Sleep Apnea and Depression - A Complex Relationship

By Admin

In simple terms, depression is a symptom of sleep apnea. But depression is also a mood disorder with symptoms of its own. The relationship between these two disorders can be complicated, and though numerous studies have identified a clear link between them, it remains a subject of considerable scrutiny by researchers across the disciplinary spectrum. The biggest concern for doctors and patients is not necessarily how these disorders develop, but how best to treat or prevent their occurrence. Proper treatment requires proper diagnosis. In some cases, for example, depression symptoms can be a direct result of the sleep deprivation caused by sleep apnea events. In these cases, treatments such as Continued Positive Airway Pressure (CPAP) therapy can be used to treat the entire range of symptoms developed by the comorbid condition. In other cases, depression may be an entirely separate condition unrelated to sleep or sleep apnea; thus, a more complex treatment plan may be needed to target each disorder separately. Sleep apnea, if not treated effectively, can always potentially exacerbate the problems of depression, whether it is the root cause or not. The only way to distinguish these possibilities is to receive a proper diagnosis that takes into account the often dynamic pathologies associated with sleep and mood. While this may mean more referrals, and therefore more doctor visits, it also means more resources will be made available to patients, which greatly increases the likelihood of an effective, life-saving treatment.

Symptom Overlap and Comorbidity

Sleep apnea and depression share a number of symptoms, and in some cases this can make it very difficult to identify both disorders and how they are related. Other conditions such as anxiety, insomnia, or any number of associated disorders can further complicate the issue with similar signs, symptoms, and risk factors involved. According to a study published in the Annals of Family Medicine, roughly 80% of the United States Medicare budget is used to treat patients with four or more health conditions, a figure that remains on the rise as diagnostic tools become more effective. But as the treatment of individuals with multiple coexisting conditions becomes the norm, healthcare services must reflect this complexity with more tailored, specialized care. For Sleep Apnea and Depression, the most commonly overlapping symptoms include the following:

Fatigue or tiredness

Difficulty sleeping or sleep disturbances

Attention problems or difficulty concentrating

Irritability

Sadness or hopelessness

Low energy or low self esteem

Confusion or irrational thoughts

Appetite or weight changes

Headaches

Loss of interest or pleasure in normal activities

Anxiety

Other symptoms may result from either condition, but the above list includes the most commonly observed symptoms for both disorders. What makes differential diagnosis more difficult are the diverse manifestations of the syndromes. Obstructive Sleep Apnea (OSA) has its own distinct set of symptoms that differ from those of Central Sleep Apnea (CSA) and Mixed/Complex Sleep Apnea. OSA is a physical development that obstructs breathing in the upper airway, while CSA and other forms often involve irregular breathing in a more general sense, caused by disrupted signals from the brain. Each condition has its own pathology and symptomatology, as well as its own disparate syndrome types. And Depression is even more diverse, developing from chemical imbalances in the brain, or as an emotional response to life events. According to Harvard Health online, depression often develops from problems with mood regulation, genetic vulnerabilities, or other medical issues. There are billions of chemical reactions associated with mood and life experiences, and our behaviors play a significant role as well. The two most common forms of clinical depression are Major Depression and Persistent Depression:

Major Depression or Major Depressive Disorder (MDD)—The Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition criteria for MDD includes persistent symptoms throughout the majority of day hours for at least two weeks, posing an interference with work, sleep, studying, eating, and/or a capacity to enjoy life experiences.

Persistent Depressive Disorder or Dysthymia—PDD involves symptoms of depression for at least two years. These symptoms can at times be less severe than those of Major Depression, but are longer lasting.

Other forms of depression include:

Perinatal or Postpartum Depression—depression related to pregnancies or births.

Seasonal Affective Disorder (SAD)—a type of depression related to seasons.

Psychotic Depression—which includes fixations or delusions.

Substance Use Disorder— this can be a cause or a development of any depressive disorder, and often leads to further complications for treatment.

There are many other depressive disorders listed in the DSM-5, and further resources can be found on the National Institute of Mental Health (NIMH) website (www.nimh.nih.gov). Depressive disorders affect people in different ways depending on sex, age, health, lifestyle, and genetics, and anyone is susceptible regardless of social status or personality type. Women tend to have depression more often than men, and there are biological and hormonal reasons for this. Characteristically, women tend to exhibit depressive symptoms differently than men, showing signs of isolation and sadness, as opposed to the more common symptoms of irritability, fatigue, and loss of interest in men. Depressive moods or disorders can develop from sleep problems rather quickly, and there is almost always a sleep-related problem associated with any depressive disorder. For this reason, the proper identification of apnea-induced versus independent or depression-induced symptoms constitutes a challenge in daily clinical practice. In addition, drug use, including alcohol and prescription drugs, can induce symptomatology that resembles both depressive and sleep-related disorders, and can also exacerbate existing conditions. For this reason, it is imperative that your doctor or healthcare provider knows your medication and drug or alcohol history prior to an exam or diagnosis.

Research

In one of the earliest studies on depression and sleep disordered breathing among the general public, the National Health and Nutrition Examination Survey of 2005-2008 discovered a high number of individuals who had symptoms of both depression and sleep apnea. Men and women who reported sleep-related breathing disorders were three times more likely to report depression symptoms as well. These findings sparked further studies in the subject area, and the results have been surprising. One study, published in 2014, found an even higher correlation, linking nearly 50 percent of its OSA-diagnosed participants with depressive symptoms. Other studies have linked sleep apnea to suicidal thoughts and behaviors, and a recent report from the National Sleep Foundation found that insomnia related specifically to sleep maintenance — such as the case with sleep apnea — had the largest correlation to depression and anxiety. Although the connection between sleep apnea and depression has been firmly established, many questions, particularly those concerning etiology, remain topics of considerable debate among mental health professionals. But what is clear, given the extent of the research, is that sleep, mood, weight, and self confidence are all intricately related in the human psyche. Ignoring the risk factors for either condition can increase the likelihood of developing them both in the long term.

PAP Therapy and Depression

Even in studies not specifically associated with the link between sleep apnea and depression, there have been notable connections discovered. For example, a number of studies observing the effectiveness of PAP therapy on sleep apnea syndromes have revealed that many of the symptoms associated with depression are positively affected through continued use of the PAP therapy device. This has led to stronger recommendations for PAP therapy where depressive symptoms are an issue. In cases where comorbidity exists, and especially where depression may be a result of the sleep apnea disturbances, CPAP is highly recommended by healthcare professionals. In many ways, this finding has led to more effective and affordable treatments for those with more than one health concern, as the use of a single therapy device can greatly improve a patient’s overall condition with both short-term and long-term benefits. One study in particular, titled “Depressive Symptoms Before and After Treatment of Obstructive Sleep Apnea in Men and Women,” reported in its conclusions that depressive symptoms, “common in OSA and related to its severity,” “improve markedly with CPAP.” These kinds of studies highlight the benefit of PAP therapy, but they also demonstrate advancements in the research and development of treatments for complex and comorbid sleep disorder conditions.

Differential Diagnosis

Differential Diagnosis is the process of differentiating between two or more conditions or disorders that have similar symptoms. With the best diagnostic tools available, doctors can identify root causes and treat them holistically. As the role of the sleep specialist becomes more prominent in diagnostic processes, a referral to a sleep center is becoming much more likely when apnea symptoms are involved. It is also not uncommon for a primary doctor to recommend both psychological and sleep study evaluations, depending on the specifics of the case. In cases involving severe depression, there may be a need for highly specialized treatment models, assessments, and interventions. But the first step in differential diagnosis can be surprisingly simple. Since sleep apnea is often a root cause of depressive symptoms, it is best to determine first if you have sleep apnea, and follow up with mental health screenings and continued assessments as needed. Always start by making an appointment with your primary doctor. A primary doctor will refer you to the necessary specialists for a more complete diagnostic process. If sleep apnea is not your top concern, simply request a referral to the proper mental health services for a behavioral or psychological evaluation. The most important thing to remember is that treating disorders is often a process, rather than a single event. The more information your healthcare providers receive about your particular condition, the better off you will be.