Clinical ReviewObstructive sleep apnea and depression
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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