Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidenceBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7084.851 (Published 22 March 1997) Cite this as: BMJ 1997;314:851
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The goals of the treatment of obstructive sleep apnea (OSA) should be
aimed at alleviating symptoms while decreasing morbidity and mortality in
a manner that minimizes side effects.
Isolated UPPP has been shown to have limited success for treatment of
OSA patients. In comparison, palatal procedures combined with other
surgical approaches that address the multiple sites of obstruction in the
upper aerodigestive tract seem to have improved success in the carefully
Many surgical procedures have been described during the last 20
years . The uvulopalatopharyngoplasty (UPPP) first described in 1981 by
Fujita et al , continues to be the mainstay. Since its introduction,
there has been considerable effort expended studying the efficacy of this
procedure and the role that it should play in the management of OSA.
Unfortunately, the results of these studies have shown that UPPP as an
isolated intervention for the treatment of OSA has met with mediocre
Sher et al  have shown that UPPP is effective in only
approximately half of the cases of OSA when success is defined as a drop
in the AHI by 50%. When more stringent criteria are used-absolute decline
in the apnea index to less than 10 or an AHI less than 20-the success rate
is lowered to 40.7% .
1. Sher AE. Upper airway surgery for obstructive sleep apnea. Sleep
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modifications of the upper airway in adults with obstructive sleep apnea
syndrome. Sleep. 1996 Feb;19(2):156-77.
Competing interests: No competing interests
Obstructive sleep apnea (OSA) is characterized by periodic complete
or partial upper airway obstruction during sleep, causing intermittent
cessations of breathing (apneas) or reductions in airflow (hypopneas)
despite ongoing respiratory effort. This disorder has been described for
decades, but its recognition has remained a problem.
Depressive symptoms are widely regarded as typical clinical sequelae
of Obstructive Sleep Apnea Syndrome (OSAS) [1–3]. Most case–control
studies have reported increased prevalence rates of depression in OSAS
compared to controls [4–7].
OSAS can lead to feelings of fatigue, tiredness, lack of energy, and
irritability. These somatic symptoms are also hallmarks of depression .
Thus, one possibility for elevated depression scores in OSAS patients is
that they may frequently endorse such items on depression scales. Rather
than being related to a distinct psychiatric disorder, however,
affirmative responses may more accurately reflect the consequences of
apnea severity. Indeed, this view that depression is largely an
epiphenomenon of OSAS has led some to conclude that the relationship
should be conceptualized as a mood disorder secondary to a medical
disorder . Support for this hypothesis comes largely from studies
showing reduced depression following CPAP treatment [10–13], even when
treatment adherence is poor
. Improvement in depression following CPAP therapy is not a universal
finding, however,  and treatment studies with short-term follow-ups
have found that symptomatic improvement may reflect a placebo-response
An alternative explanation is that the relationship between OSAS and
depression is indirect, mediated by a correlate of OSAS, such as obesity.
Obesity is the strongest risk factor for the development of OSAS [18,19].
One theory to explain this relationship suggests that obese
individuals suffer body image dissatisfaction, discrimination, guilt from
past failures to lose weight, and psychosocial distress . Moreover,
body image dissatisfaction has been shown to mediate partially the
relationship between obesity and depression [21,22]. Experimental studies
also support this view, showing that changes in body image associated with
significant weight loss are associated with significant reductions in
depressed mood .
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sleepdisordered breathing in ages 40–64 years: a population-based survey.
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Competing interests: No competing interests