Elsevier

Clinical Psychology Review

Volume 24, Issue 8, December 2004, Pages 1031-1049
Clinical Psychology Review

The roles of depression and anxiety in the understanding and treatment of Obstructive Sleep Apnea Syndrome

https://doi.org/10.1016/j.cpr.2004.08.002Get rights and content

Abstract

Obstructive Sleep Apnea Syndrome (OSAS) is a debilitating condition stemming from disruption to the respiratory system during sleep. At present, the nature of the relationship between OSAS and mood, specifically depression and anxiety, is still unclear. The purpose of this paper is to shed some light on this relationship. PsycINFO was used to locate relevant papers on this topic. This literature search formed the basis of our investigation. Results showed that the anxiety and depression methodology is weak. It is now clear that there is an urgent need to better understand the roles of anxiety and depression in OSAS. For example, the research literature suggests that depression and anxiety covary with OSAS. However, because of methodological issues, such as difficulties involved in diagnosis and the use of inappropriate instruments, this conclusion remains tenuous. Future directions are discussed.

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.

References (69)

  • A. Malhotra et al.

    Obstructive sleep apnoea

    Lancet

    (2002)
  • J. Aikens et al.

    MMPI correlates of sleep and respiratory disturbance in obstructive sleep apnea

    Sleep

    (1999)
  • J. Aikens et al.

    Differential rates of psychopathology symptoms in periodic limb movement disorder, obstructive sleep apnea, psychophysiological insomnia, and insomnia with psychiatric disorder

    Sleep

    (1999)
  • J.E. Aikens et al.

    Replicability of psychometric differences between obstructive sleep apnea, primary snoring, and periodic limb movement disorder

    Sleep and Hypnosis

    (1999)
  • J.E. Aikens et al.

    A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea

    Sleep

    (1999)
  • S. Ancoli-Israel

    “Sleep is not tangible” or what the Hebrew tradition has to say about sleep

    Psychosomatic Medicine

    (2001)
  • R.C. Arnau et al.

    Psychometric evaluation of the Beck Depression Inventory II with primary medical patients

    Health Psychology

    (2001)
  • F. Baker et al.

    A POMS short form for cancer patients: Psychometric and structural evaluation

    Psycho-oncology

    (2002)
  • W.A. Bardwell et al.

    Types of coping strategies are associated with increased depressive symptoms in patients with sleep apnea

    Sleep

    (2001)
  • W.A. Bardwell et al.

    Psychological correlates of sleep apnea

    Journal of Psychosomatic Research

    (1999)
  • W.A. Bardwell et al.

    Fatigue in obstructive sleep apnea: Driven by depressive symptoms instead of apnea severity

    American Journal of Psychiatry

    (2003)
  • H. Bearpark et al.

    Snoring and sleep apnea: A population study in Australian men

    American Journal of Respiratory and Critical Care Medicine

    (1995)
  • E.O. Bixler et al.

    Prevalence of sleep-disordered breathing in women: Effects of gender

    American Journal of Respiratory and Critical Care Medicine

    (2001)
  • A.J. Block et al.

    Sleep apnea, hypoapnea and oxygen desaturation in normal subject

    New England Journal of Medicine

    (1979)
  • J. Borak et al.

    Psychopathological characteristics of the consequences of obstructive sleep apnea prior to and three months after CPAP

    Psychiatria Polska

    (1994)
  • P.E. Brander et al.

    Effect of obesity and erect/supine posture on lateral cephalometry: Relationship to sleep disordered breathing

    European Respiratory Journal

    (1999)
  • I. Charuzi et al.

    The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome

    Surgery

    (1985)
  • P. Dahloef et al.

    Surgical treatment of the sleep apnea syndrome reduces associated major depression

    International Journal of Behavioral Medicine

    (2000)
  • P.A. Derry et al.

    Influence of seizure content on interpreting psychpathology on the MMPI-2 in patients with epilepsy

    Journal of Clinical and Experimental Neuropsychology

    (1997)
  • J.B. Dixon et al.

    Depression in association with severe obesity: Changes with weight loss

    Archives of International Medicine

    (2003)
  • J. Edinger et al.

    Psychological status, syndromatic measures, and compliance with nasal cpap therapy for sleep apnea

    Perceptual and Motor Skills

    (1994)
  • L.J. Findley et al.

    Automobile accidents involving patients with obstructive sleep apnea

    American Review of Respiratory Disease

    (1988)
  • M.F. Fitzpatrick et al.

    Do patients with sleep apnea/hypopnea syndrome drink more alcohol?

    Sleep

    (1992)
  • M. Franceschi et al.

    Excessive daytime sleepiness: A one year study in an unselected inpatient population

    Sleep

    (1982)

    • Cited by (65)

    • Impact of psychiatric disorders

      2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition

    • Insomnia and treatment-resistant depression

      2023, Progress in Brain Research

    • Is night eating syndrome associated with obstructive sleep apnea, BMI, and depressed mood in patients from a sleep laboratory study?

      2016, Eating Behaviors
      Citation Excerpt :

      Individuals with NES are more likely to have depressed mood compared to normal individuals (Birketvedt et al., 1999; Gluck et al., 2001; Allison, Grilo, Masheb, & Stunkard, 2005; Allison et al., 2006; Lundgren, Allison, O'Reardon, & Stunkard, 2008; Olbrich et al., 2009; Fischer, Meyer, Hermann, Tuch, & Munsch, 2012; Hood, Reutrakul, & Crowley, 2014; Kucukgoncu, Tek, Bestepe, Musket, & Guloksuz, 2014; Runfola, Allison, Hardy, Lock, & Peebles, 2014). The relationship between OSA and depression is less clear (Saunamaki & Jehkonen, 2007) as some studies have found that OSA is associated with higher rates of depression (Aloia et al., 2005; Haba-Rubio, 2005; Ishman, Cavey, Mettel & Gourin; Schroder & O'Hara, 2005), while others have found no relationship (Andrews & Oei, 2004; Baran & Richert, 2003; Sateia, 2003). Thus, it has been shown that NES, SRED, and OSA share some common characteristics.

    • The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: A systematic review and meta-analysis

      2016, Sleep Medicine Reviews
      Citation Excerpt :

      The relationship between objectively-rated features of OSA and symptoms like depression, anxiety, and excessive daytime sleepiness (EDS) is poorly understood [8–10]. This constellation of symptoms is often referred to as subjective symptoms of OSA, as there is typically no consistent correlation between the severity of these symptoms and the severity of OSA measured by objectively-rated sleep variables [11–17]. Current models for the relationship between OSA and psychiatric conditions suggest that underlying biological, metabolic and neurological dysregulation contributes to a feed-forward mechanism that manifests as psychiatric disorders, sleep fragmentation, cardiovascular and metabolic disease [8–10].

    • OSA Symptoms Associated With and Predictive of Anxiety in Middle-Aged Men: Secondary Analysis of NHANES Data

      2014, Archives of Psychiatric Nursing

    • Investigation of smell and taste function in patients with obstructive sleep apnoea syndrome

      2019, Journal of Laryngology and Otology
    View all citing articles on Scopus
    View full text
    Copyright © 2004 Elsevier Ltd. All rights reserved.