Sleep and Breathing

, Volume 7, Issue 1, pp 31–42 | Cite as

Changes in Depressive Symptoms after Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea

  • Melanie K. Means
  • Kenneth L. Lichstein
  • Jack D. Edinger
  • Daniel J. Taylor
  • H. Heith Durrence
  • Aatif M. Husain
  • R. Neal Aguillard
  • Rodney A. Radtke
Original Article


It is generally believed that obstructive sleep apnea (OSA) causes depression in some patients, yet it is unknown whether this depression is an actual clinical phenomenon or purely a result of overlapping somatic/physical symptoms shared by both disorders. The present study investigated changes in both somatic and affective/cognitive symptoms of depression associated with the introduction of continuous positive airway pressure (CPAP) treatment for OSA. Participants were 39 outpatients (35 males, 4 females) with no current or past mental health problems, diagnosed with OSA in a hospital sleep disorders clinic. The Beck Depression Inventory (BDI) was administered prior to treatment and again 3 months after CPAP. Total BDI scores improved after CPAP, independent of objectively monitored CPAP compliance rates. Both somatic and affective/ cognitive symptoms of depression improved in a similar manner after treatment. Our findings suggest that depressive symptoms experienced by OSA patients are not solely the result of physical OSA symptoms but include a mood component as well. We introduce a hypothetical model to conceptualize the relationship between OSA and depression.


Sleep apnea depression CPAP 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bassiri AG, Guilleminault C. Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome. In: Dement WC, ed. Principles and Practice of Sleep Medicine 3rd ed. Philadelphia: WB Saunders 2000:869–878Google Scholar
  2. 2.
    Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. New Engl J Med 1993;328:1230–1235Google Scholar
  3. 3.
    Day R, Gerhardstein R, Lumley A, Roth T, Rosenthal L. The behavioral morbidity of obstructive sleep apnea. Prog Cardiovasc Dis 1999;41:341–354Google Scholar
  4. 4.
    Baldwin CM, Griffith KA, Nieto FJ, et al. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep 2001;24:96–105Google Scholar
  5. 5.
    Engleman HM, Kingshott RN, Wraith PK, et al. Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 1999;159:461–467Google Scholar
  6. 6.
    Aikens JE, Caruana-Montaldo B, Vanable PA, Tadimeti L, MendelsonWB. Depression and general psychopathology in obstructive sleep apnea. Sleep 1998;21:71–71Google Scholar
  7. 7.
    Millman RP, Fogel BS, McNamara ME, Carlisle CC. Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry 1989;50:348–351Google Scholar
  8. 8.
    Mosko S, Zetin M, Glen S, et al. Self-reported depressive symptomatology, mood ratings, and treatment outcome in sleep disorders patients. J Clin Psychol 1989;45:51–60Google Scholar
  9. 9.
    Nambu Y, Nagasaka Y, Fujita E, Hamada S, Fukuoka M. Effect of mandibular advancement splint on psycho-intellectual derangements in patients with sleep apnea syndrome. Tohoku J Exp Med 1999;188:119–132Google Scholar
  10. 10.
    Reynolds 3rdCF, Kupfer DJ, McEachran AB, et al. Depressive psychopathology in male sleep apneics. J Clin Psychiatry 1984;45:287–290Google Scholar
  11. 11.
    Yamamoto H, Akashiba T, Kosaka N, Ito D, Horie T. Long-term effects of nasal continuous positive airway pressure on daytime sleepiness, mood and traffic accidents in patients with obstructive sleep apnoea. Respir Med 2000;94:87–90Google Scholar
  12. 12.
    Cheshire K, Engleman H, Deary I, Shapiro C, DouglasNJ. Factors impairing daytime performance in patients with sleep apnea/hypopnea syndrome. Arch Intern Med 1992;152:538–541Google Scholar
  13. 13.
    Kales A, CaldwellAB, Cadieux RJ, et al. Severe obstructive sleep apnea—II: associated psychopathology and psychosocial consequences. J Chronic Dis 1985;38:427–434Google Scholar
  14. 14.
    Meslier N, Lebrun T, Grillier-Lanoir V, et al. A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life. Eur Respir J 1998;12:185–192Google Scholar
  15. 15.
    Bliwise DL, Yesavage JA, Sink J, Widrow L, DementWC. Depressive symptoms and impaired respiration in sleep. J Consult Clin Psychol 1986;54:734–735Google Scholar
  16. 16.
    Sink J, BliwiseDL, Dement WC. Self-reported excessive daytime somnolence and impaired respiration in sleep. Chest 1986;90:177–180Google Scholar
  17. 17.
    Gall R, Isaac L, Kryger M. Quality of life in mild obstructive sleep apnea. Sleep 1993;16:S59–61Google Scholar
  18. 18.
    Pillar G, Lavie P. Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index. Chest 1998;114:697–703Google Scholar
  19. 19.
    Maczaj M, Kapuria S, Pieczalski M, et al. Use of the SCID as an objective measure for evaluating the prevalence of depression in patients with OSAS. Sleep 2000;23:A365–A365Google Scholar
  20. 20.
    Dahlof P, Ejnell H, Hallstrom T, Hedner J. Surgical treatment of the sleep apnea syndrome reduces associated major depression. Int J Behav Med 2000;7:73–88Google Scholar
  21. 21.
    Borak J, Cieslicki J, Szelenberger W, et al. Psychopathological characteristics of the consequences of obstructive sleep apnea prior to and three months after CPAP. Psychiatria Polska 1994;28:33–44Google Scholar
  22. 22.
    Charbonneau M, Tousignant P, LampingDL, et al. The effects of nasal continuous positive airway pressure (nCPAP) on sleepiness and psychological functioning in obstructive sleep apnea (OSA). Am Rev Respir Dis 1992;145:A168–A168Google Scholar
  23. 23.
    Derderian SS, Bridenbaugh RH, Rajagopal KR. Neuropsychologic symptoms in obstructive sleep apnea improve after treatment with nasal continuous positive airway pressure. Chest 1988;94:1023–1027Google Scholar
  24. 24.
    Douglas NJ, Engleman HM. Effects of CPAP on vigilance and related functions in patients with the sleep apnea/ hypopnea syndrome. Sleep 2000;23:S147–149Google Scholar
  25. 25.
    Mayleben DW, Scharf MB, Sachais BA. Change in MMPI factors in patients undergoing prolonged CPAP treatment for obstructive sleep apnea. Sleep Res 1990;19:252–252Google Scholar
  26. 26.
    Engleman HM, Cheshire KE, Deary IJ, Douglas NJ. Daytime sleepiness, cognitive performance and mood after continuous positive airway pressure for the sleep apnoea/ hypopnoea syndrome. Thorax 1993;48:911–914Google Scholar
  27. 27.
    Ramos-Platon MJ, Sierra JE. Changes in psychopathological symptoms in sleep apnea patients after treatment with nasal continuous positive airway pressure. Int J Neurosci 1992;62:173–195Google Scholar
  28. 28.
    Engleman HM, Martin SE, Deary IJ, Douglas NJ. Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome. Thorax 1997;52:114–119Google Scholar
  29. 29.
    Engleman HM, Martin SE, Deary IJ, Douglas NJ. Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome. Lancet 1994;343:572–575Google Scholar
  30. 30.
    Kingshott RN, Vennelle M, HoyCJ, et al. Predictors of improvements in daytime function outcomes with CPAP therapy. Am J Respir Crit Care Med 2000;161:866–871Google Scholar
  31. 31.
    Borak J, Cieslicki JK, KoziejM, Matuszewski A, Zielinski J. Effects of CPAP treatment on psychological status in patients with severe obstructive sleep apnoea. J Sleep Res 1996;5:123–127Google Scholar
  32. 32.
    Engleman HM, Martin SE, Kingshott RN, et al. Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome. Thorax 1998;53:341–345Google Scholar
  33. 33.
    Munoz A, Mayoralas LR, Barbe F, Pericas J, AgustiAG. Long-term effects of CPAP on daytime functioning in patients with sleep apnoea syndrome. Eur Respir J 2000;15:676–681Google Scholar
  34. 34.
    Wright J, White J. Continuous positive airways pressure for obstructive sleep apnea (Cochrane Review). In: The Cochrane Library, Issue 1, Oxford; Update SoftwareGoogle Scholar
  35. 35.
    Kaplan R. Obstructive sleep apnoea and depression—diagnostic and treatment implications. Aust N Z J Psychiatry 1992;26:586–591Google Scholar
  36. 36.
    Lee S. Depression in sleep apnea: a different view. J Clin Psychiatry 1990;51:309–310Google Scholar
  37. 37.
    Lee S, WingYK, Chen CN. Obstructive sleep apnoea and depression. Aust N Z J Psychiatry 1993;27:162–166Google Scholar
  38. 38.
    Cavanaugh SV. Diagnosing depression in the hospitalized patient with chronic medical illness. J Clin Psychiatry 1984;45:13–17Google Scholar
  39. 39.
    Koenig HG, Cohen HJ, Blazer DG, Krishnan KR, Sibert TE. Profile of depressive symptoms in younger and older medical inpatients with major depression. J Am Geriatr Soc 1993;41:1169–1176Google Scholar
  40. 40.
    Aikens JE, Mendelson WB. A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea. Sleep 1999;22:355–359Google Scholar
  41. 41.
    Bardwell WA, Moore P, Ancoli-Israel S, DimsdaleJE. Does obstructive sleep apnea confound sleep architecture findings in subjects with depressive symptoms?. Biol Psychiatry 2000;48:1001–1009Google Scholar
  42. 42.
    Berry DTR, Phillips BA, Cook YR, et al. Geriatric sleep apnea syndrome: a preliminary description. J Gerontol 1990;45:M169–M174Google Scholar
  43. 43.
    Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford Press; 1979Google Scholar
  44. 44.
    Tanaka JS, Huba GJ. Confirmatory hierarchical factor analyses of psychological distress measures. J Pers Soc Psychol 1984;46:621–635Google Scholar
  45. 45.
    Neimeyer RA, Baker KD, Haykal RF, Akiskal HS. Patterns of symptomatic change in depressed patients in a private inpatient mood disorders program. Bull Menninger Clin 1995;59:460–471Google Scholar
  46. 46.
    Barbe F, Pericas J, Munoz A, et al. Automobile accidents in patients with sleep apnea syndrome. An epidemiological and mechanistic study. Am J Respir Crit Care Med 1998;158:18–22Google Scholar
  47. 47.
    Barnes M, McEvoyRD, Pierce RJ. Neurobehavioural impairment in mild sleep apnea patients compared to control subjects. Sleep 2001;24:A276–A276Google Scholar
  48. 48.
    Yang CK, Clerk A, ShinHR. Depression, perceived stress, and coping strategies of patients with sleep-related breathing disorder. Sleep 1998;21:74–74Google Scholar
  49. 49.
    Watson R, Greenberg G, Bakos L. Sleep apnea and depression. Sleep Res 1987;16:293–293Google Scholar
  50. 50.
    McCullogh PA. Obstructive Sleep Apnea: Does Level of Severity Correlate with Level of Depression?[master’s thesis]. Louisville, KY: University of Louisville; 1997Google Scholar
  51. 51.
    Klonoff H, Fleetham J, Taylor DR, ClarkC. Treatment outcome of obstructive sleep apnea. Physiological and neuropsychological concomitants. J Nerv Ment Dis 1987;175:208–212Google Scholar
  52. 52.
    Rechtschaffen A, Kales A, eds. A Manual of Standardized Terminology, Techniques, and Scoring System for Sleep Stages of Human Subjects. Los Angeles: Brain Information Service/Brain Research Inst, University of California; 1968Google Scholar
  53. 53.
    Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100CrossRefGoogle Scholar
  54. 54.
    Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory. A review. Psychopathology 1998;31:160–168CrossRefPubMedGoogle Scholar
  55. 55.
    Katz R, Katz J, ShawBF. Beck Depression Inventory and hopelessness scale. In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Hillsdale, NJ: Lawrence Erlbaum; 1994:279–291Google Scholar
  56. 56.
    Krieger J, Kurtz D, Petiau C, Sforza E, Trautmann D. Long-term compliance with CPAP therapy in obstructive sleep apnea patients and in snorers. Sleep 1996;19:S136–143Google Scholar
  57. 57.
    American Academy of Sleep Medicine. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine Task Force. Sleep 1999;22:667–689Google Scholar
  58. 58.
    National Heart Lung and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: National Institutes of Health. 1998:xi–xxxxGoogle Scholar
  59. 59.
    Herdegen JJ, Clark LJ, Stepanski EJ, et al. Treating sleep-disordered breathing: a longitudinal analysis of patient characteristics and positive airway pressure compliance. Sleep 2000;23:A82–A82Google Scholar
  60. 60.
    Rosenthal L, Gerhardstein R, Lumley A, et al. CPAP therapy in patients with mild OSA: implementation and treatment outcome. Sleep Med 2000;1:215–220Google Scholar
  61. 61.
    Barbe F, Mayoralas LR, DuranJ, et al. Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. A randomized, controlled trial. Ann Intern Med 2001;134:1015–1023Google Scholar
  62. 62.
    Engleman HM, Martin SE, Douglas NJ. Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. Thorax 1994;49:263–266Google Scholar
  63. 63.
    Reeves-Hoche MK, Meck R, ZwillichCW. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med 1994;149:149–154Google Scholar
  64. 64.
    Weaver TE, Kribbs NB, Pack AI, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep 1997;20:278–283Google Scholar
  65. 65.
    Greenham-Conway B, Michalow B, Potaski C, Mouton A. Subjective changes in mood and daytime sleepiness in apnea patients treated with nasal CPAP. Sleep 2000;23:A80–81Google Scholar
  66. 66.
    Hers V, Liistro G, Dury M, et al. Residual effect of nCPAP applied for part of the night in patients with obstructive sleep apnoea. Eur Respir J 1997;10:973–976Google Scholar
  67. 67.
    Yu BH, Ancoli-Israel S, DimsdaleJE. Effect of CPAP treatment on mood states in patients with sleep apnea. J Psychiatr Res 1999;33:427–432Google Scholar

Copyright information

© Thieme Medical Publishers, Inc. 2003

Authors and Affiliations

  • Melanie K. Means
    • 1
    • 6
  • Kenneth L. Lichstein
    • 2
  • Jack D. Edinger
    • 1
    • 3
  • Daniel J. Taylor
    • 4
  • H. Heith Durrence
    • 2
  • Aatif M. Husain
    • 1
    • 3
  • R. Neal Aguillard
    • 5
  • Rodney A. Radtke
    • 3
  1. 1.Department of Veterans Affairs Medical CenterDurham
  2. 2.The University of MemphisMemphis
  3. 3.Duke University Medical CenterDurham
  4. 4.Brown Medical SchoolProvidence
  5. 5.Methodist University HospitalMemphis
  6. 6.Psychology Service 116B, Department of Veterans Affairs Medical CenterDurham

Personalised recommendations