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

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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.

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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.

Author information

Authors and Affiliations

  1. The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia

    Ahmed S. BaHammam

  2. Institute for Clinical Evaluative Science, Sunnybrook Health Sciences Center, Toronto, ON, Canada

    Tetyana Kendzerska

  3. Department of Psychiatry & Sleep Clinic, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Doiwala, Dehradun, India

    Ravi Gupta

  4. M.S. Chellamuthu Trust and Research Foundation, K.K. Nagar, Madurai, 625 002, India

    Chellamuthu Ramasubramanian

  5. Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    David N. Neubauer

  6. Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

    Meera Narasimhan

  7. Somnogen Canada Inc., College Street, Toronto, ON, M6H 1C5, Canada

    Seithikurippu R. Pandi-Perumal

  8. Sleep and Fatigue Institute, The University of Calgary, 922 5th Ave SW, #518, Calgary, Alberta, T2P 5R4, Canada

    Adam Moscovitch

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  1. Ahmed S. BaHammam
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Comments

The review article by BaHamman et al. provides clinicians with an up-to-date summary on the topic of comorbid depression and obstructive sleep apnea; yet, in the 25 years since this comorbidity was described by Millman et al., it remains an “under-recognized association.” Obstructive sleep apnea likely remains under-recognized by behavioral health providers, and depression is typically not screened for in sleep disorders centers. As the authors note, much of the research utilizes screening tools and questionnaires that are intended for rating severity, and potentially tracking symptoms and response to therapy, rather than diagnosing depression.

Patients with depression who fail to respond to treatment should absolutely be screened for obstructive sleep apnea. By the same token, screening for depression should occur in OSA patients with unexplained poor PAP adherence or excessive daytime sleepiness despite adequate adherence. Notably, depression can negatively impact PAP compliance, just as occurs with compliance for numerous other medical comorbidities. While recent studies have shown modest benefits in mood symptoms, and many patients with good CPAP adherence improve, a substantial number will have refractory symptoms of depression despite good adherence. The article by BaHamman et al. highlights the significant gaps in our understanding of these associated illnesses and should serve as a call for clinicians and researchers to increase awareness, improve diagnostic strategies, devise therapeutic regimens, and explain the biologic underpinnings for comorbid depression and OSA.

Jacob Collen, Vincent Mysliwiec

Texas, USA

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BaHammam, A.S., Kendzerska, T., Gupta, R. et al. Comorbid depression in obstructive sleep apnea: an under-recognized association. Sleep Breath 20, 447–456 (2016). https://doi.org/10.1007/s11325-015-1223-x

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