleys WM model (2000), WM has four

main components. The first one is called the central executive, and this component is

thought to manipulate information and to act as a supervisory system that controls the
 5

information flow from and to its three so-called slave systems: the phonological loop, the

visuo-spatial sketchpad, and the episodic buffer. The three slave systems, the other three

components, are responsible for the temporary maintenance of different kinds of information.

Previous research showed that even moderate sleep loss, as a result of sleep deprivation,

seriously affected WM performance (Smith et al., 2002). Moreover, both sleep quality and

sleep quantity (e.g., Pilcher et al., 1997) were found to be related to WM performance

(Steenari et al., 2003).

WM problems in patients with schizophrenia (e.g., Brbion et al., 2009; Kim et al., 2004)

as well as in patients with depression (e.g., Christopher and MacDonald, 2005; Korsnes et al.,

2013) are well documented. The general results in patients with schizophrenia reveal that

these patients are consistently impaired in their performance of WM tasks and that this is the

case for all different WM domains (e.g., verbal, spatial, or object) or processing requirements

(e.g., maintenance, monitoring, or manipulation) (Conklin et al., 2005). In several studies,

correlations between reduced WM performance and processing speed were found (Brbion et

al., 2000), which led to the processing speed hypothesis, which states that the memory

problems observed in patients with schizophrenia are accounted for by a decreased processing

speed (Brbion et al., 2014; Brbion et al., 2011). The general results in patients with

depression show that these patients are consistently impaired in their performance of WM

tasks, but researchers do not agree on what components of Baddeleys WM model (Baddeley,

2000) cause these WM problems. On the one hand, Channon et al. (1993), as well as Hartlage

et al. (1993), hypothesized that WM impairment in patients with depression was limited to

Baddeley's (2000) central executive and that tasks requiring automatic processing, such as

those involving the phonological loop and visuo-spatial sketchpad slave systems, were

unaffected in patients with depression. On the other hand, Christopher and MacDonald (2005)

hypothesized, in contrast to Channon et al. (1993) and Hartlage et al. (1993), that depression
 6

affected not only the central executive, but also the phonological loop and the visuo-spatial

sketchpad.

The main objective of the present study was to investigate whether a relationship existed

between sleep problems in patients with schizophrenia and with depression and their reduced

WM performance. First, it was hypothesized that both patients with schizophrenia and with

depression would show worse WM performance than healthy control participants and that this

would be particularly the case when both the storage and the processing components of the

WM were tapped. Secondly, the possible relationship between sleep problems and WM

performance was tested. Patients with schizophrenia and with depression, who suffered from

severe sleep problems, were expected to show worse WM performance than patients with

only mild sleep problems. Thirdly, several leading theories on why patients with

schizophrenia and patients with depression show decreased WM performances were tested.

2. METHODS

2.1 Participants

Ninety participants were enrolled in this study: 23 males and 67 females, all between 19

and 64 (mean (M) = 41.20, standard deviation (SD) = 10.78) years old. Of the 90 participants,

30 were being treated for schizophrenia, 30 were being treated for depression, and 30 were

healthy controls, and all patients were diagnosed by their psychiatrist according to the ICD-10

(World Health Organization, 1992).

As can be seen in Table 1, the Analysis of Variance (ANOVA) showed no significant

gender differences between the three groups (F(2,87) = 2.194, p = 0.118, 2 = 0.048). In

addition, no significant differences in the average ages between the three groups (F(2,87) =

2.206, p = 0.116, 2 = 0.048) were found. Because previous research had shown that

intelligence and WM performance were related (e.g., Dang et al., 2014), an ANOVA was
 7

conducted and showed no significant differences in the mean Mehrfach-Wortschatz-

Intelligenz-Test-B (MWT-B) (Lehrl, 2005) scores between the three groups (F(2,78) = 2.472, p

= 0.091, 2 = 0.060).

The study was approved by the local ethics committee (rztekammer Nordrhein, number:

2008331); moreover, the clinical trial has officially been registered under number NTR3132

at the Dutch Trial Register (see also

http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3132). Finally, the study was

performed in accordance with the Declaration of Helsinki

(http://www.wma.net/en/30publications/10policies/b3/).

2.2 Sleep assessment

2.2.1 Pittsburgh Sleep Quality Index

The Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) was used, which is a self-

rated questionnaire that assesses sleep disturbances and sleep quality over a 1-month period.

The global PSQI score ranged between 0 and 21.

2.3 Simple WM tasks

2.3.1 Digit span forward task

The first simple WM task was the digit span forward task (Wechsler, 1997), during which the

experimenter read a set of numbers aloud, and the participant had to repeat those numbers in

the same order. The total number of correct answers was counted, and the scores ranged from

0 to 16.
 8

2.3.2 Digit span backward task

The second simple WM task was the digit span backward task. This test (Wechsler, 1997)

consisted of a set of numbers that was read aloud again, but during this test, the participant

had to repeat the numbers in the opposite order. The total number of correct answers was

counted and ranged from 0 to 14.

2.4 Complex WM tasks

2.4.1 Letter-number sequencing task

Two complex WM tasks were used. During the letter-number sequencing task (Wechsler,

1997), the experimenter read aloud a series of random letters and numbers. The participant

had to repeat those in a special order. The numbers had to be given in order of increasing

magnitude, followed by the letters, which had to be given in alphabetic order. The total

number of correct answers was counted and ranged from 0 to 21.

2.4.2 Reading span task

The second complex WM task was the reading span task (for a detailed description, we refer

to Van den Noort et al., 2008). The participant had to read the sentences aloud, after which he

or she had to press the space bar, which initiated another sentence to appear. After a set, the

word recall appeared, and the participants had to recall all sentence-final words within that

set. The remembered sentence-final words and the reading time of all sentences were

collected and the range within which each participant could score was from 0 to 100.
 9

2.5 Procedure

All participants were tested in a quiet testing room in the clinic. After general instructions,

participants received detailed instructions for each separate task (see Figure 1 for a diagram

flow of the study).

First, the PSQI was completed by the participants. Then, the WM tasks (e.g., digit span

forward and backward task, letter-number sequencing, and the reading span task) were

conducted. The participants were tested by apprentices, who were not informed about the aim

of the study. Finally, a debriefing was offered to all participants, in which they were

individually informed about their test results. The total duration of the study was about 60

minutes.

2.6 Statistical analyses

SPSS version 22.0 (http://www-01.ibm.com/support/docview.wss?uid=swg21646821) was

used for all statistical analyses. An overall ANOVA was conducted in order to identify the

significant differences on the PSQI, the digit span forward and backward task, the letter-

number sequencing task, and the reading span task between the schizophrenia group, the

depression group, and the healthy control group. When a significant result was found on the

ANOVA, Sidak Post Hoc Tests were then conducted to determine how the schizophrenia

group, the depression group, and the healthy control group differed on the experimental tasks.

Moreover, a Pearson correlation analysis (2-tailed) was used on all participants, as well as on

each group separately (i.e., schizophrenia, depression, and healthy control group), to test for

possible linear relationships between the average sentence reading times and the total reading

span scores. Furthermore, an ANOVA was conducted to test whether the 50% fastest
 10

participants differed in total reading span score from the 50% slowest participants (on the

basis of median split), this analysis being conducted for the schizophrenia, the depression, and

the healthy control group separately. In addition, a Pearson correlation analysis (2-tailed) was

used to test for possible linear relationships between the PSQI scores and both the simple and

the complex WM scores. Finally, a cut-off score of 6 (Hametner et al., 2012) on the PSQI was

used to split all participants into a group of good sleepers ( 6) and a group of poor sleepers

( 7), after which the total reading span scores and the average sentence reading times of both

groups were compared. For all analyses, a significance level of p < 0.05 was used.

3. RESULTS

3.1 Sleep results

3.1.1 Pittsburgh Sleep Quality Index

As can be seen in Table 2, the overall ANOVA showed significant group differences (F(2,88) =

16.176, p < 0.001, 2 = 0.271) on the PSQI. The pair-wise comparisons revealed that the

patients with schizophrenia (p = 0.001) and the patients with depression (p < 0.001) had

significantly higher mean scores on the PSQI than the healthy control participants. No

significant differences existed between the two psychiatric groups; the patients with

depression had similar mean scores on the PSQI as the patients with schizophrenia. Moreover,

by using the strict cut-off score of 6 (Hametner et al., 2012), the PSQI assessment results

revealed a difference in the number of good and poor sleepers in the two patient groups; there

were 7 good and 23 poor sleepers in the depression group, 14 good and 16 poor sleepers in the

schizophrenia group, and 24 good and 6 poor sleepers in the healthy control group

respectively.
 11

3.2 Simple WM results

3.2.1 Digit span forward task

The overall ANOVA showed significant group differences (F(2,81) = 3.188, p = 0.047, 2 =

0.074) on the digit span forward task between the three groups. As can be seen in Table 2, the

pair-wise comparisons showed that the patients with schizophrenia and the patients with

depression did not differ on the digit span forward task (p = 0.999). Moreover, a trend

showing that the patients with schizophrenia and the patients with depression scored lower

than the healthy control participants was visible in the data on the digit span forward task (p =

0.072 versus p = 0.095 respectively).

3.2.2 Digit span backward task

The overall ANOVA showed significant group differences (F(2,81) = 3.430, p = 0.037, 2 =

0.079) (see also Table 2). The pair-wise comparisons revealed that a borderline significant

effect showing that the patients with schizophrenia scored lower than the patients with

depression on the digit span backward task was visible in the data (p = 0.057). No significant

differences in the average digit span backward task scores were found between the patients

with schizophrenia and the healthy control participants (p = 0.121) nor between the patients

with depression and the healthy control participants (p = 0.998).

3.3 Complex WM results

3.3.1 Letter-number sequencing task

The overall ANOVA showed significant group differences (F(2,81) = 3.823, p = 0.026, 2 =

0.087) on the letter-number sequencing task between the three groups (see also Table 2). The

pair-wise comparisons revealed that the patients with schizophrenia had significantly lower
 12

scores on the letter-number sequencing task than the healthy control participants (p = 0.034).

No significant differences in the average scores on the letter-number sequencing task were

found between the patients with depression and the healthy control participants (p = 0.888) or

between the patients with schizophrenia and the patients with depression (p = 0.118).

3.3.2 Reading span task

As can be seen in Table 2, the overall ANOVA showed significant group differences (F(2,88) =

12.229, p < 0.001, 2 = 0.219) on the total reading span task score. The pair-wise comparisons

showed that the patients with schizophrenia had significantly lower total scores on the reading

span task than the healthy control participants (p < 0.001), as did the patients with depression

(p = 0.003). No significant differences were found between the patients with schizophrenia

and the patients with depression (p = 0.383).

The analysis of the average sentence reading time showed a trend toward significantly

different scores between the three groups (F(2,88) = 2.596, p = 0.080, 2 = 0.056). A trend

toward significantly slower average sentence reading times for the patients with schizophrenia

in comparison with the healthy control participants was noted (p = 0.074). No significant

differences in average sentence reading times were found between the patients with

schizophrenia and the patients with depression (p = 0.521) or between the patients with

depression and the healthy controls (p = 0.663).

As can be seen in Table 3, the analyses of the 5 different series of the reading span task

revealed that the patients with schizophrenia performed significantly worse than the healthy

control participants on all 5 series: series 1 (p = 0.003), series 2 (p < 0.001), series 3 (p =

0.001), series 4 (p < 0.001), and series 5 (p < 0.001). The patients with depression performed

significantly worse than the healthy control participants on 4 out of the 5 series: series 1 (p =
 13

0.004), series 2 (p = 0.014), series 4 (p = 0.023), and series 5 (p = 0.005), the only exception

being series 3 (p = 0.066). No significant differences on all 5 different reading span task series

were found between the two psychiatric groups.

Moreover, the analyses of the average sentence reading times of the 5 different series of

the reading span task revealed that the patients with schizophrenia read significantly more

slowly than the healthy control participants on series 1 (p = 0.039), but no differences in

average sentence reading times on the other 4 series were found. The patients with depression

did not differ from the healthy control participants on all 5 series. Finally, no significant

differences in average sentence reading times were found between the two psychiatric groups

on all 5 series.

Furthermore, correlation analyses on the average sentence reading times and the total

scores on the reading span task were conducted. The Pearson correlation analysis of all

participants revealed a significant negative correlation between the average sentence reading

time and the total score on the reading span task (r = -0.242, p = 0.022). The correlation

analyses for all three groups separately revealed a significant negative correlation between the

average sentence reading time and the total score on the reading span task for the

schizophrenia group (r = -0.395, p = 0.031), but not for the depression group (r = -0.204, p =

0.279) or for the healthy control group (r = 0.116, p = 0.540).

Finally, when the schizophrenia group of 30 patients was split into a subgroup of the 15

individuals with the slowest average sentence reading times and a subgroup of the 15

individuals with the fastest average sentence reading times and the total reading span scores

of both subgroups were analyzed, a significant difference between the two subgroups was

found (F(1,29) = 7.034, p = 0.013, 2 = 0.201). The subgroup of patients with the slowest

average sentence reading times scored significantly worse on total reading span score than the

subgroup of patients with the fastest average sentence reading times: M = 39.47 (SD = 10.05)
 14

total reading span score versus M = 49.53 (SD = 10.73) total reading span score. This was not

the case for the depression group (F(1,29) = 0.337, p = 0.566, 2 = 0.012) or for the healthy

control group (F(1,29) = 0.438, p = 0.514, 2 = 0.015).

3.4 Correlation analyses on sleep quality and WM performance

Correlation analyses on the PSQI and the simple and the complex WM tests were conducted.

The Pearson correlation analysis on the PSQI and the simple working memory tests revealed

no significant correlations between the scores on the PSQI and the digit span forward task (r =

-0.086, p = 0.438) or the digit span backward task (r = -0.145, p = 0.190). The Pearson

correlation analysis on the PSQI and the complex working memory tests revealed no

significant correlations between the scores on the PSQI and on the letter-number sequencing

task (r = -0.113, p = 0.308); however, a significant negative correlation between the PSQI and

the RST was found (r = -0.242, p = 0.022). When Pearson correlation analyses were

conducted on the PSQI and the 5 different series of the RST separately, significant negative

correlations between the PSQI score and the first and the last 2 series of the RST were found,

i.e., between the PSQI and series 1 (r = -0.222, p = 0.036), between the PSQI and series 4 (r =

-0.260, p = 0.013), and between the PSQI and series 5 (r = -0.308, p = 0.003).

Finally, a tendency towards higher reading span scores for the good sleepers M = 52.71

(SD = 12.01) compared to the poor sleepers M = 48.07 (SD = 12.06) was found (F(1,89) =

3.349, p = 0.071, 2 = 0.037). However, no difference in average sentence reading times

between the good sleepers M = 5897 ms (SD = 713 ms) and the poor sleepers M = 5955 ms

(SD = 684 ms) was found (F(1,89) = 0.154, p = 0.696, 2 = 0.002).

 15

4. DISCUSSION

In line with our first hypothesis, no differences between the patients with schizophrenia and

with depression and the healthy control participants were found on the digit span forward task

(Wechsler, 1997), which is a test that only taps the storage component of the WM. This was

also true for the digit span backward task (Wechsler, 1997), as expected. However, a

significant borderline trend (p = .057) was visible in the data, showing that patients with

schizophrenia performed worse than patients with depression on the digit span backward task.

In fact, in addition to the storage component, the digit span backward task has a kind of

processing element because the subjects have to repeat the number set in exactly the opposite

order, but that processing component of the WM is only minimally tapped. Nevertheless, the

WM problems of patients with schizophrenia seemed so severe that a WM task that required

only minimal processing skills could easily reveal them.

The results of the complex WM tasks, in line with our first hypothesis, showed that the

patients with schizophrenia performed significantly worse than the healthy control

participants on both the letter-number sequencing task and the reading span task, but that the

patients with depression did so only on the reading span task. No significant differences

between the two psychiatric groups were visible in the complex WM tasks. Surprisingly,

however, the patients with depression did not perform significantly worse than the healthy

control participants on the letter-number sequencing task. Although the reading span task and

the letter-number sequencing task are both complex WM tasks, the WM storage and

processing requirements seem to be larger in the reading span task; thus, the patients with

depression thereby showed reduced WM functioning compared to the healthy control

participants.
 16

Regarding our second hypothesis, the results of the present study indeed showed a

significant negative relationship between the Pittsburgh Sleep Quality Index score and the

WM scores on series 1, 4, and 5 of the reading span task. The higher the scores on the

Pittsburgh Sleep Quality Index was (meaning more reported sleep problems), the lower the

scores on series 1, 4, and 5 of the reading span task (meaning worse performance on the

complex verbal WM). In addition, when the total reading span scores for the group of good

sleepers was compared to those for the group of poor sleepers, a tendency for the reading span

scores of the good sleepers to be higher than those of the poor sleepers was found. This

finding is in line with previous research, showing that poor sleep affects WM performance

(Killgore, 2010; Smith et al., 2002; Steenari et al., 2003). However, the finding by Smith et al.

(2002) that poor sleep led to slower responses could not be replicated in the present study; the

average sentence reading times on the reading span task for the good sleepers and the poor

sleepers were comparable. Furthermore, in this study, a correlation between sleep problems

and WM performance could only be found for the most complex WM task (the reading span

task), but not for the less complex letter-number sequencing task or the simple digit span

forward task and digit span backward task WM tasks.

Finally, in this study, further support for the processing speed hypothesis in schizophrenia

was found (Brbion et al., 2011, 2014). In line with previous studies (Brbion et al., 2000), a

negative correlation between processing speed and WM performance on the reading span task

was found for the patients with schizophrenia. The memory problems observed in patients

with schizophrenia seem to be, at least partly, accounted for by a decreased processing speed

(Brbion et al., 2011, 2014). This is further supported by the fact that the slowest 50% of the

individuals with schizophrenia performed significantly worse than the fastest 50%. Finally, in

accordance with the hypothesis, that was not the case for the depression group and for the

healthy control group.

 17

With respect to the leading hypotheses for reduced WM in depression, the results of the

present study found evidence against Christopher and MacDonalds (2005) hypothesis that

depression affects not only the central executive, but also the phonological loop and the visuo-

spatial sketchpad. In line with their hypothesis, one would expect both the patients with

depression and the patients with schizophrenia to have significantly decreased performances

on both the simple and the complex WM tasks compared to the healthy controls, but that was

clearly not the case. The patients with depression only performed worse on the most complex

WM task, the reading span task. On the other hand, our results are in line with the hypothesis

(Channon et al., 1993; Hartlage et al., 1993) that WM impairment in patients with depression

is limited to Baddeleys (2000) central executive, and as a result, the phonological loop and/or

the visuo-spatial sketchpad are not affected in patients with depression. Indeed, the patients

with depression did not differ from the healthy control participants on the simple WM tasks

that tapped only the storage component of the WM (i.e., the phonological loop); however,

more research is needed to further investigate whether or not the visuo-spatial sketchpad is

affected in patients with depression. In order to do so, patients with depression need to be

tested on a simple visual WM task, such as the Corsi block-tapping test (Kessels et al., 2000),

as well. Of course, the visuo-spatial sketchpad is involved in the reading span task, but

because the phonological loop, the visuo-spatial sketchpad, and the central executive of the

WM are all involved in complex verbal WM tasks, drawing conclusions on the functioning of

the visuo-spatial sketchpad alone is not possible.

One of the limitations of the present study is the small sample size, which noticeably limits

the generalizability of the findings, both the positive and negative ones. The reason was that

our clinic and the ethics committee only gave us the approval to recruit patients within the

LVR-Klinik Bedburg-Hau. Another limitation is the fact that all psychiatric patients

continued their medication (note that a complete overview can be obtained from the authors)
 18

due to ethical reasons. This might have influenced our findings. Finally, from a

methodological point of view, it would have been better to implement another patient group

having sleep disturbances but not schizophrenia or clinically significant depression/anxiety in

order to be able to investigate the relation between sleep and working memory performance.

In the present clinical study, we did not have the approval from the local ethics committee

(rztekammer Nordrhein, number: 2008331) to implement such a patient group; however, we

request it in future research.

To conclude, this study seems to indicate that a reduced quality and quantity of sleep in

patients with schizophrenia and with depression affect the WM performances of those

patients; moreover, reduced quality and quantity of sleep may explain the often reported

memory complaints in these psychiatric groups. However, future research with an additional

patient group having sleep disturbances but not schizophrenia or clinically significant

depression/anxiety is needed before firm conclusions on the relation between sleep and

working memory performance in patients with depression and with schizophrenia can be

drawn. Based on the present results and on the scientific literature (e.g., Afonso et al., 2014;

Cohrs, 2008), there seems to be an increased need to add disturbed sleep as one of the

characteristic symptoms of schizophrenia, just as it is listed as one of the characteristic

symptoms of depression in the DSM-5 (The Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition) (American Psychiatric Association, 2013) and in the ICD-10 (10th

revision of the International Classification of Diseases and Related Health Problems) (World

Health Organization, 1992). Moreover, sleep needs to receive more priority when treating

patients with depression and especially patients with schizophrenia because better sleep

improves (working) memory performance and daily functioning.

 19

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adherence and quality of sleep in schizophrenia outpatients. Int. J. Psychiatry. Clin.

Pract. 18 (1) 7076.

American Psychiatric Association., 2013. Diagnostic and Statistical Manual of Mental

Disorders, fifth ed. American Psychiatric Publishing, Arlington, VA.

Baddeley, A.D., 1986. Working Memory. Oxford University Press, New York, NY.

Baddeley, A.D., 1992. Working memory. Science. 255 (5044) 556559.

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Figure 1: Diagram flow of the study. Thirty patients with schizophrenia, 30 patients with depression, and 30

healthy control participants entered the study. The PSQI was used to assess quality of sleep, the digit span

forward task and the digit span backward task were used to assess simple working memory capacity, and the

letter-number sequencing task and the reading span task were used to assess complex working memory capacity.
 24

TABLE 1

Descriptives of the schizophrenia group, the depression group, and the healthy control group

________________________________________________________________________________

Schizophrenia Depression Healthy Control

Group Group Group

_______________________________________________________________________________

Gender 11m/19f 4m/26f 8m/22f

Age 42.27 (10.44) 43.40 (8.99) 37.93 (12.24)

MWT-B1 104.55 (12.17) 100.70 (7.03) 107.05 (11.44)

_______________________________________________________________________________
 25

TABLE 2

Means and standard deviations on the different psychological tests for the schizophrenia

group, the depression group, and the healthy control group

________________________________________________________________________________

Psychological Test Schizophrenia Depression Healthy Control

Scores Group Group Group

_______________________________________________________________________________

Pittsburgh Sleep Quality Index1 7.97b (4.44)2 9.73b (4.23) 4.23 (2.50)

Digit Span Forward Task3 9.23 (1.85) 9.30 (2.35) 10.52 (1.78)

Digit Span Backward Task4 5.87 (2.03) 7.13 (2.39) 7.04 (1.55)

Letter-Number Sequencing Task5 8.73b (3.22) 10.30 (3.01) 10.83 (2.35)

Reading Span Task6 44.50b (11.43) 48.60b (11.81) 58.07 (9.29)

_______________________________________________________________________________

Notes: 1The maximum score on the Pittsburgh Sleep Quality Index = 21, 2standard deviations are in parentheses,
3
the maximum score on the Digit Span Forward Task = 16, 4the maximum score on the Digit Span Backward

Task = 14, 5the maximum score on Letter-Number Sequencing Task = 21, 6the maximum score on the Reading

Span Task = 100, a the mean score is significantly different (p < 0.05) from the mean score of the patient group

with depression, and b the mean score is significantly different (p < 0.05) from the mean score of the healthy

control group.
 26

TABLE 3

The average number of remembered sentence-final words and average sentence reading time

on the five different series of the reading span task for the schizophrenia group, the depression

group, and the healthy control group

_______________________________________________________________________________

Reading Span Task Schizophrenia Depression Healthy Control

Series Group Group Group

_______________________________________________________________________________

RSFW1 Series 1 8.772b (2.96)3 8.87b (3.20) 11.47 (3.03)

RSFW Series 2 8.90b (2.63) 9.50b (2.37) 11.20 (1.67)

RSFW Series 3 8.90b (2.68) 9.90 (2.63) 11.47 (2.53)

RSFW Series 4 8.87b (2.46) 10.33b (2.35) 12.00 (2.30)

RSFW Series 5 8.63b (2.34) 9.87b (2.71) 11.93 (2.38)

ASRT4 Series 1 61795b (515) 5927 (789) 5736 (701)

ASRT Series 2 6121 (663) 5921 (762) 5774 (705)

ASRT Series 3 6164 (568) 5907 (768) 5783 (714)

ASRT Series 4 6116 (582) 5904 (761) 5712 (788)

ASRT Series 5 6085 (631) 5910 (722) 5654 (857)

_______________________________________________________________________________

Notes: 1RSFW = remembered sentence-final words, 2the maximum score per series = 20, 3standard deviations are

in parentheses, 4ASRT = average sentence reading time, 5sentence reading time is in milliseconds, a the mean

score is significantly different (p < 0.05) from the mean score of the patient group with depression, and b the

mean score is significantly different (p < 0.05) from the mean score of the healthy control group.