Elsevier

Sleep Medicine Reviews

Volume 13, Issue 6, December 2009, Pages 437-444
Sleep Medicine Reviews

Clinical Review
Obstructive sleep apnea and depression

https://doi.org/10.1016/j.smrv.2009.04.001Get rights and content

Summary

There are high rates of depression in people with obstructive sleep apnea (OSA) in both community and clinical populations. A large community study reported a rate of 17% and reports for sleep clinic samples range between 21% and 41%. A large cohort study found OSA to be a risk factor for depression, but we are unaware of any longitudinal study of the reverse association. However correlations have not generally been found in smaller studies. Well-designed longitudinal studies are needed to examine temporal relationships between the two conditions and further research is needed to establish the role of confounders, and effect modifiers such as gender, in any apparent relationship. Symptoms common to OSA and depression, such as sleepiness and fatigue, are obstacles to determining the presence and severity of one condition in the presence of the other, in research and clinically. Sleep clinicians are advised to consider depression as a likely cause of sleepiness and fatigue. Several possible causal mechanisms linking OSA and depression have been proposed but not established. Patients who have depression as well as OSA appear worse off than those with OSA only, and depressive symptoms persist in at least some patients in short term studies of treatment for OSA. Direct treatment of depression in OSA might improve acceptance of therapy, reduce sleepiness and fatigue and improve quality of life, but intervention trials are required to answer this question.

Introduction

Obstructive sleep apnea (OSA) is a common disease, characterised by repetitive upper airway obstruction during sleep and associated with increased morbidity and mortality and diminished quality of life. Depression, a major cause of disease burden and a cardiovascular risk factor, appears to be prevalent in OSA and it has been proposed that depression may be caused by OSA pathology or its symptoms. Existing literature on the prevalence, cause and treatment of depression in OSA is copious but fragmented, making it difficult to assess research to date on the underlying relationship between the two conditions and the impact of treatments in patients with both conditions. This paper therefore reviews the prevalence of depression in OSA, evidence for causal links, possible causal mechanisms, and the impact of OSA and depression therapies. It then highlights practice points and research needed, shown by the review.

Section snippets

Methodological issues

Several methodological issues need to be taken into account in reviewing this field. These include definitions of depression in the OSA-depression literature, how depression is measured, possible confounders to be considered when assessing prevalence and correlational studies, and referral and reporting biases.

Population and community prevalence

There are few reports of purpose-designed studies to determine the prevalence of depression comorbid with OSA in general or primary care populations. A population survey sampling 18,980 adults from 5 European countries used the “Sleep-EVAL” expert system in telephone interviews to identify sleep and depressive disorders.23 This system has not been extensively validated as a screen for depression but is based on Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, criteria.23 Among the

Correlational studies

While depression or depressive symptoms are prevalent in OSA populations, they may stem from factors other than OSA. A direct link between OSA and depression would be further supported by evidence of dose–response and temporal relationships, with possible confounding factors investigated.

Impact of OSA therapies on depression

If there is a direct causative link between OSA and the onset of depression, then depression would be expected to improve with successful treatment of OSA. While improvements in depression scores have been reported in some6, 48, 49, 50 but not all51 studies without placebo arms, the weakness of such uncontrolled designs has been highlighted by reports of a large placebo effect for depression scores both generally52 and in OSA.53, 54 A recent Cochrane meta-analysis covered randomised controlled

The impact of depression on OSA

Comorbid depression has been found to impact adversely on self-management, treatment adherence and functioning and to increase symptom perception and health care cost in other chronic medical illnesses.38, 62 Though there has been little research on the impact of depression in OSA, patients who have depression as well as OSA also appear worse off than their counterparts with OSA only. OSA patients with high levels of depression are those with most daytime sleepiness,18 fatigue, 16 and lowest

Possible basic mechanisms

If the observation from one longitudinal study is repeated, showing OSA to be a risk factor for the onset of depression, basic mechanisms will be of interest. Existing data suggests some potential pathophysiological links.

Discussion

Despite a plethora of studies we still have no clear view of the role of OSA in the causation of depression. Neither do we know whether successful treatment of OSA also improves depressive illness. Depression has not been a primary outcome in trials to date but these trials are now needed, and would focus on subjects with clinical levels of depression with outcomes including validated measures of depression and measures of excessive daytime sleepiness. Markers of individual differences likely

Acknowledgements

The authors thank an anonymous reviewer for improvements to this paper including suggestions on the flow of argument and suggestions to include referral bias, physical exercise as a possible confounder, and arguments against hypertension as a confounder.

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      Finally, in this study, those with sleep apnea had less severe depression, including fewer problems with motivation and lack of energy, which may facilitate treatment. However, this is a unique finding (Harris et al., 2009) that is perhaps due to the nature of the sample (e.g., those without sleep apnea may have been psychiatric referrals and thus had higher levels of depression symptoms). In terms of clinical implications, those seeking CBT-I with depression, anxiety, severe poor sleep quality, and delayed bedtimes may be most at risk for dropout.

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