Indian Journal of Sleep Medicine

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VOLUME 7 , ISSUE 2 ( April-June, 2012 ) > List of Articles


Prevalence of Depression and Anxiety in Patients with Sleep-Disordered Breathing and its Correlation with Disease Severity

Poulomi Chatterjee, M. K. Sen

Keywords : OSA, Depression, Anxiety, PHQ-9 Score, GAD-7 score, RDI

Citation Information : Chatterjee P, Sen MK. Prevalence of Depression and Anxiety in Patients with Sleep-Disordered Breathing and its Correlation with Disease Severity. Indian Sleep Med 2012; 7 (2):55-61.

DOI: 10.5958/j.0973-340X.7.2.012

License: CC BY-SA 4.0

Published Online: 01-06-2012

Copyright Statement:  Copyright © 2012; Jaypee Brothers Medical Publishers (P) Ltd.


Objective: Primary objective of the study was to assess the prevalence of depression and anxiety among obstructive sleep apnoea (OSA) patients presenting to the sleep clinic of Safdarjung Hospital. Secondary aim was to study the correlation between and severity of depression, anxiety and respiratory disturbance index (RDI) and to see any relation with gender. Study design: Case–control study. Materials and Methods: One hundred seventy-two patients with OSA were evaluated before treatment and compared with controls by using the Patient Health Questionnaire-9 (PHQ-9) and anxiety on the basis of General Anxiety Disorder Assessment-7 score (GAD-7). Based on these scores, depression and anxiety were categorised as mild, moderate and severe, respectively. OSA was assessed by Epworth Sleepiness Scale, and polysomnography was used for sleep scoring and classified to mild, moderate and severe OSA by RDI. RESULTS: Depressive symptoms were identified in 14% (25 of 172) of controls, and 36.4% (62 of 172) of patients with OSA by using PHQ-9 screening (P<0.006). Anxiety was identified in 19.2% (33 of 172) OSA patients as compared to 6.7% of controls. Evaluation of the patients with OSA compared to the control group showed depression and anxiety to be significantly more common in OSA patients than in controls (P-values 0.006 and 0.01, respectively). Overall, 41.9% and 58.1% of men and women, respectively, with OSA had elevated PHQ-9 scores; 05% and 11% of male and female control patients, respectively, exhibited depressive symptoms (P<0.001). In all, 75.75% patients were female OSA cases with symptoms of anxiety (25 of 33), while 24.25% were male (P<0.02) as screened by GAD- 7 scores. Analysis of depression scores by OSA disease severity category found significant difference in depressive symptoms between participants with mild OSA, moderate OSA and severe OSA (P-value <0.006). In this study, the association between OSA disease severity (as determined from the RDI) and PHQ-9 on univariate analysis (P ¼ .OO) was significant, with association found (P-value<0.003) on multivariable analysis, after controlling for sex. Partial linearity was noted. Analysis of anxiety scores by GAD-7 scores found no significant difference in anxiety symptoms between subgroups with mild, moderate and severe OSA (P-value <0.23) on univariate analysis, association between disease severity 0f OSA and GAD-7 scores was not significant, however, on multivariate analysis ruling out confounding factors like sex was significant (P-value <0.003). CONCLUSIONS: Patients with OSA and daytime sleepiness are more likely to have depressive and anxiety symptoms as compared with controls. OSA disease severity, as measured with the RDI score, is a predictor of PHQ-9 score, but no correlation was seen between the severity of OSA and GAD-7 scores. These data suggest that OSA patients with symptoms of excessive sleepiness have the highest risk of associated depressive symptoms and may benefit most from depression screening.

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  1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165: 1217–39.
  2. Aikens JE, Mendelson WB. A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea. Sleep 1999; 22: 355–9.
  3. Yang EH, Hla KM, McHorney CA, et al. Sleep apnea and quality of life. Sleep 2000; 23: 535–41.
  4. Akashiba T, Kawahara S, Akahoshi T, et al. Relationship between quality of life and mood or depression in patients with severe obstructive sleep apnea syndrome. Chest 2002; 122: 861–5.
  5. Yue W, Hao W, Liu P, et al. A case–control study on psychological symptoms in sleep apnea–hypopnea syndrome. Can J Psychiatry 2003; 48: 318–23.
  6. Lee S. Depression in sleep apnea: a different view. J Clin Psychiatry 1990; 51: 309–10.
  7. Flemons WW, Whitelaw WA, Brant R, Remmers JE. Likelihood ratios for a sleep apnea clinic prediction rule. Am J Respir Crit Care Med 1994; 150:1279–85.
  8. Klonoff H, Fleetham J, Taylor R, Clark C. Treatment outcome of obstructive sleep apnea: physiological and neuropsychological concomitants. J Nervous Mental Dis 1987; 175: 208–1.
  9. Pillar G, Lavie P. Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index. Chest 1998; 114: 697–703.
  10. Saunamaki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007; 116: 277–288.
  11. Ohayon MM. The effects of breathing-related sleep disorders on mood disturbances in the general population. J Clin Psychiatry 2003; 64: 1195–1200.
  12. Chandra RK, Epstein VA, Fishman AJ. Prevalence of depression and antidepressant use in an otolaryngology patient population. Otolaryngol Head Neck Surg 2009; 141: 136–138.
  13. Harris M, Glozier N, Ratnavadivel R, Grunstein RR. Obstructive sleep apnea and depression. Sleep Med Rev 2009; 13: 437–444.
  14. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003; 54: 216–226.
  15. PHQ-9 & GAD-7 quiestionnaires
  16. AASM. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. AASM, West Chester, IL 2007.
  17. Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea: the Epworth sleepiness scale. Chest 1993; 103: 30–6.
  18. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540–5.
  19. Rechtschaffen A, Kales A. A manual of standardized terminology techniques, and scoring system for sleep stages of human subjects. UCLA Brain Information Service/Brain Research Institute, Los Angeles 1968.
  20. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Association, Washington, DC 2000.
  21. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia
  22. As a risk factor for developing anxiety and depression. Sleep 2007; 30: 873–80.
  23. Popescu G, Latham M, Allgar V, Elliott MW. Continuous positive airway pressure for sleep apnoea/hypopnoea syndrome: usefulness of 2 week trial to identify factors associated with long term use. Thorax 2001; 56: 727–33.
  24. Munoz A, Mayoralas LR, Barbe F, Pericas J, Agusti AG. Long-term effects of CPAP on daytime functioning in patients with sleep apnoea syndrome. Eur Respir J 2000; 15: 676– 81.
  25. Kingshott RN, Vennelle M, Hoy CJ, et al. Predictors of improvements in daytime function outcomes with CPAP therapy. Am J Respir Crit Care Med 2000; 161: 866–71.
  26. Campos-Morales R, Valencia-Flores M, Castano-Meneses A. Sleepiness, performance and mood state in a group of Mexican undergraduate students. Biol Rhythm Res 2005; 96: 1–8.
  27. Babson KA, Traino CD, Feldner MT, Blumenthal H. A test of the effects of acute sleep deprivation on general and specific self-reported anxiety and depressive symptoms: an experimental extension. J Behav Ther Exp Psychiatry 2010; 40: 297–303.
  28. Riemann D, Voderholzer U. Primary insomnia: a risk factor to develop depression? J Affect Disord 2003; 76: 255– 259.
  29. Taylor DJ. Insomnia and depression. Sleep 2008; 31: 447– 448.
  30. Novati A, Roman V, Cetin T, et al. Chronically restricted sleep leads to depression-like changes in neurotransmitter receptor sensitivity and neuroendocrine stress reactivity in rats. Sleep 2008; 31: 1579–1585.
  31. Gontzas AN, Papanicolaou DA, Bixler EO, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab 2000; 85: 1151–8.
  32. Vgontzas AN, Papanicolaou DA, Bixler EO, Kales A, Tyson K, Chrousos GP. Elevation of plasma cytokines in disorders of excessive daytime sleepiness: role of sleep disturbance and obesity. J Clin Endocrinol Metab 1997; 82: 1313–6.
  33. Vgontzas AN, Zoumakis E, Lin HM, Bixler EO, Trakada G, Chrousos GP. Marked decrease in sleepiness in patients with sleep apnea by etanercept, a tumor necrosis factoralpha antagonist. J Clin Endocrinol Metab 2004; 89: 4409– 13.
  34. Irwin MR, Miller AH. Depressive disorders and immunity: 20 years of progress and discovery. Brain Behav Immun 2007; 21: 374–83.
  35. Jans LAW, Riedel WJ, Markus CR, Blokland A. Serotonergic vulnerability and depression: assumptions, experimental evidence and implications. Mol Psychiatry 2007; 12: 522– 43.
  36. Fenik P, Veasey SC. Pharmacological characterization of serotonergic receptor activity in the hypoglossal nucleus. Am J Respir Crit Care Med 2003; 167: 563–9.
  37. Ishman SL, Cavey RM, et al. Depression, sleepiness, and disease severity in patients with obstructive sleep apnea. Laryngoscope 2010; 120(11): 2331–5.
  38. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006; 81: 82–85.
  39. Aloiaa MS, Arnedta JT, et al. Examining the construct of depression in obstructive sleep apnea syndrome.; Sleep Med 2005; 6: 115–121.
  40. Bardwell WA, Berry CC, Ancoli-Israel S, Dimsdale JE. Psychological correlates of sleep apnea. J Psychosom Res 1999; 47: 583–96.
  41. YueW, HaoW, Liu P, Liu T, Ni M, Guo Q. A case–control study on psychological symptoms in sleep apnea-hypopnea syndrome. Can J Psychiatry 2003; 48: 318–23.
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