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Treatment of Obstructive Sleep Apnea Linked to Short and Long Term Decrease in Symptoms of Depression
| Author: Jonathan R.L. Schwartz, MD |
| Article Date: 2/1/2008 |
Obstructive sleep apnea (OSA) shares many symptoms with depression. 1,2,3 These shared symptoms include daytime sleepiness, fatigue, and reduced motivation.4 In the past, multiple studies have demonstrated that short-term treatment for OSA in the form of continuous positive airway pressure (CPAP) is associated with improvement of symptoms of depression. 1,5 A recent study also reports that long-term CPAP therapy is associated with a significant and sustained decrease in depressive symptoms.5 A growing body of evidence showing links between treatment for OSA and reduction in depressive symptoms suggests that screening for OSA and other sleep disturbances by healthcare professionals should become a standard practice in patients with symptoms and signs of depression.
Overview of OSA
OSA is a serious and under-diagnosed medical condition, characterized by impaired breathing during sleep. Studies indicate that one in five adults suffer from OSA, ranging in severity from mild to severe.6 Approximately 24% of men and 9% of women have OSA, and nearly one-third of men between the ages of 50 and 60 experience some degree of breathing impairment (apnea or hypopnea) during sleep.7 An apnea is defined as a complete obstruction of the upper airway lasting ten seconds or longer and associated with oxygen desaturation, central nervous system(CNS) arousal, or both. A hypopnea is defined as partial obstruction of the upper airway with decreased ventilation lasting ten seconds or longer resulting in oxygen desaturation, CNS arousal, or both. Despite the prevalence of these figures, as many as 80% of those suffering from OSA go undiagnosed.6
Common signs and symptoms of sleep apnea include:
Obesity
Snoring
Excessive daytime sleepiness and fatigue
Neck size of greater 17 in for males, 16 in for females
Morning headaches
Elevated blood pressure
Poor motivation
Memory loss/difficulty concentrating Ð decreased cognitive functioning
Depressive symptoms
Comorbidities: The Associated Health and Safety Risks of OSA
OSA causes a decrease in quality of life through a variety of factors. Undiagnosed OSA can affect an individualÕs work life and their ability to sustain a healthy and active lifestyle. There are also more wide-ranging safety effects. As one example, among individuals who have traffic accidents the prevalence of OSA is significantly higher than average.8
Most alarmingly from a public health perspective, OSA has demonstrated links with other serious health risks. Comorbidities for OSA include heart disease, high blood pressure, diabetes, stroke, and obesity.9 -15 The US National Institutes of Health has listed OSA as an identifiable cause of hypertension, and studies indicate that 35% of all people with high blood pressure also have OSA.12 This number increases to 80% for those taking three or more blood pressure medications.16 OSA is associated with increased mortality among individuals with moderate or severe heart failure, and recent research shows that treating OSA improves cardiac function.17-19 Among stroke victims, 60% also have OSA, and OSA is associated with higher mortality and lower functional outcomes for stroke survivors.15 Approximately 50% of diabetes patients also have OSA, and treatment of OSA has been shown to improve insulin sensitivity and post-prandial glucose.13,20-21 77% of morbidly obese bariatric surgery patients have sleep apnea, and the treatment of sleep apnea may improve the ability to exercise and be more active.14
Depression and OSA
A recent study has added long term evidence to the already-established links between OSA and depression. These researchers found that a large number of patients being referred to the center for evaluation of potential OSA had also been prescribed anti-depressant medicine prior to their referral. The incidence of these types of referrals (39%), combined with the prevalence in those patients of symptoms suggesting the diagnosis of depression, appeared disproportionate to the incidence of depression in the general population.5 This led the researchers to suspect that incidence of OSA might be misdiagnosed as depression, or that conversely the affects of OSA might express themselves in patients as clinical depression.
There is remarkable overlap between the common symptoms of OSA and clinical depression, to the point that a real difficulty appears for doctors in isolating which of the two conditions any given patient might have. Patients with OSA report symptoms including sleepiness and fatigue, irritability, and difficulty concentrating and with memory, all of which are common symptoms of depression.1,2,3,4,5 Furthermore, all of these symptoms have been associated as well with a tendency toward social withdrawal and potential loss of enjoyment in work and other activities for OSA patients.22 Whereas the particular cause of the symptoms may be difficult to determine, the association of the symptoms with both conditions suggests the necessity that OSA should be considered as a factor affecting both the expression and diagnosis (or mis-diagnosis) of clinical depression.
The mitigation of depression symptoms in OSA by sustained CPAP therapy
Past studies by this group, as well as by other researchers, have indicated that CPAP therapy has led to the improvement of some symptoms of depression in patients during a short-term period (4-12 weeks).1,5
In a more recent study, however, patients diagnosed with OSA who also exhibited symptoms of depression were placed on consistent CPAP therapy and evaluated after the short (4-6 weeks) and long term (one year or longer). The results of the study show that both in the short and long term CPAP treatment in OSA patients was associated with a statistically significant improvement in the Beck Depression Inventory(BDI), which is a validated measure of symptoms of depression. The BDI is a tool that asks 7 questions pertaining to feelings of sadness, pessimism, personal failures, decreases in self-confidence and increases in self-criticism, the ability to derive pleasure from things, and suicidal ideation. Notably, it does not ask any questions about fatigue, tiredness, or sleepiness, the symptoms traditionally associated with OSA. The BDI is ranked on a scale of 1-21 (3 points per question), with a score of ten or above indicating severe symptoms of depression.
In this study, patients with sleep apnea who also exhibited symptoms of depression were administered the BDI before beginning CPAP therapy. After 4-6 weeks of CPAP therapy, those who had registered some level of depression on the BDI were re-evaluated. The BDI score was found to have fallen an average of 4.9 points. When patients were re-evaluated again after a year, the reduction in BDI persisted from the 4-6 week evaluation. The improvement shown in the first six weeks was sustained through the entire year for those patients who maintained consistent use of the CPAP.
This evidence showing a significant and persistent improvement in depressive symptoms supports screening for sleep apnea and other sleep disorders as a standard practice in patients exhibiting symptoms and signs of depression. In addition, due to the significant comorbidities and quality of life issues associated with untreated OSA, health care professionals should ask all patients about their sleep and wakefulness.
Screening for Sleep Apnea and Making a Referral
A number of simple screening methods exist which doctors can easily incorporate into standard practice. These begin with simple questionnaires such as the Epworth Sleepiness Scale (ESS) or the Berlin Questionnaire, and can also include the use of portable screening devices. Some clinics have also found that sleep-screening questions can be added to patient history questionnaires as a routine form of screening before the patient even sees the physician. If the patient is suspected of having OSA, the next step is to refer the patient to a sleep disorders center for further evaluation and an overnight sleep study called polysomnography (PSG).
For patients who are diagnosed with OSA at the sleep disorders center, a variety of treatment options exist depending upon the severity of the OSA. Nasal continuous positive airway pressure(CPAP) is the gold standard of treatment for most patients with OSA, and a number of devices and masks are available that allow customized therapy for the individual needs of the patient. Proper instruction and mask-fitting, as well as short and long-term follow-up are essential to maintain compliance with CPAP therapy. Treatment of coexisting rhinitis can also improve CPAP compliance. Weight reduction in overweight patients should be encouraged.
Conclusion
The overlap of symptoms of both OSA and depression presents challenges in isolating the condition responsible for the symptoms, and all patients with depressive symptoms should be screened for OSA and other sleep disorders. CPAP therapy has been shown to result in sustained improvement in depressive symptoms. As OSA is frequently undiagnosed and is associated with multiple comorbidities, screening for sleep disorders should become a standard part of every health care professionalÕs practice. Treatment of OSA has been shown to improve quality of life and is cost-effective, with CPAP therapy resulting in a reduction in healthcare utilization and costs.
References
1. Schwartz DJ et al Chest 2005
2. Chervin RD. Chest 2000
3. Peppard, PE et al. Arch Intern Med 2006
4. Gonsalves MA et al. Chest 2004
5. Schwartz DJ et al JCSM 2007
6. Young et al. Amer Jrn Resp Crit Care 2002.
7. Young et al. NEJM 1993
8. Teran-Santos J et al. NEJM 1999
9.Javaheri et al. Circulation 1999
10. Schafer et al. Cardiology 1999
11. Somers et al. Circulation 2004
12. Sjostrom et al. Thorax 2002
13. Einhorn et al. Endocrine Prac 2007
14. OÕKeeffe & Patterson. Obes Surgery 2004
15. Yaggi. NEJM 2005
16. Logan et al. J Hypertension 2001
17. Kaneko et al. NEJM 2003
18. Maisel et al. UCSD VA Hospital Ð Case Study 2002
19. Teschler et al. AJRCCM 2001
20. Harsch et al. Am J ResP Crit Care Med 2004
21. Babu et al. Arch Intern Med 2005
22. Vandeputte, M, et al Sleep Med 2003
Overview of OSA
OSA is a serious and under-diagnosed medical condition, characterized by impaired breathing during sleep. Studies indicate that one in five adults suffer from OSA, ranging in severity from mild to severe.6 Approximately 24% of men and 9% of women have OSA, and nearly one-third of men between the ages of 50 and 60 experience some degree of breathing impairment (apnea or hypopnea) during sleep.7 An apnea is defined as a complete obstruction of the upper airway lasting ten seconds or longer and associated with oxygen desaturation, central nervous system(CNS) arousal, or both. A hypopnea is defined as partial obstruction of the upper airway with decreased ventilation lasting ten seconds or longer resulting in oxygen desaturation, CNS arousal, or both. Despite the prevalence of these figures, as many as 80% of those suffering from OSA go undiagnosed.6
Common signs and symptoms of sleep apnea include:
Obesity
Snoring
Excessive daytime sleepiness and fatigue
Neck size of greater 17 in for males, 16 in for females
Morning headaches
Elevated blood pressure
Poor motivation
Memory loss/difficulty concentrating Ð decreased cognitive functioning
Depressive symptoms
Comorbidities: The Associated Health and Safety Risks of OSA
OSA causes a decrease in quality of life through a variety of factors. Undiagnosed OSA can affect an individualÕs work life and their ability to sustain a healthy and active lifestyle. There are also more wide-ranging safety effects. As one example, among individuals who have traffic accidents the prevalence of OSA is significantly higher than average.8
Most alarmingly from a public health perspective, OSA has demonstrated links with other serious health risks. Comorbidities for OSA include heart disease, high blood pressure, diabetes, stroke, and obesity.9 -15 The US National Institutes of Health has listed OSA as an identifiable cause of hypertension, and studies indicate that 35% of all people with high blood pressure also have OSA.12 This number increases to 80% for those taking three or more blood pressure medications.16 OSA is associated with increased mortality among individuals with moderate or severe heart failure, and recent research shows that treating OSA improves cardiac function.17-19 Among stroke victims, 60% also have OSA, and OSA is associated with higher mortality and lower functional outcomes for stroke survivors.15 Approximately 50% of diabetes patients also have OSA, and treatment of OSA has been shown to improve insulin sensitivity and post-prandial glucose.13,20-21 77% of morbidly obese bariatric surgery patients have sleep apnea, and the treatment of sleep apnea may improve the ability to exercise and be more active.14
Depression and OSA
A recent study has added long term evidence to the already-established links between OSA and depression. These researchers found that a large number of patients being referred to the center for evaluation of potential OSA had also been prescribed anti-depressant medicine prior to their referral. The incidence of these types of referrals (39%), combined with the prevalence in those patients of symptoms suggesting the diagnosis of depression, appeared disproportionate to the incidence of depression in the general population.5 This led the researchers to suspect that incidence of OSA might be misdiagnosed as depression, or that conversely the affects of OSA might express themselves in patients as clinical depression.
There is remarkable overlap between the common symptoms of OSA and clinical depression, to the point that a real difficulty appears for doctors in isolating which of the two conditions any given patient might have. Patients with OSA report symptoms including sleepiness and fatigue, irritability, and difficulty concentrating and with memory, all of which are common symptoms of depression.1,2,3,4,5 Furthermore, all of these symptoms have been associated as well with a tendency toward social withdrawal and potential loss of enjoyment in work and other activities for OSA patients.22 Whereas the particular cause of the symptoms may be difficult to determine, the association of the symptoms with both conditions suggests the necessity that OSA should be considered as a factor affecting both the expression and diagnosis (or mis-diagnosis) of clinical depression.
The mitigation of depression symptoms in OSA by sustained CPAP therapy
Past studies by this group, as well as by other researchers, have indicated that CPAP therapy has led to the improvement of some symptoms of depression in patients during a short-term period (4-12 weeks).1,5
In a more recent study, however, patients diagnosed with OSA who also exhibited symptoms of depression were placed on consistent CPAP therapy and evaluated after the short (4-6 weeks) and long term (one year or longer). The results of the study show that both in the short and long term CPAP treatment in OSA patients was associated with a statistically significant improvement in the Beck Depression Inventory(BDI), which is a validated measure of symptoms of depression. The BDI is a tool that asks 7 questions pertaining to feelings of sadness, pessimism, personal failures, decreases in self-confidence and increases in self-criticism, the ability to derive pleasure from things, and suicidal ideation. Notably, it does not ask any questions about fatigue, tiredness, or sleepiness, the symptoms traditionally associated with OSA. The BDI is ranked on a scale of 1-21 (3 points per question), with a score of ten or above indicating severe symptoms of depression.
In this study, patients with sleep apnea who also exhibited symptoms of depression were administered the BDI before beginning CPAP therapy. After 4-6 weeks of CPAP therapy, those who had registered some level of depression on the BDI were re-evaluated. The BDI score was found to have fallen an average of 4.9 points. When patients were re-evaluated again after a year, the reduction in BDI persisted from the 4-6 week evaluation. The improvement shown in the first six weeks was sustained through the entire year for those patients who maintained consistent use of the CPAP.
This evidence showing a significant and persistent improvement in depressive symptoms supports screening for sleep apnea and other sleep disorders as a standard practice in patients exhibiting symptoms and signs of depression. In addition, due to the significant comorbidities and quality of life issues associated with untreated OSA, health care professionals should ask all patients about their sleep and wakefulness.
Screening for Sleep Apnea and Making a Referral
A number of simple screening methods exist which doctors can easily incorporate into standard practice. These begin with simple questionnaires such as the Epworth Sleepiness Scale (ESS) or the Berlin Questionnaire, and can also include the use of portable screening devices. Some clinics have also found that sleep-screening questions can be added to patient history questionnaires as a routine form of screening before the patient even sees the physician. If the patient is suspected of having OSA, the next step is to refer the patient to a sleep disorders center for further evaluation and an overnight sleep study called polysomnography (PSG).
For patients who are diagnosed with OSA at the sleep disorders center, a variety of treatment options exist depending upon the severity of the OSA. Nasal continuous positive airway pressure(CPAP) is the gold standard of treatment for most patients with OSA, and a number of devices and masks are available that allow customized therapy for the individual needs of the patient. Proper instruction and mask-fitting, as well as short and long-term follow-up are essential to maintain compliance with CPAP therapy. Treatment of coexisting rhinitis can also improve CPAP compliance. Weight reduction in overweight patients should be encouraged.
Conclusion
The overlap of symptoms of both OSA and depression presents challenges in isolating the condition responsible for the symptoms, and all patients with depressive symptoms should be screened for OSA and other sleep disorders. CPAP therapy has been shown to result in sustained improvement in depressive symptoms. As OSA is frequently undiagnosed and is associated with multiple comorbidities, screening for sleep disorders should become a standard part of every health care professionalÕs practice. Treatment of OSA has been shown to improve quality of life and is cost-effective, with CPAP therapy resulting in a reduction in healthcare utilization and costs.
References
1. Schwartz DJ et al Chest 2005
2. Chervin RD. Chest 2000
3. Peppard, PE et al. Arch Intern Med 2006
4. Gonsalves MA et al. Chest 2004
5. Schwartz DJ et al JCSM 2007
6. Young et al. Amer Jrn Resp Crit Care 2002.
7. Young et al. NEJM 1993
8. Teran-Santos J et al. NEJM 1999
9.Javaheri et al. Circulation 1999
10. Schafer et al. Cardiology 1999
11. Somers et al. Circulation 2004
12. Sjostrom et al. Thorax 2002
13. Einhorn et al. Endocrine Prac 2007
14. OÕKeeffe & Patterson. Obes Surgery 2004
15. Yaggi. NEJM 2005
16. Logan et al. J Hypertension 2001
17. Kaneko et al. NEJM 2003
18. Maisel et al. UCSD VA Hospital Ð Case Study 2002
19. Teschler et al. AJRCCM 2001
20. Harsch et al. Am J ResP Crit Care Med 2004
21. Babu et al. Arch Intern Med 2005
22. Vandeputte, M, et al Sleep Med 2003