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artykuł oryginalny / original research article
Role of psychiatric status assessment
of patient with obstructive sleep apnea
Znaczenie oceny stanu psychicznego pacjenta
z obturacyjnym bezdechem sennym
Marek Daniłosio1, Jarosław Wysocki2,3
Luxmed Medical Center in Chełm
Department of Health Sciences, Siedlce University of Natural Sciences and Humanities. Head: Prof. Alina Górska, MD. PhD.
3
Department and Clinic of Otolaryngology of the Medical University of Warsaw Department Head: Prof. Kazimierz Niemczyk, MD, PhD
1
2
Article history: Received: 03.12.2014 Accepted: 12.01.2015 Published: 28.02.2015
SUMMARY Obstructive sleep apnea (OSA) is a medical problem of a wide social extent. The severe form of the disorder affects 2-4%
of population in developed countries while the mild form affects approximately 15% of adults. Predominant symptoms
include excessive daytime sleepiness, feeling exhausted, sleep disorders, nightmares, night sweats, and nocturia. It is well
known that, over time, untreated severe OSA leads to arterial hypertension, cardiac arrhythmias, impaired myocardial contractility, and acute cardiac events. The knowledge that OSA significantly adversely affects the psychiatric health of the patient is much less common. This literature review examines the available reports on this problem. Psychiatric problems experienced by patients with OSA include excessive daytime sleepiness, insomnia, cognitive disorders, depressive disorders,
bipolar disorder, anxiety disorders, posttraumatic stress disorder, psychosis, neurasthenia and other neurotic disorders.
About 6.4 to 57.6% of patients with the diagnosis of OSA are reported to suffer from insomnia while the coexistence of both
disorders is reported to be associated with a significantly increased risk of acute cardiovascular events. The reason for this is
supposedly the increased activity of the hypothalamic-pituitary-adrenal axis due to the arousals resulting in fragmentation
of sleep. Other psychiatric disorders are much less common and their incidence does not exceed 10% of cases of obstructive
sleep apnea. A considerable variation of data provided by individual investigators should be pointed out, resulting mainly
from methodological differences, especially in the criteria for diagnosing insomnia.
KEYWORDS: sleep apnea, psychiatric disorders, literature review
STRESZCZENIE
Obturacyjny bezdech senny (OBS) jest problemem medycznym o zasięgu społecznym. W postaci ciężkiej dotyczy 2-4%
populacji krajów uprzemysłowionych, a w postaci łagodnej ok. 15% dorosłych. Dominujące objawy to nadmierna senność dzienna, uczucie wyczerpania, zaburzenia snu, koszmary senne, poty nocne, nykturia. Wiadomo powszechnie, że
nieleczony ciężki OBS prowadzi z czasem do nadciśnienia tętniczego, zaburzeń rytmu serca, kurczliwości mięśnia sercowego, a także ostrych incydentów kardiologicznych. Wiedza o tym, że OBS istotnie negatywnie wpływa na stan psychicznych chorego jest zdecydowanie mniej powszechna. W niniejszym przeglądzie piśmiennictwa przeanalizowano doniesienia dotyczące tego problemu. Do problemów psychicznych chorego z OBS należą: nadmierna senność dzienna,
bezsenność, zaburzenia funkcji poznawczych, zaburzenia depresyjne, zaburzenia afektywne dwubiegunowe, zaburzenia
lękowe, zespół stresu pourazowego, psychozy, neurastenia i inne zaburzenia nerwicowe. Na bezsenność ma cierpieć od
od 6,4 do 57,6% chorych z rozpoznaniem OBS, przy czym chorzy ze współistnieniem tych chorób mają mieć istotnie podwyższone ryzyko ostrych incydentów sercowo-naczyniowych. Przyczyną tego ma być podwyższenie aktywności osi podwzgórzowo-przysadkowo-nadnerczowej, pobudzanej poprzez tzw. wzbudzenia – arousals, prowadzące do fragmentacji
snu. Pozostałe zaburzenia psychiczne występują znacznie rzadziej, a ich częstość nie przekracza 10% chorych na obturacyjny bezdech senny. Należy podkreślić bardzo znaczne zróżnicowanie danych podawanych przez poszczególnych badaczy, na co maja wpływ różnice metodologiczne, zwłaszcza w przypadku kryteriów rozpoznawania bezsenności.
SŁOWA KLUCZOWE: bezdech senny, zaburzenia psychiczne, przegląd piśmiennictwa
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 1 (2015), s. 7-14
DOI: 10.5604/20845308.1136062
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INTRODUCTION
Obstructive sleep apnea (OSA) is a medical problem of wide
social extent. This is due to its widespread incidence and
potentially serious consequences for patients in case of late
diagnosis and initiation of treatment. The Wisconsin Sleep
Cohort Study – a broad screening study conducted in the
US, OSA was confirmed in 24% of males and 9% of females,
and cases requiring urgent medical intervention were assessed to account for ca. 2-4% of the general study population [1]. OSA markedly reduces the quality of life and work
productivity, increasing the number of days off work [2, 3].
Daytime sleepiness and concentration disorders due to OSA
are the cause of numerous road accidents [4].
OSA is considered to be one of the treatable, resolvable causes of cardiovascular morbidity and mortality [5]. At the same
time, the awareness of the nature of the disorder and the risks associated therewith is much less common than the awareness of cardiovascular disorders or cancer, and OBS itself
should be considered to be underdiagnosed [6]. The symptoms are disregarded by both patients and those they live or
work with for many years. They are also not included in routine medical investigations [7]. Surveys conducted in physicians, including tests making use of training case histories
suggest that the knowledge of the disorder is insufficient not
only in novice, but also in experienced family physicians [5].
Besides daytime sleepiness, the natural history of OSA includes numerous accompanying disorders, including depression
and anxiety disorders [3, 8, 9]. Literature identified several
categories of psychiatric problems experienced by OSA patients. They include:
1. excessive daytime sleepiness
2. insomnia
3. cognitive function disturbances
4. depressive disorders
5. bipolar affective disorders
6. anxiety disorders
7. post-traumatic stress disorder
8. psychotic disorders
9. neurastenia and other neurotic disorders
PSYCHIATRIC HEALTH PROFILE
OF AN OBSTRUCTIVE SLEEP
APNEA PATIENT.
The extensive incidence of psychiatric problems experienced by OSA patients is demonstrated by the results of bro8
ad-scale epidemiological studies [10]. A review of 4,060,504
medical histories recorded within the Veterans Health Administration database in years 1998- 2001 revealed a total
of 118,105 (2.91%) cases of OSA. In this group (hereinafter
considered to comprise 100% of the study population), psychiatric diagnoses concomitant to OSA included depression
(21.8%), anxiety disorders (16.7%), post-traumatic stress
disorder (11.9%), psychoses (5.1%), and bipolar diseases
(3.3%). These disorders were significantly more common as
compared to patients not diagnosed with OSA (P<0.0001).
Vice-versa, patients diagnosed with depression were also
significantly more often diagnosed with OSA than patients
diagnosed with other disorders (7.4% vs. 2.9%, respectively).
Excessive daytime sleepiness is the most common symptom
of OSA [9]. If significant, it presents a very serious limitation
to everyday functioning [11]. The cause of excessive daytime
sleepiness is the deficit of deep sleep and sleep fragmentation [12-14]. An interesting finding is that excessive daytime
sleepiness as expressed e.g. in the popular Epworth scale, is
poorly, if at all, correlated with the severity of sleep apnea
expressed by the apnea-hypnea index (AHI) [14-19].
Insomnia and OSA are quite commonly considered opposites [20]. According to common belief, OSA patients suffer
from overwhelming sleepiness and falls asleep on all possible occasions. Such situations may be common rather in
patients with severe apnea, most particularly burdened by
severe obesity. Meanwhile, concurrent OSA and insomnia
are referred to “sleep apnea plus” [21] and have been reported for more than 40 years [22-34]. Although it is a general
consensus that insomnia is more common in OSA patients as
compared to the overall population, data reported by individual researchers differ significantly in the reported OSA-related insomnia incidence rates. According to the retrospective analysis conducted as part of the National Ambulatory
Medical Care Survey and National Hospital Ambulatory
Medical Care Survey for the period of 1995-2010, insomnia
was experienced by 6.4% of OSA patients [36]. According to
the authors of clinical studies, insomnia may be diagnosed
in 7.3% to as much as 57.6% [22] OSA patients. According
to the United States National Health and Nutrition Examination Survey (NHANES) conducted in 12047 subjects, insomnia was experienced by 43% of patients diagnosed with
OBS as compared to 30% of non-OSA patients [34].
The incidence of insomnia in OSA is not linearly correlated to
the severity of apnea as although some studies demonstrated
increased incidence of insomnia only in patients with severe
OSA [33, 36], some studies revealed the increased incidence
of insomnia in mild OSA [30] while other suggested no reWWW.OTORHINOLARYNGOLOGYPL.COM
lationship between the frequency of OSA diagnoses in groups classified according to sleep parameters [21, 22, 31, 37].
These significant discrepancies are due to the methodological differences between individual studies, particularly to
the differences in the strictness of the diagnostic criteria of
insomnia [20]. In general, insomnia is referred to as difficulty with falling asleep, waking up at night, waking up early, non-restorative sleep, and disturbing daytime symptoms
urging the patient to seek medical help [38, 39]; however,
differently formulated questionnaires and scoring systems
are used by different authors. According to various criteria,
insomnia is diagnosed in 6-48% of subjects [40].
The results of Icelandic Sleep Apnea Cohort Study [22] indicate a 57.6% incidence of insomnia in patients with obstructive sleep apnea confirmed by PSG (n=824) as compared
to a 31% incidence in appropriately selected control group
(n=762) of Icelandic population. In this study, insomnia was
diagnosed by means of positive answers to 2 questions included in the Basic Nordic Sleep Questionnaire: “I have problems with falling asleep” and “I wake up often during the
night” as regarded the previous month. Patients indicated
their responses using a 5-point scale (from “never or nearly
never”, to “every day or nearly every day of the week”). According to the authors, the score of ≥4 was sufficient to diagnose insomnia. On the other hand, Norwegian Hordaland
Health Study (n = 6892) revealed the incidence of insomnia
in 7.3% of patients diagnosed with OSA and 4.9% in non-OSA patients [32]. However, stricter diagnostic criteria were
used in this study. The symptoms of insomnia had to persist
for more than one month and the diagnosis was based on
Karolinska Sleep Questionnaire, consisting of 4 categories,
each of which is graded according to a 5-point scale: “never”,
“rarely”, “sometimes”, “frequently”, and “always” with reference to the calendar, i.e. several times a year, month, or week,
respectively). Insomnia was diagnosed on the basis of at least 1 point in each of the following categories: falling asleep, maintenance of sleep, early awakening, or combination
of the above together with disturbances in everyday work.
In a group of 394 post-menopausal women with chronic insomnia without serious psychiatric or medical dysfunctions
OSA (AHI ≥ 5)could be diagnosed in 67% of patients on the
basis of home-administered PSG [27].
According to a study conducted in the group of 200 residents
of a nursing home, ca. 30% of patients diagnosed with insomnia were diagnosed with OSA (defined as AHI ≥ 15) as
well; however, OBS was also diagnosed in as much as 38%
of patients in whom OSA was excluded [25].
Patients diagnosed with OSA and insomnia were reported
to present with a milder form of sleep apnea as measured
by AHI in comparison to patients in whom insomnia was
excluded (AHI of 46/h and 58/h, respectively). In this study, conducted in 231 patients, the criterion for diagnosing
insomnia consisted in a positive answer to at least 2 of 3 questions regarding at least 30 minutes needed to fall asleep,
frequent night-time awakenings or difficulties with falling
asleep again [21].
The use of the Insomnia Severity Index Score (including questions regarding the persistence of sleep disorders (a minimum of 6 months), sleep latency or insomnia time of at least
30 minutes according to PSG, at least one insomnia-related
daytime complaint) allowed to demonstrate a strong correlation (r=0.79) between AHI and the questionnaire score [33].
However, no such correlation was confirmed in another study conducted using the same questionnaire [30].
Both OSA [41, 42] and insomnia [43, 44] are independently
related with an increased risk of cardiovascular disorders.
Similarly, both OSA [45, 46], and insomnia [47] are independently related with an increased risk of psychiatric disorders.
Additive effects of concurrent OSA and insomnia were also
postulated [33, 44, 48-50]. However, opinions with this regard also vary. Sivertsen et al. [32] demonstrated a significant
relationship with the patient-reported stroke episode (but
not with coronary disease or myocardial infarction) in the
group of patients with concomitant insomnia as compared
to patients without insomnia. Vozoris [34] and [22] could
not demonstrate increased cardiovascular risk in patients
diagnosed with both OSA and insomnia. IN a retrospective
study conducted by Gupta et al. [35] in a population of 7234
subjects, patients with both OSA and insomnia had significantly higher odds ratios of arterial hypertension (OR =
1.83) and cerebrovascular diseases (OR = 6.58).
Patients with OSA and insomnia were significantly less frequently diagnosed with overweight or obesity as compared
to patients diagnosed with OBS only [34, 35]. This was interesting in light of the clearly higher odds ratio of arterial
hypertension (OR = 1.83) and cerebrovascular diseases (OR
= 6.58) in the group with OSA accompanied by insomnia as
compared to the group not diagnosed with insomnia [35].
This may demonstrate that there is an increased risk of cardiovascular diseases in case of concurrent OSA and insomnia and not related to excess body weight. However, also in
this case, the results are ambiguous: according to some researchers [22, 39] no significant difference in BMI was observed between both groups while others [32] reported significantly higher average body weights in the group of patients
9
with both OSA and insomnia. In the population consisting
of nursing home residents, patients with both OSA and insomnia were characterized by significantly larger neck circumference and BMI values as compared to patients diagnosed with insomnia only [25].
Some studies revealed no significant age-related [21, 24, 25,
30] or gender-related [21, 24] differences between groups of
OSA patients with or without concomitant insomnia. In one
study [30], a slightly higher percentage of female OSA patients suffered from concomitant insomnia (51.4% vs. 48.6%
in males); however, according to other researchers [39], the
trend was just opposite, with male OSA patients suffering
from insomnia more frequently than female OSA patients.
According to an US study, non-Hispanic white patients diagnosed with OSA suffered from insomnia more frequently
than Hispanic patients [21].
According to some authors, insomnia combined with OSA
may lead to a higher incidence of psychotic disorders [30],
emotional problems, cognitive and mental disorders as well
as purely physical complaints [21]. This population of patients appears therefore to be at a higher risk of road accidents. A strong correlation between the intensity of OSA
and cognitive capacity test results (delayed reaction times,
memory and operational disorders) is well documented in
the literature [51-53]. Patients with OSA score significantly
worse in the functional tests of P3 wave latency tests as compared to both patients with no sleep apnea and habitually
snoring patients in whom OSA was ruled out. OSA is also
slightly more common in patients with Alzheimer’s disease
as compared to an age-matched control group [52], although the latter finding was not confirmed by all authors [54].
Depression is a quite not uncommon and significant problem in OSA patients as reported by numerous researchers
[8, 30, 32-34, 37, 55, 56, 30]. However, the study by Gupta
et al. [35] revealed no higher incidence of psychiatric diseases, including depressive or anxiety disorders. The study by
Lee et al. [31] revealed a higher incidence of depression in
the group male patients, but not female patients, with both
OSA and insomnia. Using the Beck Depression Scale, Lichstein et al. [39], identified no differences in the incidence of
depression in both groups. Also a 5-year prospective, parallel-group cohort study conducted in elderly nursing home
residents with OSA provided no statistical evidence of a
significant correlation between depression and OSA [57].
Pillar et al. [58] were also unable to identify any statistically significant correlation between both disorders in a group
of 2271 patients assessed using the Symptom Self-Report
Inventory (SCL-90) questionnaire. However, Yue et al. [59]
10
were able to demonstrate a higher incidence of depression
in OSA patients when using the same tool. Patients with
both OSA and insomnia scored lower in the geriatric depression scale as compared to patients suffering only from
insomnia; however, mean results in both groups fell within
normal ranges [25, 39].
Studies on the concurrence of OSA and insomnia generally point out a higher incidence of emotional symptoms and
mood swings in these patients [21, 22, 30, 32-34, 37].
Researcher’s opinions of the etiopathogenetic background
of depression and anxiety disorders in OSA are quite discrepant. According to some authors, depression is a direct
consequence of a generally poor health, hypoxia, and sleep
fragmentation [60, 61]. Excessive daytime sleepiness and
fatigue lead to problems in everyday functioning and depression [11]. The depression is related to and manifested
by insomnia. Vital exhaustion without depressive mood as
assessed using the Beck Depression Scale is one of the main
manifestations of depression [62].
A significant percentage of patients with OSA present with
features of anxiety disorders, [21, 30, 33-34, 34, 37, 59], although the relationship could not be demonstrated in all
studies [35]. The study by Lee et al. [31] demonstrated the
effect of concurrent insomnia in the frequency of anxiety
disorders being diagnosed in in male patients only. The incidence of OSA in patients diagnosed with anxiety disorder
is significantly higher than in the patients not diagnosed
with OSA [10]. According to Yue et al. [59] patients with
OSA scored higher in Global Severity Index scale. Borak
et al. [63] demonstrated a strong correlation between the
anxiety levels and AHI scores. Krakow et al. [21] demonstrated co-occurrence of post-traumatic stress disorder and
OSA pointing to the arousal index as the factor responsible for the finding.
Psychotic disorders are also reported among psychiatric
problems observed in OSA [64]. Ancoli-Israel et al. [65]
demonstrated a 48% increase in the frequency of OSA diagnoses (defined as AHI ≥ 10) in schizophrenic patients as
compared to the control group free of psychotic symptoms.
Similar as in the case of other psychiatric disorders, effective
treatment of OSA as assessed by reduction in AHI score leads to reduction in the intensity of psychotic symptoms [11].
Attempts to elucidate the cause of psychiatric/neuropsychological disorders in OSA lead the researchers to conclude that the key role was played by the disturbed function
of the hypothalamic-pituitary-adrenal (HPA) axis [29, 46,
WWW.OTORHINOLARYNGOLOGYPL.COM
66], most probably due to repeated arousals [67]. This leads
to permanent increase in the activity of renin-angiotensin-aldosterone-cortisol syndrome [66, 68]. Increased cortisol
levels are reported to promote the development of psychiatric disorders, particularly depression [89]. Many studies pointed out to the strong relationship between insomnia and
excess activation of HPA axis [70, 71]. Increased activity/
secretion of corticotropin releasing hormone due to previous stress or genetic predisposition may lead to enhancement of everyday stress responses and thus to permanently
elevated activity of the central nervous system resulting in
insomnia [72], increased risk of cardiovascular events [67]
and mood disturbances [72].
The evidence that the concurrence of psychiatric disorders
in OSA patients is not accidental consists in reduced intensity/resolution of psychotic symptoms along with the progress in OSA treatment. Means et al. demonstrated that
the treatment of OSA using the CPAP method reduced the
symptoms of depression. Similar effects were observed for
mood disturbances [60]. The use of CPAP, overnight placement of mandibular advancement splints and bilateral
conchoplasty procedures in OSA patients led to reduced
insomnia and daytime sleepiness [73]. No such effects, particularly as regards daytime sleepiness, were observed in the
group of patients subjected to cognitive behavioral therapy
targeted at insomnia [73]. In a prospective crossover study of 30 patients with mild OSA and insomnia, matched in
terms of age and gender, managed with either CBT and surgical procedures as the primary treatment for OSA, surgical treatment itself led to resolution of insomnia in 5 out of
15 patients while not causing resolution of insomnia in any
of the patients in the group initially treated with insomnia.
Only when initiated following the surgical treatment, CBT
afforded improvement in all patients [28]. The treatment
was also reported to improve cognitive functions related to
prefrontal cortex [74].
SUMMARY
Significant discrepancies in data reported by different researchers, including evidently contradictory results of some
studies of co-occurrence of OSA and psychiatric disorders
appear to be due to several factors. Firstly, the quite arbitrary criteria for the diagnosis of insomnia as used by different researchers hindered or completely precluded comparison of individual studies [20]. Similar differences are
encountered in OSA diagnosis; some researchers qualified
their patients on the basis of AASM criteria (AHI ≥ 5 plus
accompanying symptoms) while others used a significanPOLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 1 (2015), s. 7-14
tly elevated threshold of incidence of respiratory events
(AHI ≥ 10 or AHI ≥ 15).
Numerous psychiatric disorders, including depressive disorders, include various sleep disturbances in their clinical
presentations. On the other hand, Beck Depression Scale
questionnaire includes questions regarding symptoms that
are also typical of OSA (sleepiness, fatigue, libido, concentration). Sleep quality index is also known to be strongly
correlated to the depression and anxiety scales [41, 75, 76].
This leads to difficulties in interpretation of data regarding
co-occurrence of OSA and depression.
The natural history of OSA is different in every patient and
depends not only on the value of AHI, but also on overall
health, age, systemic compensation abilities and psychiatric
profile. Numerous researchers point out that interrelations
between the intensity of OSA and the accompanying symptoms are not evident (16, 18, 36, 37, 59, 77, 78). The intensity of depression is either poorly [77] or not at all [8, 79, 80]
correlated with AHI. Similar lack of correlation is observed
in the analyses of anxiety scores [39, 63]. This is in line with
numerous observations suggesting that AHI, albeit of primary importance in OSA, is not a universal parameter of sleep
quality [35, 81]. A probable cause is that AHI reflects only the
overall number of respiratory events without considering their
severity, i.e. duration and degree of desaturation, respiratory
effort etc. The arousal index is reported to be better correlated
e.g. with fatigue [59, 82] while SO2 nadir is better correlated
with daytime sleepiness [13] or cardiovascular risk [83, 84].
Finally, the principal problem of determination of psychiatric disorders at least in part of OSA patients should be pointed out. It is known that according to the diagnostic criteria of psychiatric disorders they are by definition not related
to organic background. However, it turned out that such
background could be demonstrated in neuroimaging studies of OSA patients [85, 86]. Numerous evidence supports
the hypothesis that mood and emotional disorders are due
to microdamages within the central nervous system [75, 76,
87, 88]. CNS microdamages are observed in patients with
anxiety disorders and depression [75, 85, 86, 89]. Therefore,
these cases constitute rather a sort of psychoorganic syndromes of natural history identical to neurotic or psychotic
disorders, albeit with organic damages in the background.
As demonstrated by this literature review, the problem of
co-occurrence of OSA and psychiatric disorders, although
confirmed in numerous papers, requires further studies
and every new publication based on clinical material would
present a valuable contribution to the current knowledge.
11
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Word count: 3198 Tables: – Figures: – References: 90
Access the article online: DOI: 10.5604/20845308.1136062 Full-text PDF: www.otorhinolaryngologypl.com/fulltxt.php?ICID=1136062
Corresponding author: [email protected]
Copyright © 2015 Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o. All rights reserved Competing interests: The authors declare that they have no competing interests.
Cite this article as: Daniłosio M., Wysocki J.: Role of psychiatric status assessment of patient with obstructive sleep apnea. Pol Otorhino Rev 2015; 4(1): 7-14
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