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Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence

BMJ 1997; 314 doi: (Published 22 March 1997) Cite this as: BMJ 1997;314:851

Obstructive Sleep Apnea Syndrome and Depression

Dear Editor,

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 [8].
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 [9]. Support for this hypothesis comes largely from studies
showing reduced depression following CPAP treatment [10–13], even when
treatment adherence is poor
[14]. Improvement in depression following CPAP therapy is not a universal
finding, however, [15] 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 [20]. 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 [23].



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Competing interests:
None declared

Competing interests: No competing interests

06 April 2005
Mustafa S. Gozeler
Department of Otolaryngology, Head&Neck Surgery
Murat Enoz
Istanbul University, School of Medicine Turkey