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Sleep and Breathing

, Volume 20, Issue 2, pp 447–456 | Cite as

Comorbid depression in obstructive sleep apnea: an under-recognized association

  • Ahmed S. BaHammamEmail author
  • Tetyana Kendzerska
  • Ravi Gupta
  • Chellamuthu Ramasubramanian
  • David N. Neubauer
  • Meera Narasimhan
  • Seithikurippu R. Pandi-Perumal
  • Adam Moscovitch
Review

Abstract

Background

Obstructive sleep apnea (OSA) and depression may coexist in the same patient. This article aims to review the link between OSA and comorbid depression and critically evaluate the results of studies that assessed the correlation between OSA and depression, the impact of OSA treatment on comorbid depression, and the impact of comorbid depression on continuous positive airway pressure (CPAP) adherence.

Methods

An integrative review was conducted on English language studies and reports that assessed the relationship between OSA and depression. Studies were identified by searching PubMed, Web of Science and Google Scholar databases, and reference lists of included studies.

Results

Generally, cross-sectional studies show a higher prevalence of depression among OSA patients with both community and sleep disorder clinic samples. Nevertheless, the relationship between OSA and depression is complicated by the fact that the disorders have overlapping symptoms. Longitudinal studies demonstrate an increased risk of developing depression among people with OSA, as well as an association between OSA severity and the likelihood of developing depression. On the other hand, studies assessing the impact of CPAP therapy on depression among OSA patients report conflicting results. Therefore, it is essential to consider how the disorders affect one another and to understand the clinical consequences of treating each disorder in isolation.

Conclusion

Depression is prevalent among patients with OSA both in the community and in sleep disorder clinics. Clinicians in general should be aware of this significant association and should aim to treat both disorders.

Keywords

Depression Obstructive sleep apnea CPAP 

Notes

Acknowledgments

This work was supported by a grant from the Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia

Conflict of interest

The authors declare that they have no competing interests.

References

  1. 1.
    American Psychiatric Association (DSM-5) (2013) Diagnostic and statistical manual of mental disorders, 5th edn. Washington, DCGoogle Scholar
  2. 2.
    Ye L, Pien GW, Ratcliffe SJ, Bjornsdottir E, Arnardottir ES, Pack AI, Benediktsdottir B, Gislason T (2014) The different clinical faces of obstructive sleep apnoea: a cluster analysis. Eur Respir J. doi: 10.1183/09031936.00032314 Google Scholar
  3. 3.
    Gagnon K, Baril AA, Gagnon JF, Fortin M, Decary A, Lafond C, Desautels A, Montplaisir J, Gosselin N (2014) Cognitive impairment in obstructive sleep apnea. Pathol Biol (Paris) 62(5):233–240. doi: 10.1016/j.patbio.2014.05.015 CrossRefGoogle Scholar
  4. 4.
    Harris M, Glozier N, Ratnavadivel R, Grunstein RR (2009) Obstructive sleep apnea and depression. Sleep Med Rev 13(6):437–444. doi: 10.1016/j.smrv.2009.04.001 PubMedCrossRefGoogle Scholar
  5. 5.
    Aloia MS, Arnedt JT, Smith L, Skrekas J, Stanchina M, Millman RP (2005) Examining the construct of depression in obstructive sleep apnea syndrome. Sleep Med 6(2):115–121. doi: 10.1016/j.sleep.2004.09.003 PubMedCrossRefGoogle Scholar
  6. 6.
    Farney RJ, Lugo A, Jensen RL, Walker JM, Cloward TV (2004) Simultaneous use of antidepressant and antihypertensive medications increases likelihood of diagnosis of obstructive sleep apnea syndrome. Chest 125(4):1279–1285PubMedCrossRefGoogle Scholar
  7. 7.
    Peppard PE, Szklo-Coxe M, Hla KM, Young T (2006) Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med 166(16):1709–1715. doi: 10.1001/archinte.166.16.1709 PubMedCrossRefGoogle Scholar
  8. 8.
    Chen HL, Lu CH, Lin HC, Chen PC, Chou KH, Lin WM, Tsai NW, Su YJ, Friedman M, Lin CP, Lin WC (2015) White matter damage and systemic inflammation in obstructive sleep apnea. Sleep 38(3):361–370Google Scholar
  9. 9.
    Berk M, Williams LJ, Jacka FN, O’Neil A, Pasco JA, Moylan S, Allen NB, Stuart AL, Hayley AC, Byrne ML, Maes M (2013) So depression is an inflammatory disease, but where does the inflammation come from? BMC Med 11:200. doi: 10.1186/1741-7015-11-200 PubMedPubMedCentralGoogle Scholar
  10. 10.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571PubMedCrossRefGoogle Scholar
  11. 11.
    Weissman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke BZ (1977) Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol 106(3):203–214PubMedGoogle Scholar
  12. 12.
    Gough HG (1946) Diagnostic patterns on the Minnesota Multiphasic Personality Inventory. J Clin Psychol 2:23–37PubMedCrossRefGoogle Scholar
  13. 13.
    Chandarana PC, Eals M, Steingart AB, Bellamy N, Allen S (1987) The detection of psychiatric morbidity and associated factors in patients with rheumatoid arthritis. Can J Psychiatry 32(5):356–361PubMedGoogle Scholar
  14. 14.
    Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Derogatis LR, Lipman RS, Covi L (1973) SCL-90: an outpatient psychiatric rating scale—preliminary report. Psychopharmacol Bull 9(1):13–28PubMedGoogle Scholar
  16. 16.
    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20):22–33, quiz 34–57 PubMedGoogle Scholar
  17. 17.
    Zung WW (1965) A Self-Rating Depression Scale. Arch Gen Psychiatry 12:63–70PubMedCrossRefGoogle Scholar
  18. 18.
    Ohayon MM (2003) The effects of breathing-related sleep disorders on mood disturbances in the general population. J Clin Psychiatry 64(10):1195–1200, quiz, 1274–1196 PubMedCrossRefGoogle Scholar
  19. 19.
    Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M (2005) Association of psychiatric disorders and sleep apnea in a large cohort. Sleep 28(11):1405–1411PubMedGoogle Scholar
  20. 20.
    Wheaton AG, Perry GS, Chapman DP, Croft JB (2012) Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005–2008. Sleep 35(4):461–467. doi: 10.5665/sleep.1724 PubMedPubMedCentralGoogle Scholar
  21. 21.
    Sivertsen B, Overland S, Glozier N, Bjorvatn B, Maeland JG, Mykletun A (2008) The effect of OSAS on sick leave and work disability. Eur Respir J 32(6):1497–1503. doi: 10.1183/09031936.00044908 PubMedCrossRefGoogle Scholar
  22. 22.
    Ejaz SM, Khawaja IS, Bhatia S, Hurwitz TD (2011) Obstructive sleep apnea and depression: a review. Innov Clin Neurosci 8(8):17–25PubMedPubMedCentralGoogle Scholar
  23. 23.
    Schwartz DJ, Kohler WC, Karatinos G (2005) Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure. Chest 128(3):1304–1309. doi: 10.1378/chest.128.3.1304 PubMedCrossRefGoogle Scholar
  24. 24.
    Yamamoto H, Akashiba T, Kosaka N, Ito D, Horie T (2000) Long-term effects nasal continuous positive airway pressure on daytime sleepiness, mood and traffic accidents in patients with obstructive sleep apnoea. Respir Med 94(1):87–90. doi: 10.1053/rmed.1999.0698 PubMedCrossRefGoogle Scholar
  25. 25.
    Vandeputte M, de Weerd A (2003) Sleep disorders and depressive feelings: a global survey with the Beck depression scale. Sleep Med 4(4):343–345PubMedCrossRefGoogle Scholar
  26. 26.
    Wahner-Roedler DL, Olson EJ, Narayanan S, Sood R, Hanson AC, Loehrer LL, Sood A (2007) Gender-specific differences in a patient population with obstructive sleep apnea-hypopnea syndrome. Gend Med 4(4):329–338PubMedCrossRefGoogle Scholar
  27. 27.
    Alotair H, Bahammam A (2008) Gender differences in Saudi patients with obstructive sleep apnea. Sleep Breath 12(4):323–329. doi: 10.1007/s11325-008-0184-8 PubMedCrossRefGoogle Scholar
  28. 28.
    McCall WV, Harding D, O’Donovan C (2006) Correlates of depressive symptoms in patients with obstructive sleep apnea. J Clin Sleep Med 2(4):424–426PubMedGoogle Scholar
  29. 29.
    Asghari A, Mohammadi F, Kamrava SK, Tavakoli S, Farhadi M (2012) Severity of depression and anxiety in obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol 269(12):2549–2553. doi: 10.1007/s00405-012-1942-6 PubMedCrossRefGoogle Scholar
  30. 30.
    Rey de Castro J, Rosales-Mayor E (2013) Depressive symptoms in patients with obstructive sleep apnea/hypopnea syndrome. Sleep Breath 17(2):615–620. doi: 10.1007/s11325-012-0731-1 PubMedCrossRefGoogle Scholar
  31. 31.
    Douglas N, Young A, Roebuck T, Ho S, Miller BR, Kee K, Dabscheck EJ, Naughton MT (2013) Prevalence of depression in patients referred with snoring and obstructive sleep apnoea. Intern Med J 43(6):630–634. doi: 10.1111/imj.12108 PubMedCrossRefGoogle Scholar
  32. 32.
    Phillips BA, Berry DT, Lipke-Molby TC (1996) Sleep-disordered breathing in healthy, aged persons. Fifth and final year follow-up. Chest 110(3):654–658PubMedCrossRefGoogle Scholar
  33. 33.
    Pillar G, Lavie P (1998) Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index. Chest 114(3):697–703PubMedCrossRefGoogle Scholar
  34. 34.
    Bajpai S, Im KB, Dyken ME, Sodhi SK, Fiedorowicz JG (2014) Obstructive sleep apnea and risk for late-life depression. Ann Clin Psychiatry 26(2):E1–E8Google Scholar
  35. 35.
    Yilmaz E, Sedky K, Bennett DS (2013) The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis. J Clin Sleep Med 9(11):1213–1220. doi: 10.5664/jcsm.3178 PubMedPubMedCentralGoogle Scholar
  36. 36.
    Kripke DF, Ancoli-Israel S, Klauber MR, Wingard DL, Mason WJ, Mullaney DJ (1997) Prevalence of sleep-disordered breathing in ages 40–64 years: a population-based survey. Sleep 20(1):65–76PubMedPubMedCentralGoogle Scholar
  37. 37.
    Ishman SL, Cavey RM, Mettel TL, Gourin CG (2010) Depression, sleepiness, and disease severity in patients with obstructive sleep apnea. Laryngoscope 120(11):2331–2335. doi: 10.1002/lary.21111 PubMedCrossRefGoogle Scholar
  38. 38.
    Macey PM, Woo MA, Kumar R, Cross RL, Harper RM (2010) Relationship between obstructive sleep apnea severity and sleep, depression and anxiety symptoms in newly-diagnosed patients. PLoS One 5(4), e10211. doi: 10.1371/journal.pone.0010211 PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Enright PL, Newman AB, Wahl PW, Manolio TA, Haponik EF, Boyle PJ (1996) Prevalence and correlates of snoring and observed apneas in 5,201 older adults. Sleep 19(7):531–538PubMedGoogle Scholar
  40. 40.
    Smith R, Ronald J, Delaive K, Walld R, Manfreda J, Kryger MH (2002) What are obstructive sleep apnea patients being treated for prior to this diagnosis? Chest 121(1):164–172PubMedCrossRefGoogle Scholar
  41. 41.
    Sforza E, de Saint HZ, Pelissolo A, Rochat T, Ibanez V (2002) Personality, anxiety and mood traits in patients with sleep-related breathing disorders: effect of reduced daytime alertness. Sleep Med 3(2):139–145PubMedCrossRefGoogle Scholar
  42. 42.
    Lee W, Lee SA, Chung YS, Kim WS (2015) The relation between apnea and depressive symptoms in men with severe obstructive sleep apnea: mediational effects of sleep quality. Lung 193(2):261–267. doi: 10.1007/s00408-015-9687-9 PubMedCrossRefGoogle Scholar
  43. 43.
    Chen YH, Keller JK, Kang JH, Hsieh HJ, Lin HC (2013) Obstructive sleep apnea and the subsequent risk of depressive disorder: a population-based follow-up study. J Clin Sleep Med 9(5):417–423. doi: 10.5664/jcsm.2652 PubMedPubMedCentralGoogle Scholar
  44. 44.
    Daabis R, Gharraf H (2012) Predictors of anxiety and depression in patients with obstructive sleep apnea. Egypt J Chest Dis Tuberc 61:171–177CrossRefGoogle Scholar
  45. 45.
    Rezaeitalab F, Moharrari F, Saberi S, Asadpour H, Rezaeetalab F (2014) The correlation of anxiety and depression with obstructive sleep apnea syndrome. J Res Med Sci 19(3):205–210PubMedPubMedCentralGoogle Scholar
  46. 46.
    McDaid C, Griffin S, Weatherly H, Duree K, van der Burgt M, van Hout S, Akers J, Davies RJ, Sculpher M, Westwood M (2009) Continuous positive airway pressure devices for the treatment of obstructive sleep apnoea-hypopnoea syndrome: a systematic review and economic analysis. Health Technol Assess 13 (4):iii-iv, xi-xiv, 1–119, 143–274. doi: 10.3310/hta13040
  47. 47.
    Bazzano LA, Khan Z, Reynolds K, He J (2007) Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea. Hypertension 50(2):417–423. doi: 10.1161/HYPERTENSIONAHA.106.085175 PubMedCrossRefGoogle Scholar
  48. 48.
    Kawahara S, Akashiba T, Akahoshi T, Horie T (2005) Nasal CPAP improves the quality of life and lessens the depressive symptoms in patients with obstructive sleep apnea syndrome. Intern Med 44(5):422–427PubMedCrossRefGoogle Scholar
  49. 49.
    Diamanti C, Manali E, Ginieri-Coccossis M, Vougas K, Cholidou K, Markozannes E, Bakakos P, Liappas I, Alchanatis M (2013) Depression, physical activity, energy consumption, and quality of life in OSA patients before and after CPAP treatment. Sleep Breath 17(4):1159–1168. doi: 10.1007/s11325-013-0815-6 PubMedCrossRefGoogle Scholar
  50. 50.
    Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ (2006) Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 3, CD001106. doi: 10.1002/14651858.CD001106.pub3 PubMedGoogle Scholar
  51. 51.
    Henke KG, Grady JJ, Kuna ST (2001) Effect of nasal continuous positive airway pressure on neuropsychological function in sleep apnea-hypopnea syndrome. A randomized, placebo-controlled trial. Am J Respir Crit Care Med 163(4):911–917. doi: 10.1164/ajrccm.163.4.9910025 PubMedCrossRefGoogle Scholar
  52. 52.
    Haensel A, Norman D, Natarajan L, Bardwell WA, Ancoli-Israel S, Dimsdale JE (2007) Effect of a 2 week CPAP treatment on mood states in patients with obstructive sleep apnea: a double-blind trial. Sleep Breath 11(4):239–244. doi: 10.1007/s11325-007-0115-0 PubMedCrossRefGoogle Scholar
  53. 53.
    Bardwell WA, Norman D, Ancoli-Israel S, Loredo JS, Lowery A, Lim W, Dimsdale JE (2007) Effects of 2-week nocturnal oxygen supplementation and continuous positive airway pressure treatment on psychological symptoms in patients with obstructive sleep apnea: a randomized placebo-controlled study. Behav Sleep Med 5(1):21–38. doi: 10.1080/15402000709336724 PubMedCrossRefGoogle Scholar
  54. 54.
    Povitz M, Bolo CE, Heitman SJ, Tsai WH, Wang J, James MT (2014) Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. PLoS Med 11(11), e1001762. doi: 10.1371/journal.pmed.1001762 PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Habukawa M, Uchimura N, Kakuma T, Yamamoto K, Ogi K, Hiejima H, Tomimatsu K, Matsuyama S (2010) Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: contribution of daytime sleepiness to residual depressive symptoms. Sleep Med 11(6):552–557. doi: 10.1016/j.sleep.2010.02.007 PubMedCrossRefGoogle Scholar
  56. 56.
    Gagnadoux F, Le Vaillant M, Goupil F, Pigeanne T, Chollet S, Masson P, Bizieux-Thaminy A, Humeau MP, Meslier N (2014) Depressive symptoms before and after long-term CPAP therapy in patients with sleep apnea. Chest 145(5):1025–1031. doi: 10.1378/chest.13-2373 PubMedCrossRefGoogle Scholar
  57. 57.
    Kjelsberg FN, Ruud EA, Stavem K (2005) Predictors of symptoms of anxiety and depression in obstructive sleep apnea. Sleep Med 6(4):341–346. doi: 10.1016/j.sleep.2005.02.004 PubMedCrossRefGoogle Scholar
  58. 58.
    Grenard JL, Munjas BA, Adams JL, Suttorp M, Maglione M, McGlynn EA, Gellad WF (2011) Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. J Gen Intern Med 26(10):1175–1182. doi: 10.1007/s11606-011-1704-y PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Poulet C, Veale D, Arnol N, Levy P, Pepin JL, Tyrrell J (2009) Psychological variables as predictors of adherence to treatment by continuous positive airway pressure. Sleep Med 10(9):993–999. doi: 10.1016/j.sleep.2009.01.007 PubMedCrossRefGoogle Scholar
  60. 60.
    Lewis KE, Seale L, Bartle IE, Watkins AJ, Ebden P (2004) Early predictors of CPAP use for the treatment of obstructive sleep apnea. Sleep 27(1):134–138PubMedGoogle Scholar
  61. 61.
    Stepnowsky CJ Jr, Bardwell WA, Moore PJ, Ancoli-Israel S, Dimsdale JE (2002) Psychologic correlates of compliance with continuous positive airway pressure. Sleep 25(7):758–762PubMedGoogle Scholar
  62. 62.
    Law M, Naughton M, Ho S, Roebuck T, Dabscheck E (2014) Depression may reduce adherence during CPAP titration trial. J Clin Sleep Med 10(2):163–169. doi: 10.5664/jcsm.3444 PubMedPubMedCentralGoogle Scholar
  63. 63.
    Wallace DM, Vargas SS, Schwartz SJ, Aloia MS, Shafazand S (2013) Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans. Sleep Breath 17(1):351–363. doi: 10.1007/s11325-012-0702-6 PubMedCrossRefGoogle Scholar
  64. 64.
    Wallace DM, Wohlgemuth WK (2014) Does race-ethnicity moderate the relationship between CPAP adherence and functional outcomes of sleep in US veterans with obstructive sleep apnea syndrome? J Clin Sleep Med 10(10):1083–1091. doi: 10.5664/jcsm.4106 PubMedPubMedCentralGoogle Scholar
  65. 65.
    Means MK, Ulmer CS, Edinger JD (2010) Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med 8(4):260–273. doi: 10.1080/15402002.2010.509255 PubMedCrossRefGoogle Scholar
  66. 66.
    Kasasbeh E, Chi DS, Krishnaswamy G (2006) Inflammatory aspects of sleep apnea and their cardiovascular consequences. South Med J 99(1):58–67. doi: 10.1097/01.smj.0000197705.99639.50, quiz 68–59, 81 PubMedCrossRefGoogle Scholar
  67. 67.
    Irwin MR, Miller AH (2007) Depressive disorders and immunity: 20 years of progress and discovery. Brain Behav Immun 21(4):374–383. doi: 10.1016/j.bbi.2007.01.010 PubMedCrossRefGoogle Scholar
  68. 68.
    Katon W, Lin EH, Kroenke K (2007) The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 29(2):147–155. doi: 10.1016/j.genhosppsych.2006.11.005 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Ahmed S. BaHammam
    • 1
    Email author
  • Tetyana Kendzerska
    • 2
  • Ravi Gupta
    • 3
  • Chellamuthu Ramasubramanian
    • 4
  • David N. Neubauer
    • 5
  • Meera Narasimhan
    • 6
  • Seithikurippu R. Pandi-Perumal
    • 7
  • Adam Moscovitch
    • 8
  1. 1.The University Sleep Disorders Center, Department of Medicine, College of MedicineKing Saud UniversityRiyadhSaudi Arabia
  2. 2.Institute for Clinical Evaluative ScienceSunnybrook Health Sciences CenterTorontoCanada
  3. 3.Department of Psychiatry & Sleep ClinicHimalayan Institute of Medical SciencesDoiwalaIndia
  4. 4.M.S. Chellamuthu Trust and Research FoundationMaduraiIndia
  5. 5.Department of Psychiatry and Behavioral ScienceJohns Hopkins University School of MedicineBaltimoreUSA
  6. 6.Department of Neuropsychiatry and Behavioral ScienceUniversity of South Carolina School of MedicineColumbiaUSA
  7. 7.Somnogen Canada Inc.TorontoCanada
  8. 8.Sleep and Fatigue InstituteThe University of CalgaryAlbertaCanada

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