The roles of depression and anxiety in the understanding and treatment of Obstructive Sleep Apnea Syndrome
Section snippets
Prevalence
The prevalence of OSAS is summarized in Table 1. As can be seen from Table 1, estimations regarding the prevalence of OSAS vary considerably between studies. Variation is dependent on numerous factors, namely, criteria used for diagnosis and the nature of the population being sampled (in particular gender and age). Some estimates of OSAS prevalence (see Table 1) have been as high as 10% for those who are middle aged and are believed to rise dramatically in the elderly. Estimates in this domain
Risk factors and pathogenesis
As previously mentioned, OSAS represents several supervening medical and psychological factors. The manifestation of OSAS represents the end point of several different risk factors that have run their course. Acknowledgement of the myriad of different risk factors associated with this physical dysfunction leads practitioners to affirm that the manifestation of OSAS in and of itself is not just one disease, but is a common pathway for many diseases (Saskin, 1997). Recognition of the
Disease pathway 1: obesity
Of all of these pathways, obesity is the most important. Obesity is present in 70% of people with OSAS. Ominously, obesity is likely to reach epidemic proportions in the First World in the future. However, while increasing rates of obesity appear to be ominous, it is the only reversible risk factor for OSAS (Malhotra & White, 2002).
As a person gains weight, extra adipose tissue compromises the integrity of the respiratory process. The original conception is such that this compromise occurs via
Disease pathway 2: anatomical differences
Studies of OSAS sufferers who are not obese has highlighted that obesity is not the only risk factor operating in the development of the condition. Dempsey et al. (2002) showed that among groups of non-obese individuals, BMI bore no relationship with the Apnea/Hypoapnea Index. What they found was that within this group, four cephalometric measurements accounted for 24% of the variance. Additionally, they noted that moderate to severe OSAS was increased between three and seven times when a
Pathway 3: over use of alcohol
Alcohol increases the likelihood of an obstruction in the upper airway. This occurs through the relaxation of the upper airway dilator muscles that are instrumental in the respiration process. Habitual drinking poses greater health risks than non-drinking, as alcohol may decrease the likelihood that the sufferer becomes aroused when the airway is obstructed. This makes it less likely that oxygen levels would return to normal when an apneic awakes from sleep. The over use of alcohol represents
Pathway 4: gender
Studies of prevalence of OSAS indicate a strong gender bias. Ratio estimates of the condition comparing male to female sufferers range from 2:1 to 9:1 (Block et al., 1979, Charuzi et al., 1985, Young et al., 1993). It was originally assumed that sex differences could be accounted for with hormones or obesity. However, treatment with progesterone has failed to alleviate the difficulty (Orr, Imes, & Martin, 1979), and fat distribution has not accounted for all of the differences found between
Pathway 5: age
The relationship between sleep disordered breathing and age is a complex one. Recent evidence suggests that sleep disordered breathing in older people is a condition distinct from the condition found in younger people (Young et al., 2002). Specifically, the occurrence of apneic episodes in older people is not related to excessive daytime somnolence and hypertension the way it is in the younger population. Young, Peppard, and Gottlieb (2002) found that the more widely recognized predictors of
Sleep Apnea and its relationship with depression/anxiety
As outlined above, this article seeks to review the relationship between OSAS and depression, and between OSAS and anxiety. The reason for this is because a comprehensive review of this area has not been attempted. The relationship between OSAS and other medical conditions, such as hypertension and obesity, continues to enjoy considerable attention in the research literature while the relationship between OSAS and mental health does not. To review the status of the research regarding this area
Depression
The literature on OSAS paints an ambiguous picture of the role of depression in sleep apnea. There are perhaps, three general positions on the issue of depression. The first maintains that higher levels of depression do exist. The second position also maintains that it exists, but considers it to be incidental and as such does not warrant attention. The third position, though less common, maintains that higher levels of depression do not exist in this population.
Table 2 outlines the particular
Anxiety
Reports of anxiety in the context of OSAS are less common than depression but are nevertheless not unusual. Moreover, many research literatures concerned themselves mainly with whether or not there are clinical levels of depression. Thus, the full complex array of psychopathology may not have been adequately acknowledged in quantity and quality. This represents an oversight in the investigation into the relationship between OSAS and mental health, as recent evidence suggests that when
Problems and future directions
The relationship between OSAS and mental health has historically focused on whether or not there is a significant amount of depression in this population. There have been problems with this approach. The problem with this approach has been the inappropriate use of depression measures that has confused outcomes. Specifically, this can be seen with the use of measures such as BDI, MMPI, and POMS that assess psychopathology based on vegetative symptoms that are core features of OSAS.
Our review of
Acknowledgements
This paper was partially supported by a research development grant from the Faculty of Social and Behavioral Sciences. Professor Oei is also the Director, CBT Unit, Toowong Private Hospital.
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