Megan Brooks

June 14, 2012

June 14, 2012 (Boston, Massachusetts) — Depressive symptoms improve after positive airway pressure (PAP) for obstructive sleep apnea (OSA), clinicians from the Cleveland Clinic Sleep Disorders Center found in a large study.

An easing of depressive symptoms was seen "in all study patients," even those who were only partially adherent to the PAP regimen, principal investigator Charles Bae, MD, reported here at SLEEP 2012: Associated Professional Sleep Societies 26th Annual Meeting.

The greatest benefit, however, was seen in patients who were adherent to PAP therapy.

In comments to Medscape Medical News, Shelby F. Harris, PsyD, CBSM, director, Behavioral Sleep Medicine Program, Sleep-Wake Disorders Center, Montefiore Medical Center, Bronx, New York, who was not involved in this research, said it's a "promising study overall, and one that continues to stress the correlations between apnea and depression."

Benefits All Around

The association between sleep apnea and depressive symptoms is "well-known," Dr. Bae said during his oral presentation here, yet there are "conflicting reports" on the benefit of PAP therapy on easing depressive symptoms.

He and his colleagues studied 779 patients being seen at the Cleveland Clinic Sleep Disorders Center between January 2008 and July 2011. Their average age was 52.9 years, 47.6% were men, 77.5% were white, and 61.8% were married.

The researchers used the Patient Health Questionnaire 9 (PHQ-9) to measure change in depressive symptoms after using PAP therapy for OSA. All study patients had to have at least 2 outpatient visits with a pre-PAP PHQ-9 score of 5 or higher, indicating minimal or greater depressive symptoms.

Six hundred sixty-two patients (85%) were adherent PAP users ( > 4 hours/night), and 117 were nonadherent users (15%). In the PAP-adherent group, 47 (61.5%) had an Epworth Sleepiness Scale (ESS) score of 10 or higher. Baseline PHQ-9 scores for adherent vs nonadherent PAP users were similar (11.2 and 11.8, respectively).

Dr. Bae reported that all patients who used PAP showed a significant decrease in depressive symptoms on the PHQ-9. The PHQ-9 score decrease for adherent PAP users was 3.8, compared with 2.0 for nonadherent PAP users (P = .0002).

Within the PAP-adherent group, baseline PHQ-9 scores for sleepy (ESS score 10 or greater) vs nonsleepy patients were 12.1 and 9.9, respectively (P = .0015). Among adherent PAP users, the PHQ-9 score decrease for sleepy patients was 4.3 compared with 3.1 for nonsleepy patients (P = .0041).

"The score improvements remained significant even after taking into account whether a patient had a prior diagnosis of depression or was taking an antidepressant," Dr. Bae commented in a conference statement. "The improvements were greatest in sleepy, adherent patients but even non-adherent patients had better PHQ-9 scores."

"Interestingly," he said, married patients had a greater decrease in PHQ-9 scores compared with single or divorced patients.

An Area of Debate

Whether continuous PAP (CPAP) therapy eases depressive symptoms has been "an area of debate for a number of years with data being quite mixed looking at the effect of CPAP treatment on depression. However, this is a large study (many are not) and uses the PHQ-9, which many have not used before."

"The study," Dr. Harris said, "adds more information, using a different depression scale in a large sample, to the depression/CPAP debate. Patients who present with OSA need to be thoroughly assessed for depression and suicidal/homicidal ideation. The apnea needs to be treated regardless."

Her advice: "Consider the severity of the depression and make a clinical call whether or not increasing energy may also have a positive impact on their depression. If the depression is moderate to severe in nature, consider therapy or medication in addition CPAP as the data is still not completely consistent across the board that depression is lessened with CPAP use."

The authors and Dr. Harris have disclosed no relevant financial relationships.

SLEEP 2012: Associated Professional Sleep Societies 26th Annual Meeting. Abstract #0403. Presented June 12, 2012.

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