Obstructive sleep apnea and psychiatric disorders: a systematic review

Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.

The Microbiome in Obstructive Sleep Apnea

Recent evidence has highlighted important associations between obstructive sleep apnea and the microbiome. Although the intricacies of the pathophysiologic mechanisms are not well understood, available evidence suggests a bidirectional relationship between OSA and microbiota composition. Sleep fragmentation, intermittent hypoxia, and intermittent hypercapnia all play significant roles in altering the microbiome, and initial evidence has shown that alterations of the microbiota affect sleep patterns. Animal model evidence strongly supports the idea that the microbiome mediates disease states associated with OSA including hypertension, atherosclerosis, and obesity. The majority of evidence focuses on changes in the gut microbiome, which may result from OSA as well as contribute to sleep pattern changes, OSA-related CVD, and obesity. Meanwhile, a developing body of work suggests changes in the upper airway microbiome may be associated with OSA and periodontitis-related oral cavity microbiome changes may have significance in OSA-related CVD. Lastly, while evidence is limited, several studies suggest there may be a role for treatment of OSA and OSA-related comorbidities through alteration of the microbiome with probiotics, prebiotics, and microbiota transplantation. These early animal and human studies begin to characterize the interrelationships of the microbiome and OSA and may lead to new avenues for treatment.

Psychological Well-Being in Obstructive Sleep Apnea Syndrome Associated With Obesity: The Relationship With Personality, Cognitive Functioning, and Subjective and Objective Sleep Quality

Obstructive sleep apnea (OSA) syndrome severely affects psychological well-being. This syndrome frequently occurs in obesity; however, no previous study has investigated the level of psychological well-being in the case of OSA syndrome associated with obesity. In this work, we assessed the level of psychological well-being in fifty-two individuals affected by OSA syndrome and obesity through the Psychological General Well-Being Index. Moreover, we investigated the role of personality, cognitive functioning and attentional capabilities, subjective perception and objective measurement about sleeping, on the subjective perception of psychological well-being. Our sample reported a lower level of psychological well-being; the participants' scores were below the normative cut-off in all components, except for depression symptoms. A lower expression of harm avoidance temperament and a lower level of daily sleepiness predicted a higher level of psychological well-being. Psychological well-being seemed to be severely affected in individuals affected by OSA syndrome and obesity. The temperament and subjective perception of daily alertness and sleepiness, rather than the syndrome severity, seemed to play a crucial role in the individual perception of the psychological well-being.

Mood, sleepiness, and weight gain after three years on CPAP therapy for sleep apnoea

Background: The prevalence of obstructive sleep apnoea syndrome (OSAS) keeps on rising. Daytime sleepiness resulting from fragmented sleep is the prime symptom, and obesity the major risk factor for OSAS. Quality of life with OSAS is often affected by depressive symptoms and anxiety. Nasal continuous positive airway pressure (CPAP) therapy reduces daytime sleepiness, but the results on the effect on mood, physical activity, and weight are controversial especially on long-term therapy. Purpose of this study was to evaluate these factors and predictors of weight gain during long-term CPAP therapy.

Methods: Consecutive patients (n = 223), referred to sleep study with suspected OSAS, were enrolled. Patients underwent a cardiorespiratory polygraphy at baseline and a battery of questionnaires was completed, both at baseline, and after three years of follow-up. Total of 149 (67%; M 65, F 84) patients completed the follow-up. Of the 149 patients, 76 (51.0%; M 32, F 44) used CPAP.

Results: In this study, depressive symptoms, anxiety, and sleepiness were alleviated during CPAP therapy. However, therapy did not have an influence on cravings of different food categories, or exercise habits and exercise duration. From the various factors studied, solely higher adherence to CPAP therapy was associated with weight gain.

Conclusions: This research provides further evidence that long-term CPAP therapy in patients with OSAS not only decreases sleepiness and improves sleep quality but could also alleviate depressive symptoms and anxiety. In addition, our study reinforces that CPAP therapy alone is not sufficient for weight management in patients with OSAS. Regardless of comprehensive battery of questionnaires, we were unable to establish markers predicting weight gain during therapy. We advise on life-style counselling and weight management program to all patients with obesity on CPAP therapy.

Obstructive sleep apnea syndrome as a potential cause of sexual dysfunction in women : Sexual dysfunction in women

BACKGROUND

Obstructive sleep apnea (OSA) is defined as the cessation of respiration due to recurrent and partial or complete blockade of the upper airways during sleep. Nocturnal hypoxemia due to OSA may accompany these conditions, with significant negative impact on the life quality of patients leading to mental and/or sexual dysfunction. OSA as a cause of sexual dysfunction in women has been subject to very little research. The goal of this study was to examine the effect of OSA on sexual functions in women suffering from this disorder.

METHODS

Patients with OSA were categorized into two groups, those with and those without sexual dysfunction.

RESULTS

When women with OSA and healthy women were compared, age (p < 0.001), body mass index (BMI) (p < 0.001), Beck Anxiety Inventory (BAI) (p < 0.001), Beck Depression Inventory (BDI) (p = 0.001), there was a significant difference in the Arizona Sexual Experience Scale (ASEX), (p = 0.02). When women with OSA were compared in terms of sexual dysfunction, a significant difference was found in apnea-hypopnea index (AHI) (p = 0.01) and ASEX (p < 0.001). There were no significant differences in hormonal parameters between the two groups.

CONCLUSION

Sexual dysfunction in females is a largely under-recognized but important condition. Symptoms caused by OSA may include sexual dysfunction which may increase the prevalence of depression and anxiety, further reducing the quality of life.

Sleep Duration and Snoring at Midlife in Relation to Healthy Aging in Women 70 Years of Age or Older

PURPOSE

Both short and long sleep durations are associated with higher mortality. This study examined the association between sleep duration and overall health among those who survive to older ages.

PARTICIPANTS AND METHODS

In the Nurses' Health Study, participants without major chronic diseases in 1986 and survived to age 70 years or older in 1995-2001 were included. Habitual sleep duration and snoring were self-reported in 1986. Healthy aging was defined as being free of 11 major chronic diseases and having no cognitive impairment, physical impairment, or mental health limitations. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for healthy aging.

RESULTS

Of the 12,304 participants, 1354 (11.0%) achieved healthy aging. We observed a non-linear association between sleep duration and the odds of achieving healthy aging. Compared with women sleeping 7 hours per day, women with longer sleep duration were less likely to achieve healthy aging; there was also a suggestion of lower odds of healthy aging for shorter sleepers, although the associations did not reach statistical significance: the multivariate-adjusted ORs (95% CIs) of healthy aging for those sleeping ≤5, 6, 8, and ≥9 hours were 0.94 (0.70, 1.27), 0.88 (0.76, 1.02), 0.83 (0.72, 0.96), and 0.60 (0.43, 0.84), respectively. Similar non-linear associations were consistently observed for individual dimensions of healthy aging. Regular snoring was associated with 31% lower odds of healthy aging (95% CI: 0.54, 0.88), which was primarily due to lower odds of having no major chronic diseases.

CONCLUSION

Both short and long sleep durations as well as regular snoring at midlife were associated with lower odds of healthy aging in later life.

The Complex Interaction Between the Major Sleep Symptoms, the Severity of Obstructive Sleep Apnea, and Sleep Quality

Introduction: Little information exists in the general population whether clinical presentation phenotypes of obstructive sleep apnea (OSA) differ in terms of sleep quality and comorbidities. Aim: The purpose of our study was to assess possible differences between symptomatic and asymptomatic OSA patients concerning syndrome's severity, patients' sleep quality, and comorbidities. Subjects and methods: First, in a nationwide, stratified, epidemiological survey, 4,118 Cypriot adult participants were interviewed about sleep habits and complaints. In the second stage of the survey, 264 randomly selected adults underwent a type III sleep study for possible OSA. Additionally, they completed the Greek version of Pittsburgh Sleep Quality Index (Gr-PSQI), Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), and Hospital Anxiety and Depression Scale (HADS). Results: From 264 enrolled participants, 155 individuals (40 females and 115 males) were first diagnosed with OSA. Among these 155 patients, 34% had ESS ≥ 10 and 49% AIS ≥ 6. One or both symptoms present categorized the individual as symptomatic (60%) and neither major symptom as asymptomatic (40%). There were no significant statistical differences (SSDs) between the two groups (symptomatic-asymptomatic) with regard to anthropometrics [age or gender; neck, abdomen, and hip circumferences; and body mass index (BMI)]. The two groups had no differences in OSA severity-as expressed by apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and mean oxyhemoglobin saturation (SaO₂)-and in cardiometabolic comorbidities. Symptomatic patients expressed anxiety and depression more often than asymptomatics (p < 0.001) and had poorer subjective sleep quality (Gr-PSQI, p < 0.001). According to PSQI questionnaire, there were no SSDs regarding hours in bed and the use of sleep medications, but there were significant differences in the subjective perception of sleep quality (p < 0.001), sleep efficiency (p < 0.001), duration of sleep (p = 0.001), sleep latency (p = 0.007), daytime dysfunction (p < 0.001), and finally sleep disturbances (p < 0.001). Conclusion: According to our data, OSA patients reporting insomnia-like symptoms and/or sleepiness do not represent a more severe phenotype, by the classic definition of OSA, but their subjective sleep quality is compromised, causing a vicious cycle of anxiety or depression.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Case Report: Parasomnia Overlap Disorder Induced by Obstructive Sleep Hypopnea Apnea Syndrome: A Case Report and Literature Review

Obstructive sleep apnea hypopnea syndrome (OSAHS) and parasomnia overlap disorder (POD) are types of sleep disorders. When the symptoms of both conditions coexist, the POD symptoms are most likely caused by OSAHS. In these cases, the symptoms of POD will be relieved when OSAHS is effectively treated. We refer to these cases as symptomatic POD (related to OSAHS), which differs in pathophysiology, complications, and treatment from idiopathic POD. It is important to note that the treatment for idiopathic POD may aggravate the symptoms of OSAHS. In this case, we used video polysomnography (v-PSG) on a POD patient with suspected OSAHS to distinguish idiopathic POD from symptomatic POD, to inform the appropriate treatment course. The video results and clinical features lead us to diagnose symptomatic POD, and we treated the patient with auto-set continuous positive airway pressure to address their OSAHS. This course of treatment resolved all POD-related symptoms. Here, we discuss this case and review the relevant literature. This report highlights the importance of the use of v-PSG in the clinical diagnosis, differential diagnosis, and subsequent treatment of POD.

The gut microbiome as a target for adjuvant therapy in obstructive sleep apnea

Introduction: Gut dysbiosis is assumed to play a role in obstructive sleep apnea (OSA)-associated morbidities. Pre- and probiotics, short chain fatty acids (SCFA) and fecal matter transplantation (FMT) may offer potential as novel therapeutic strategies that target this gut dysbiosis. As more mechanisms of OSA-induced dysbiosis are being elucidated, these novel approaches are being tested in preclinical and clinical development. Areas covered: We examined the evidence linking OSA to gut dysbiosis and discuss the effects of pre- and probiotics on associated cardiometabolic, neurobehavioral and gastrointestinal disorders. The therapeutic potential of SCFA and FMT are also discussed. We reviewed the National Center for Biotechnology Information database, including PubMed and PubMed Central between 2000 - 2020. Expert opinion: To date, there are no clinical trials and only limited evidence from animal studies describing the beneficial effects of pre- and probiotic supplementation on OSA-mediated dysbiosis. Thus, more work is necessary to assess whether prebiotics, probiotics and SCFA are promising future novel strategies for targeting OSA-mediated dysbiosis.

Troubles psychotiques et troubles du sommeil : revue de la littérature

Contexte La disparition de la nomenclature des troubles du sommeil dits primaires ou secondaires, rendue obsolète par le Manuel diagnostique et statistique des troubles mentaux (DSM-5), représente bien l’engouement académique actuel pour ce domaine de recherche. Il est de plus en plus reconnu que les troubles du sommeil sont plus que de simples conséquences d’un trouble psychiatrique et qu’ils peuvent persister malgré un traitement adéquat de la condition comorbide et même précéder ou exacerber cette dernière. Les troubles du sommeil dans les troubles psychotiques, très fréquents, sont donc devenus un sujet d’actualité, représentant une cible d’intervention jusqu’ici sous-estimée.

Objectif Cet article vise à présenter l’état des connaissances actuelles sur la relation entre les troubles du sommeil et les troubles psychotiques ainsi que sur l’utilisation de la thérapie cognitivo-comportementale (TCC) pour traiter les troubles du sommeil dans ce contexte.

Méthode L’article fait une recension narrative de la littérature pour décrire la relation bidirectionnelle entre la psychose et les troubles du sommeil, les corrélations cliniques et les traitements ciblant l’insomnie chez les patients psychotiques.

Résultats Malgré la présence d’une relation entre les troubles du sommeil et les troubles psychotiques, les mécanismes neuronaux, hormonaux et socioculturels régissant cette relation demeurent encore incertains. Bien que l’association reliant les troubles du sommeil et les troubles psychotiques demeure à clarifier, les études démontrent qu’elle serait bidirectionnelle et peut engendrer un cercle vicieux où ces deux composantes s’aggravent mutuellement. Dans ce contexte de comorbidités, les modèles unifiés en TCC deviennent un traitement de choix, à condition d’adapter les protocoles de TCC pour insomnie (TCC-i) à une population avec trouble psychotique (TCC-ip).

Conclusion Malgré la complexité de la relation entre les troubles psychotiques et ceux du sommeil, la TCC-i a été démontrée efficace pour traiter les troubles du sommeil dans une population psychotique et pourrait, dans certains cas, permettre d’alléger la symptomatologie psychotique. De futures études sur ce domaine pourraient permettre le développement de protocoles de thérapie cognitivo-comportementale pour les troubles du sommeil mieux adaptés à la population avec troubles psychotiques.

Association between obstructive sleep apnea and multiple involuntary job loss history among recently unemployed adults

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with negative occupational outcomes including absenteeism and poor work productivity. This analysis explored whether the severity of OSA was associated with multiple involuntary job loss history among recently unemployed adults.

METHODS

This is a cross-sectional analysis of data from the screening visit of the Assessing Daily Activity Patterns Through Occupational Transitions study. Information was collected from 261 participants who recently involuntarily lost their jobs. Data included demographics, employment, medical history, and results from a limited channel home sleep apnea test. The respiratory event index was categorized as <5 events per hour (no-OSA), 5 to <15 (mild OSA), and ≥15 (moderate to severe OSA). Logistic regression and propensity score matching were used to identify factors associated with multiple involuntary job loss.

RESULTS

A total of 44.8% of participants reported multiple involuntary job loss. Those with mild OSA had 1.85 (95%CI: 1.04, 3.28) increased odds of reporting multiple involuntary job loss as compared to participants with no OSA in the unadjusted model; while participants with moderate-to-severe OSA had 2.71 (95%CI: 1.33, 5.70) increased odds. After adjusting for age, sex, ethnicity, beginning work between 7 and 9 AM, job type, and, compensation type, the odds of involuntary job loss among participants with moderate-severe OSA were 2.46 (95%CI: 1.13, 5.52) as compared to having no OSA.

CONCLUSIONS

In a sample of recently unemployed adults, having OSA significantly increased the odds of reporting previous involuntary job losses. This study suggests OSA could be a risk factor for job loss.

Neuroendocrine abnormalities associated with untreated first episode patients of major depressive disorder with comorbid obstructive sleep apnea

There are few studies that explore the relationship of neuroendocrine hormones of the HPA, HPT and HPG axes with major depressive disorder (MDD) with comorbid obstructive sleep apnea (OSA). The aim of this study is to examine neuroendocrine abnormalities and the relationship in untreated first episode patients of MDD comorbided with OSA. Polysomnography, neuroendocrine hormones were determined for 111 patients. After excluding the influences of age and BMI, phase I in non-REM sleep (N1)% increased significantly in MDD with OSA when compared with non-OSA. In the OSA group, cortisol increased and exceeded the normal standard, and for the numbers of patients exceeding the normal range, there were significant difference between two groups. In MDD with OSA, adrenocorticotropic hormone was significantly negatively correlated with slow wave sleep (SWS)%, while thyroxine was significantly correlated with phase II in non-REM sleep (N2)%, and prolactin was significantly negatively correlated with N1%. This study revealed that for untreated first episode MDD patients with OSA, the HPA axis was hyperfunctional. Cortisol and adrenocorticotropic hormone may be increased along with disturbed sleep structure and less slow-wave sleep time. Concurrently prolactin was decreased and thyroxine increased during the N1 and N2 phase of sleep.

BMI-NECK: A simple assessment of risk of obstructive sleep apnea in schizophrenia

INTRODUCTION

A high risk of obstructive sleep apnea (OSA) has been reported in patients with schizophrenia. However, existing screening questionnaires for OSA haven't been validated in this population and the impact of OSA on schizophrenia symptoms has rarely been studied. This study aimed to investigate the prevalence and impact of OSA in patients with schizophrenia and validate the existing OSA screening scales.

METHOD

Patients with schizophrenia consecutively admitted to hospital (n = 51) and patients with schizophrenia and obesity (n = 31) were compared to healthy controls (n = 51). Apnea risk was measured with STOP-BANG, NoSAS, No-Apnea, and the Berlin Questionnaire; psychiatric symptoms were measured with the PANSS and Calgary scales and B-CATS battery. Daytime sleepiness was measured with the Epworth sleepiness scale. OSA was diagnosed using the Embletta system.

RESULTS

OSA was found more frequently in obese schizophrenia patients than in those consecutively admitted to hospital (45% vs. 22%, p < 0.05). Significant differences between patients with and without OSA were found on the PANSS negative symptoms subscale, B-CATS digit symbol test, and in daytime sleepiness. None of the used screening scales showed satisfactory sensitivity and specificity. Obesity with coexisting neck circumference ≥41 cm in women or ≥43 cm in men (BMI-NECK model) predicted OSA in 57% of cases.

CONCLUSIONS

OSA should be screened in patients with schizophrenia as it has a negative influence on psychiatric symptoms and may contribute to the higher mortality of these patients. Assessment of BMI and neck circumference proves a good screening test in ambulatory contexts.

Medication of comorbidities in females with sleep-disordered breathing during long-term CPAP therapy

BACKGROUND

Treating sleep disordered breathing (SDB) with nasal continuous positive airway pressure (CPAP) may reduce mortality, but the studies on the effect on medication use are few. Women tend to have more mild sleep apnoea and partial airway obstruction and are therefore expected to have less co-morbidity. The purpose of this study was to evaluate the effect of CPAP therapy on medication use in women as overall medication, and in different subcategories of diseases, and to evaluate the impact of nocturnal airway obstruction type as partial or complete.

METHODS

From the database of the Department of Pulmonary Diseases in Turku University Hospital from 1994 to 1998, 601 consecutive females with SDB were enrolled, and the type of SDB was evaluated. All were offered CPAP therapy. The medication use measured as defined daily doses (DDD) in overall medication and in nine subcategories were collected three years before and three years after CPAP initiation.

RESULTS

In final analyses, 182 women were included. In CPAP users (n = 66), comorbidities were more frequent and DDDs higher overall, in asthma, in chronic obstructive pulmonary disease, and in severe mental disorders, both before and after CPAP initiation. The medication use was similar regardless of the type of SDB. The change in medication use was similar as in controls.

CONCLUSIONS

CPAP therapy did not decrease medication use in three-year follow-up. However, possibly continuous rise in medication use was prevented, as the change in medication use was similar in controls. Complete and partial obstruction had similar effects.

Sleep problems in active duty military personnel seeking treatment for posttraumatic stress disorder: presence, change, and impact on outcomes

Study Objectives

To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes.

Methods

Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed.

Results

At baseline, the average sleep duration was &lt; 5 h per night on weekdays/workdays and &lt; 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (&gt;70%) and nightmares (&gt;38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments.

Conclusions

Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients.

Clinical Trial Registration

NCT01049516.

Effect of ventilation therapy on mortality rate among obesity hypoventilation syndrome and obstructive sleep apnoea patients

INTRODUCTION

The prevalence of obesity is continually increasing worldwide, which increases the incidence of obesity hypoventilation syndrome (OHS) and its consequent mortality.

METHODS

We reviewed the therapy mode, comorbidity and mortality of all OHS patients treated at our hospital between 2005 and 2016. The control group consisted of randomly selected patients with obstructive sleep apnoea (OSA) treated during the same period.

RESULTS

We studied 206 OHS patients and 236 OSA patients. The OHS patients were older (56.3 versus 52.3 years, p<0.001) and heavier (body mass index 46.1 versus 32.2 kg·m-2, p<0.001), and the percentage of women was higher (41.2% versus 24.2%, p<0.001), respectively. The OHS patients had more hypertension (83% versus 61%, p<0.001) and diabetes (62% versus 31%, p<0.001) than the OSA patients, but no higher stroke (4% versus 8%, p=0.058) or ischaemic heart disease (14% versus 15%, p=0.437) incidence. The 5- and 10-year, unadjusted survival rates were lower among the OHS patients than among the OSA patients (83% versus 96% and 74% versus 91%, respectively; p<0.001). Differences in mortality rates were not related to age, sex or body mass index; covariates such as Charlson Comorbidity Index and ventilation therapy predicted survival. The mortality rate decreased significantly (p<0.001) both in OHS and OSA patients even after adjusting for covariates.

CONCLUSIONS

The mortality rate in OHS was significantly higher than that in OSA patients even after adjusting for covariates. Ventilation therapy by continuous positive airway pressure or noninvasive ventilation have reduced mortality significantly in all patients.

Screening for obstructive sleep apnoea in an early psychosis cohort: a pilot study

OBJECTIVE

Rates of obstructive sleep apnoea (OSA) appear to be lower in the youth population (< 4%) compared to the general population (6%-17%); rates in people with psychotic illness are estimated at 13.5%-57.1%. We hypothesised that this comorbidity extends to early psychosis (EP) populations, and used previously validated OSA questionnaires to screen for OSA in an EP cohort.

METHOD

Fifty-three patients were screened using the OSA50 and STOP-Bang questionnaires with collection of anthropometric measures. Patients who screened positively were referred for polysomnography.

RESULTS

Fifteen per cent (8/53) screened positively; most frequently endorsed measures included BMI > 25, snoring, hypertension, neck circumference (> 40 cm) and male gender. Only 2/8 patients accepted polysomnography.

CONCLUSIONS

Screening indicates OSA may be more prevalent in EP populations than age-equivalent cohorts, but ongoing research is required.

Non-contact diagnosis of obstructive sleep apnea using impulse-radio ultra-wideband radar

While full-night polysomnography is the gold standard for the diagnosis of obstructive sleep apnea, its limitations include a high cost and first-night effects. This study developed an algorithm for the detection of respiratory events based on impulse-radio ultra-wideband radar and verified its feasibility for the diagnosis of obstructive sleep apnea. A total of 94 subjects were enrolled in this study (23 controls and 24, 14, and 33 with mild, moderate, and severe obstructive sleep apnea, respectively). Abnormal breathing detected by impulse-radio ultra-wideband radar was defined as a drop in the peak radar signal by ≥30% from that in the pre-event baseline. We compared the abnormal breathing index obtained from impulse-radio ultra-wideband radar and apnea-hypopnea index (AHI) measured from polysomnography. There was an excellent agreement between the Abnormal Breathing Index and AHI (intraclass correlation coefficient = 0.927). The overall agreements of the impulse-radio ultra-wideband radar were 0.93 for Model 1 (AHI ≥ 5), 0.91 for Model 2 (AHI ≥ 15), and 1 for Model 3 (AHI ≥ 30). Impulse-radio ultra-wideband radar accurately detected respiratory events (apneas and hypopneas) during sleep without subject contact. Therefore, impulse-radio ultra-wideband radar may be used as a screening tool for obstructive sleep apnea.

Sleep Disturbances and Suicidality in Posttraumatic Stress Disorder: An Overview of the Literature

A causal relationship between sleep disturbances and suicidal behavior has been previously reported. Insomnia and nightmares are considered as hallmarks of posttraumatic stress disorder (PTSD). In addition, patients with PTSD have an increased risk for suicidality. The present article gives an overview about the existing literature on the relationship between sleep disturbances and suicidality in the context of PTSD. It aims to demonstrate that diagnosing and treating sleep problems as still underestimated target symptoms may provide preventive strategies with respect to suicidality. However, heterogeneous study designs, different samples and diverse outcome parameters hinder a direct comparison of studies and a causal relationship cannot be shown. More research is necessary to clarify this complex relationship and to tackle the value of treatment of sleep disturbances for suicide prevention in PTSD.

Continuous positive airway pressure can improve depression in patients with obstructive sleep apnoea syndrome: a meta-analysis based on randomized controlled trials

Objective

Substantial research indicates a clear relationship between obstructive sleep apnoea syndrome (OSAS) and depression. The study aim was to quantitatively evaluate whether continuous positive airway pressure (CPAP) therapy improves mood symptoms in OSAS patients.

Methods

PubMed and Embase databases were systematically searched up to 2017 for publications on the impact of CPAP on mood symptoms in OSAS patients.

Results

For the final analysis, nine randomized controlled trials comprising 1,052 patients were selected. The pooled standard mean difference (SMD) of the effect of CPAP on depression was 0.31 (95% confidence interval 0.18, 0.43). A subgroup analysis showed that when CPAP use was greater than 4 hours per night, it tended to be effective in improving patients’ mood symptoms (SMD = 0.38; confidence interval 0.23, 0.54). Analysis of publication bias using Egger’s test found no evidence of publication bias.

Conclusion

CPAP treatment can improve depression in OSAS patients.

Electrocardiogram-based sleep analysis for sleep apnea screening and diagnosis

PURPOSE

Despite the increasing number of research studies of cardiopulmonary coupling (CPC) analysis, an electrocardiogram-based technique, the use of CPC in underserved population remains underexplored. This study aimed to first evaluate the reliability of CPC analysis for the detection of obstructive sleep apnea (OSA) by comparing with polysomnography (PSG)-derived sleep outcomes.

METHODS

Two hundred five PSG data (149 males, age 46.8 ± 12.8 years) were used for the evaluation of CPC regarding the detection of OSA. Automated CPC analyses were based on ECG signals only. Respiratory event index (REI) derived from CPC and apnea-hypopnea index (AHI) derived from PSG were compared for agreement tests.

RESULTS

CPC-REI positively correlated with PSG-AHI (r = 0.851, p < 0.001). After adjusting for age and gender, CPC-REI and PSG-AHI were still significantly correlated (r = 0.840, p < 0.001). The overall results of sensitivity and specificity of CPC-REI were good.

CONCLUSION

Compared with the gold standard PSG, CPC approach yielded acceptable results among OSA patients. ECG recording can be used for the screening or diagnosis of OSA in the general population.

Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms

The current report provides an updated review of sleep disturbance in posttraumatic stress disorder and anxiety-related disorders. First, this review provides a summary description of the unique and overlapping clinical characteristics and physiological features of sleep disturbance in specific DSM anxiety-related disorders. Second, this review presents evidence of a bidirectional relationship between sleep disturbance and anxiety-related disorders, and provides a model to explain this relationship by integrating research on psychological and neurocognitive processes with a current understanding of neurobiological pathways. A heuristic neurobiological framework for understanding the bidirectional relationship between abnormalities in sleep and anxiety-related brain pathways is presented. Directions for future research are suggested.

The use of visceral adiposity variables in the prediction of obstructive sleep apnea: evidence from a large cross-sectional study

PURPOSE

The purposes of this study were to evaluate the ability of visceral adiposity variables [the lipid accumulation product (LAP), the visceral adiposity index (VAI), and the triglyceride-glucose index (TyG)] in predicting obstructive sleep apnea hypopnea syndrome (OSAHS) and to determine the effect of sex on the prediction.

METHODS

A total of 5539 subjects admitted to the sleep center for suspected OSAHS were consecutively recruited from 2007 to 2016. Anthropometric measurements, biological indicators, Epworth sleepiness scale score, and polysomnographic variables were collected. Prediction models for diagnosing OSAHS were established in the test group by logistic regression and verified in the validation group by receiver operating characteristic (ROC) curves.

RESULTS

A total of 4703 patients were included in total. LAP and TyG were of moderate diagnostic accuracy for OSAHS, with the diagnostic efficiency differing between men and women. A prediction model was developed that combined visceral adiposity indicators with waist circumstance and the lowest SpO₂. The sensitivity of those indicators were both 84% in men and women, respectively, and their specificity were both 90%. In addition, the model was confirmed in the validation group with a sensitivity and specificity of 83% and 85% in men and 85% and 84% in women.

CONCLUSIONS

LAP and TyG were of moderate efficiency in screening for OSAHS. The prediction model provides a simple and practical screening tool for OSAHS.

Dreams and Nightmares in Patients With Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA) can present with or provoke various psychological symptoms. In this article, we critically review studies that have examined dreams, dream recall, and dream content in patients with OSA. Obstructive events induce recurrent sleep fragmentation and intermittent desaturations in patients with OSA, which may trigger different parasomnias, including nightmares. Contradictory results have been reported concerning dreams in patients with OSA; while some investigators have reported less dreams in OSA patients, others have described that patients with OSA have increased dreams with emotional content, mainly violent and hostile content. Although there are reports of respiratory-related dream content in patients with OSA, most studies that have assessed the dream content of patients with OSA revealed that respiratory-related dream content was unusual. A clear association between post-traumatic stress disorders, comorbid OSA, and nightmares has been reported in several studies. Furthermore, an improvement in nightmare frequency with continuous positive airway pressure (CPAP) treatment has been shown. An inverse relationship between the severity of OSA reflected by the apnea-hypopnea index and dream recall has been demonstrated in several studies. Future studies should differentiate between patients with non-stage specific OSA and patients with rapid eye movement (REM) predominant OSA.

Association of Obstructive Sleep Apnea With the Risk of Affective Disorders

Importance

Obstructive sleep apnea (OSA) is a common subtype of sleep breathing disorder; however, the association between OSA and the psychological health of affected individuals has not been fully evaluated.

Objective

To investigate the association between OSA and development of affective disorders.

Design, Setting, and Participants

This study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database comprising data from 1 025 340 patients. The study included 197 patients with OSA diagnosed between January 2004 and December 2006 and 780 individuals without OSA who were matched using propensity score matching. Data were analyzed from September 28, 2018, to March 30, 2019.

Main Outcomes and Measures

Affective disorder events over a 9-year follow-up period. Kaplan-Meier survival curves with log-rank tests and Cox proportional hazards regression models were used to calculate cumulative incidence and hazard ratios (HRs) of affective disorders for each group.

Results

Of the total population of 985 (860 male [87.3%], 540 [54.8%] were aged <45 years), the incidences per 1000 person-years of affective disorders were 49.57 and 27.18 in the OSA and comparison groups, respectively. A total of 1371.7 person-years in the OSA group and 6328.6 person-years in the comparison group were evaluated for affective disorder events. After adjustment for sociodemographic factors (age, residential area, and household income), disability, and comorbidities, the adjusted HRs for patients with OSA developing affective disorders in patients with OSA during the 9-year follow-up period was 2.04 (95% CI, 1.53-2.70). In a subgroup analysis, the adjusted HRs for patients with OSA who developed depressive and anxiety disorders were 2.90 (95% CI, 1.98-4.24) and 1.75 (95% CI, 1.26-2.44), respectively. Moreover, female patients with OSA had a significant likelihood of prospective development of depression and anxiety (adjusted HR for depression, 3.97 [95% CI, 1.54-10.19]; adjusted HR for anxiety, 2.42 [95% CI, 1.17-5.02]) compared with male patients with OSA (adjusted HR for depression, 2.74 [95% CI, 1.80-4.17]; adjusted HR for anxiety, 1.64 [95% CI, 1.13-2.39]).

Conclusions and Relevance

This observational study using nationwide data suggests that OSA is associated with an increased incidence of affective disorder, such as depression and anxiety. Further studies appear to be needed to confirm our findings and, if validated, then studies are needed to explore the nature of the observed association, including potential causality, between OSA and affective symptoms.

Redesigning Care for OSA

Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.

Pathogenetical and Neurophysiological Features of Patients with Autism Spectrum Disorder: Phenomena and Diagnoses

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is accompanied by social deficits, repetitive and restricted interests, and altered brain development. The majority of ASD patients suffer not only from ASD itself but also from its neuropsychiatric comorbidities. Alterations in brain structure, synaptic development, and misregulation of neuroinflammation are considered risk factors for ASD and neuropsychiatric comorbidities. Electroencephalography has been developed to quantitatively explore effects of these neuronal changes of the brain in ASD. The pineal neurohormone melatonin is able to contribute to neural development. Also, this hormone has an inflammation-regulatory role and acts as a circadian key regulator to normalize sleep. These functions of melatonin may play crucial roles in the alleviation of ASD and its neuropsychiatric comorbidities. In this context, this article focuses on the presumable role of melatonin and suggests that this hormone could be a therapeutic agent for ASD and its related neuropsychiatric disorders.

Prevalence and correlates of sleep disorder symptoms in psychiatric disorders

Difficulty falling asleep or maintaining sleep, poor sleep quality, nightmares, and excessive daytime sleepiness are some of the key clinical symptoms of sleep disturbances observed among individuals with psychiatric illnesses. This study aimed to determine the prevalence of symptoms of sleep disorders including parasomnia, narcolepsy, obstructive sleep apnea, circadian rhythm disorder and restless leg syndrome/periodic limb movement (RLS/PLMS) and its correlates in patients with psychiatric diagnoses. Patients aged 21-65 years (n = 400) attending the outpatient clinics with a primary diagnosis of either schizophrenia, mood or anxiety disorder based on ICD-9 criteria were included in this cross-sectional study. Sociodemographic information was collected and screening questions pertaining to specific symptoms of sleep disorders were administered by a study team member. The overall prevalence of symptoms of sleep disorders in the psychiatric outpatient sample was 40.75% (163/400). The prevalence for symptoms of narcolepsy, sleep breathing disorder, PLMS/RLS, circadian rhythm disorder and parasomnia were 12.5%, 14.5%, 14.8%, 4.5%, and 13.8% respectively. These symptoms were associated with age, low physical activity, and anxiety disorder. Results highlight the high prevalence of symptoms of sleep disorders in psychiatric patients. Present study findings should be confirmed using diagnostic interviews and objective measures.

Trauma Associated Sleep Disorder: Clinical Developments 5 Years After Discovery

PURPOSE OF REVIEW

We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research.

RECENT FINDINGS

Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

Subjective Sleep Related to Post Traumatic Stress Disorder Symptoms among Trauma-Exposed Men and Women

Objective/Background: Sleep difficulty is both a common symptom of posttraumatic stress disorder (PTSD) and a risk factor for the development and maintenance of PTSD symptomatology. Gender differences in sleep following trauma exposure have been posited to contribute to the increased risk for the development of PTSD among women, but the persistence and long-term contributions of these potential differences to the maintenance and severity of PTSD symptoms is unclear. Participants: Men and women reporting a history of trauma exposure (n = 112, 63% female) participated in this study. Methods: Subjective sleep complaints and PTSD symptom severity were assessed using well-validated measures (Pittsburgh Sleep Quality Index, PTSD Symptom Checklist). Multivariable regression models (full sample and gender-stratified) were used to predict PTSD symptom severity from global, subscale, and individual item sleep parameters, adjusted for gender, age, race/ethnicity, education, and body mass index. Results: In the full sample, traditional measures of sleep quality and sleep disturbance were associated with PTSD symptom severity. Difficulty falling asleep, poor sleep quality, and sleep disturbance from a variety of sources were related to higher PTSD symptom severity in men, while self-reported sleep disturbance related to nightmares and emotional regulation were associated with PTSD symptom severity among women. Conclusions: These findings add to the limited literature on gender-specific risk factors related to sleep and PTSD, and may inform intervention development and implementation related to PTSD severity among vulnerable adults.

Highlights from the 2018 European Respiratory Society International Congress: sleep and clinical physiology

The 2018 European Respiratory Society (ERS) International Congress held in Paris, France, served as a platform to discover the latest research on respiratory diseases, the improvement in their treatments and patient care. Specifically, the scientific sessions organised by ERS Assembly 4 provided novel insights into sleep disordered breathing and fresh knowledge in respiratory physiology, stressing its importance to understanding and treating respiratory diseases. This article, divided by session, will summarise the most relevant studies presented at the ERS International Congress. Each session has been written by early career members specialised in the different fields of this interdisciplinary assembly.

Mindfulness may be a novel factor associated with CPAP adherence in OSAHS patients

BACKGROUND

Poor adherence to continuous positive airway pressure (CPAP) remains the greatest obstacle to effective treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS). The purpose of the present study was to identify if mindfulness is associated with CPAP adherence of OSAHS patients.

METHODS

Newly diagnosed patients with OSAHS completed questionnaires including the Epworth Sleepiness Scale (ESS), the Mindful Attention Awareness Scale (MAAS), and the Hospital Anxiety and Depression Scale (HADS) and had experienced an overnight CPAP titration. Participants returned to the sleep center for a scheduled research visit after 30-day CPAP treatment at home. Demographics, disease severity, and device-related variables were collected. Multiple linear regression analysis was performed to build a multivariate predictive model for the outcome variable, mean daily CPAP use over 30 days.

RESULTS

Mean CPAP use was 4.7 ± 2.4 h/night for the study sample of 100 patients and 67% were classified as CPAP adherent. MAAS scale was 45.2 ± 18.8, whereas only 13% of patients expressed anxiety or depression. MAAS scales were significantly higher in the CPAP adherent group compared to the non-adherent group (49.5 ± 14.5 vs 40.8 ± 14.2, p < 0.001) with mean hours of daily CPAP use over 30 days for the adherent group (5.7 ± 1.4 h/night) compared to the non-adherence group (3.0 ± 1.7 h/night). There were differences between the two groups in HADS depression, AHI, lowest SaO₂, optimal CPAP pressure, residual AHI, mean days over 30 days, and mean daily CPAP use in the first week. Univariate analyses identified an unadjusted association between mean daily CPAP use over 30 days and HADS depression, MAAS, AHI, lowest SaO₂, optimal pressure, and mean daily CPAP use in the first week. Multiple linear regression analysis demonstrated only MAAS and AHI were associated (p < 0.05) with mean daily CPAP use. MAAS and AHI uniquely explained 10.1% (p < 0.001) and 8.7% (p < 0.001) of mean daily CPAP use respectively.

CONCLUSIONS

This study found a significant independent association of dispositional mindfulness with CPAP adherence. As a novel factor, mindfulness may play an important role in CPAP adherence.

Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis

BACKGROUND

Whether continuous positive airway pressure (CPAP) treatment can improve depression or anxiety symptoms in obstructive sleep apnoea (OSA) patients remains uncertain.

METHODS

Secondary analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, combined with a systematic review of randomised evidence. The SAVE secondary analyses involved 2410 patients with co-existing moderate-severe OSA and established cardiovascular disease randomly allocated to CPAP treatment plus usual care or usual care alone and followed up for 3·7 (SD 1·6) years. We evaluated the effect of CPAP treatment on depression and anxiety caseness (scores ≥ 8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A]) for OSA patients.

FINDINGS

CPAP treatment was associated with reduced odds of depression caseness (adjusted odds ratio [OR] 0·80, 95% confidence interval [CI] 0·65-0·98, P = 0·031) compared to usual care in the SAVE trial and the treatment effect was greater in those with pre-existing depression symptoms. A systematic review of 20 randomised trials including 4255 participants confirmed a benefit of CPAP in reducing depression symptoms in OSA patients: the overall effect (standardised mean difference) was - 0·18 (95% CI - 0·24 to - 0·12). No effect of CPAP treatment on anxiety caseness was found both in patients of the SAVE study (adjusted OR 0·98, 95% CI 0·78-1·24, P = 0·89) and the systematic review.

INTERPRETATION

CPAP reduces depression symptoms in patients with co-existing OSA and CVD independently of improvements in sleepiness.

Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease

Patients with serious psychiatric diseases (major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia and psychotic disorder) often complain about sleepiness during the day, fatigue, low energy, concentration problems, and insomnia; unfortunately, many of these symptoms are also frequent in patients with Obstructive Sleep Apnea (OSA). However, existing data about the clinical appearance of OSA in Psychiatric Disease are generally missing. The aim of our study was a detailed and focused evaluation of OSA in Psychiatric Disease, in terms of symptoms, comorbidities, clinical characteristics, daytime respiratory function, and overnight polysomnography data. We examined 110 patients (56 males and 54 females) with stable Psychiatric Disease (Group A: 66 with MDD, Group B: 34 with BD, and Group C: 10 with schizophrenia). At baseline, each patient answered the STOP-Bang Questionnaire, Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Hospital Anxiety and Depression Scale (HADS) and underwent clinical examination, oximetry, spirometry, and overnight polysomnography. Body Mass Index (BMI), neck, waist, and hip circumferences, and arterial blood pressure values were also measured. The mean age of the whole population was 55.1 ± 10.6 years. The three groups had no statistically significant difference in age, BMI, hip circumference, and systolic and diastolic arterial blood pressure. Class II and III obesity with BMI > 35 kg/m² was observed in 36 subjects (32.14%). A moderate main effect of psychiatric disease was observed in neck (p = 0.044, η² = 0.064) and waist circumference (p = 0.021, η² = 0.078), with the depression group showing the lowest values, and in pulmonary function (Forced Vital Capacity (FVC, %), p = 0.013, η² = 0.084), with the psychotic group showing the lowest values. Intermediate to high risk of OSA was present in 87.37% of participants, according to the STOP-Bang Questionnaire (≥3 positive answers), and 70.87% responded positively for feeling tired or sleepy during the day. An Apnea-Hypopnea Index (AHI) ≥ 15 events per hour of sleep was recorded in 72.48% of our patients. AHI was associated positively with male sex, schizophrenia, neck, and waist circumferences, STOP-Bang and ESS scores, and negatively with respiratory function. A large main effect of psychiatric medications was observed in waist circumference (p = 0.046, η² = 0.151), FVC (%) (p = 0.027, η² = 0.165), and in time spend with SaO₂ < 90% (p = 0.006, η² = 0.211). Our study yielded that patients with Psychiatric Disease are at risk of OSA, especially men suffering from schizophrenia and psychotic disorders that complain about sleepiness and have central obesity and disturbed respiratory function. Screening for OSA is mandatory in this medical population, as psychiatric patients have significantly poorer physical health than the general population and the coexistence of the two diseases can further negatively impact several health outcomes.

The relationship between anxiety, depression, daytime sleepiness in the REM-related mild OSAS and the NREM-related mild OSAS

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a common form of sleep-related respiratory disease characterized by recurrent blockages in the upper airway. Rapid eye movement (REM)-related OSAS is a condition in which apneas and hypopneas are more common during REM sleep. We investigated whether there was any difference between REM-related mild OSAS group and NREM-related mild OSAS group in terms of anxiety, depression, and daytime sleepiness.

METHODS

A total of 166 patients with mild OSAS (72 patients with REM-related and 94 NREM-related OSAS) participated in the study. Hospital Anxiety-Depression Scale (HADS) and Epworth Sleepiness Scale (ESS) questionnaires were completed by both groups.

RESULTS

Anxiety and depression scores were significantly higher in patients with REM-related OSAS in comparison to the NREM-related OSAS group (p = 0.01, p = 0.02 respectively). There was no statistically significant difference between the two groups in terms of ESS scores (p = 0.60).

CONCLUSION

The results of our study suggest that patients with REM-related OSAS have higher rates of depression and anxiety compared to non-REM-related OSAS patients and this may adversely affect quality of life. It may be possible to prevent psychiatric complications, such as depression and anxiety, by administering treatments that reduce REM sleep duration and intensity in patients with REM-related OSAS.

Risk of obstructive sleep apnea in patients with bipolar disorder: A nationwide population-based cohort study in Taiwan

AIM

Previous studies have found a high prevalence of risk factors for obstructive sleep apnea (OSA) in patients with bipolar disorder (BD). This study aimed to determine whether BD patients are associated with an increased risk of incident OSA.

METHODS

Using the National Health Insurance Research Database of Taiwan, 3650 BD patients and 18 250 non-BD controls matched by sex and age were enrolled between 2000 and 2010 and followed until the end of 2013. Patients who developed OSA confirmed by a polysomnographic examination during the follow-up period were identified. Cox regression analysis was performed to examine the risk of OSA between BD patients and comparative controls.

RESULTS

BD patients were prone to developing OSA in the crude analysis (hazard ratio [HR]: 1.63, 95% confidence interval [CI]: 1.07-2.49). After adjusting for demographics and comorbidities, the HR declined and was only marginally significant (HR: 1.54, 95%CI: 0.99-2.37). The stratification analysis by sex revealed that the risk trend with BD and subsequent OSA was mainly contributed by male BD patients (HR: 1.72, 95%CI: 1.02-2.91) and female BD patients weakened the overall association. Additionally, this study found that older age, higher income, living in urbanized areas, and some metabolic comorbidities were potential risk factors for developing OSA.

CONCLUSION

This study shows that male BD patients are associated with an increased risk of OSA, which has direct implications for the development of targeted prevention interventions or the implementation of a screening algorithm for OSA to reduce its negative health impact.

Comparison of Psychiatric Symptoms in Patients With Obstructive Sleep Apnea, Simple Snoring, and Normal Controls

OBJECTIVE

Patients with sleep-related breathing disorders are known to have more severe psychiatric symptoms than good sleepers. The aim of this study was to compare the psychiatric symptoms of participants with obstructive sleep apnea (OSA), those with simple snoring (SS), and normal controls (NC).

METHODS

A total of 386 participants (260 with OSA, 75 with SS, and 51 NC) completed self-report questionnaires including the Symptoms Checklist 90-Revised and underwent nocturnal polysomnography. The scores of nine primary symptom dimensions and three global distress indices of the Symptoms Checklist 90-Revised were compared among the three groups, adjusting for age, sex, and body mass index.

RESULTS

Participants with suspected OSA (OSA + SS) reported more severe psychiatric symptoms than the NC group. Compared with the participants with OSA, those with SS manifested more severe obsessive-compulsive (1.4 (1.0) versus 1.1 (0.7), p = .008) and depressive (1.2 (1.2) versus 0.8 (0.8), p = .031) symptoms and higher Global Severity Index (1.0 (0.9) versus 0.7 (0.6), p = .039) and Positive Symptom Distress Index (2.0 (0.8) versus 1.7 (0.6), p = .009). Only higher Pittsburgh Sleep Quality Index values predicted higher Global Severity Index (B = 0.11, p = .041) and Positive Symptom Distress Index (B = 0.46, p = .007) in suspected OSA participants.

CONCLUSIONS

This study found that individuals with suspected OSA experienced more severe psychiatric symptoms than NCs and that psychiatric symptoms were more severe in the SS group than in the OSA group. The psychiatric symptoms of suspected OSA patients were associated with subjective sleep quality rather than with the apnea-hypopnea index.

Obstructive sleep apnoea and comorbidity - an overview of the association and impact of continuous positive airway pressure therapy

INTRODUCTION

Obstructive sleep apnoea (OSA) is highly prevalent and there is considerable evidence supporting an independent association with a wide range of co-morbidities including cardiovascular, endocrine and metabolic, neuropsychiatric, pulmonary, and renal. Areas covered: A PubMed search of all the recent literature relating to OSA and co-morbidities was undertaken to critically evaluate the potential relationships and possible benefit of continuous positive airway pressure (CPAP) therapy. Expert commentary: The evidence supporting an independent association is stronger for some co-morbidities than others and in cardiovascular diseases is strongest for hypertension and atrial fibrillation. Potential mechanisms include intermittent hypoxia, fluctuating intrathoracic pressure, and recurring micro-arousals that trigger cell and molecular consequences including sympathetic excitation, systemic inflammation and oxidative stress, in addition to metabolic and endothelial dysfunction. Different mechanisms may predominate in individual co-morbidities. Recent long term randomised controlled trials have cast doubt on benefits to co-morbidities from CPAP therapy of OSA, especially where co-morbidities are already established. However, benefits may result in patients who are compliant with therapy and further research is required to clearly establish the role of OSA therapy in both primary and secondary prevention of co-morbidities.

Benzodiazepines Associated With Acute Respiratory Failure in Patients With Obstructive Sleep Apnea

Aims: Obstructive sleep apnea (OSA) and insomnia commonly coexist; hypnotics are broadly prescribed for insomnia therapy. However, the safety of hypnotics use in OSA patients is unclear. We conducted a retrospective case-control study to investigate the risk of adverse respiratory events in hypnotics-using OSA patients.

Methods: We obtained data from the Taiwan National Health Insurance Database from 1996 to 2013. The case group included 216 OSA patients with newly diagnosed adverse respiratory events, including pneumonia and acute respiratory failure. The control group included OSA patients without adverse respiratory events, which was randomly frequency-matched to the case group at a 1:1 ratio according to age, gender, and index year. Hypnotics exposure included benzodiazepines (BZD) and non-benzodiazepines (non-BZD). A recent user was defined as a patient who had taken hypnotics for 1–30 days, while a long-term user was one who had taken hypnotics for 31–365 days.

Results: Multivariable adjusted analysis showed recent BZD use is an independent risk for adverse respiratory events (OR = 2.70; 95% CI = 1.15–6.33; P < 0.001). Subgroup analysis showed both recent and long-term BZD use increased the risk of acute respiratory failure compared to never BZD use (OR = 28.6; 95% CI = 5.24–156; P < 0.001, OR = 10.1; 95% CI = 1.51–67.7; P < 0.05, respectively). Neither BZD nor non-BZD use increased the risk of pneumonia in OSA patients.

Conclusion: BZD use might increase the risk of acute respiratory failure in OSA patients.

A Pilot Study About the Dysfunction of Adipose Tissue in Male, Sleep Apneic Patients in Relation to Psychological Symptoms

Introduction: Obstructive sleep apnea (OSA) and its cardiometabolic alterations are closely associated with visceral obesity. Patients with OSA frequently present with symptoms of depression and anxiety. Although these subjective symptoms of OSA are the result of complex biological dysregulation, it remains unclear if they have a direct effect on the dysfunction of adipose tissue. Methods: In a pilot, prospective, randomized study, we evaluated 10 recently diagnosed male patients with severe OSA by full polysomnography (PSG) and 4 male non-apneic subjects matched for age and body mass index (BMI) with abdomen adipose tissue biopsies. Subjects with diabetes/prediabetes and cardiovascular and psychiatric diseases and who are current smokers were excluded. All patients underwent anthropometric measurements and completed the following questionnaires: Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Hospital Anxiety and Depression Scale (HADS-A and HADS-D). Fasting venous blood samples were collected on the day after PSG, between 8:00 and 9:00 a.m., after an overnight fast. Fat biopsies were performed at the same time periods and adipose tissue samples of 300 mg were obtained from abdominal fat. Fat cell size, extent of fibrosis, vascularity, leukocyte common antigen inflammatory infiltration, and tissue macrophage accumulation were microscopically evaluated. Results: The mean age of the group was 47.4 ± 13.8 years, with mean BMI of 35.8 ± 4.8 kg/m² and mean apnea-hypopnea index of 79.4 ± 46.1 events per hour of sleep (severe OSA). HADS-A and HADS-D scores were 5.8 ± 2.3 (3.0-8.0) and 4.7 ± 2.3 (2.0-8.0), respectively. HADS-A score correlated positively with macrophage accumulation in fat biopsy (r = 0.82, p = 0.047), whereas ESS, FSS, and HADS-D did not. Severity of fibrosis correlated largely with waist circumference (r = -0.66, p = 0.038) and neck circumference (r = -0.790, p = 0.006). Respiratory events correlated negatively with the extent of vascularization of adipose tissue (r = -0.614, p = 0.05). Conclusions: In the preliminary results of our pilot study, we assessed that the symptoms of anxiety mainly contribute to macrophage accumulation, whereas the increased number of respiratory events reduces the extent of vascularization in visceral fat in OSA. Based on this observation, further larger studies are required to verify if anxious OSA patients are more vulnerable to the metabolic manifestations of the syndrome.

X-search: an open access interface for cross-cohort exploration of the National Sleep Research Resource

BACKGROUND

The National Sleep Research Resource (NSRR) is a large-scale, openly shared, data repository of de-identified, highly curated clinical sleep data from multiple NIH-funded epidemiological studies. Although many data repositories allow users to browse their content, few support fine-grained, cross-cohort query and exploration at study-subject level. We introduce a cross-cohort query and exploration system, called X-search, to enable researchers to query patient cohort counts across a growing number of completed, NIH-funded studies in NSRR and explore the feasibility or likelihood of reusing the data for research studies.

METHODS

X-search has been designed as a general framework with two loosely-coupled components: semantically annotated data repository and cross-cohort exploration engine. The semantically annotated data repository is comprised of a canonical data dictionary, data sources with a data dictionary, and mappings between each individual data dictionary and the canonical data dictionary. The cross-cohort exploration engine consists of five modules: query builder, graphical exploration, case-control exploration, query translation, and query execution. The canonical data dictionary serves as the unified metadata to drive the visual exploration interfaces and facilitate query translation through the mappings.

RESULTS

X-search is publicly available at https://www.x-search.net/ with nine NSRR datasets consisting of over 26,000 unique subjects. The canonical data dictionary contains over 900 common data elements across the datasets. X-search has received over 1800 cross-cohort queries by users from 16 countries.

CONCLUSIONS

X-search provides a powerful cross-cohort exploration interface for querying and exploring heterogeneous datasets in the NSRR data repository, so as to enable researchers to evaluate the feasibility of potential research studies and generate potential hypotheses using the NSRR data.

An evaluation of sleep disturbance on in-patient psychiatric units in the UK

Aims and methodSleep disturbance is common on in-patient psychiatry wards. This study explored subjective and objective patterns of sleep disturbance and contributory environmental factors. Participants were recruited from mental health acute admission wards and had a range of subjective and objective assessments of sleep. Light intensity and noise levels were measured to characterise potential environmental causes for poor sleep.

RESULTS

We recruited 20 patients; 15% were high risk for obstructive sleep apnoea. Nineteen participants reported poor sleep quality on the Pittsburgh Sleep Quality Index, and 90% had significant sleep fragmentation with objective measures. Inside light levels were low (day <200 lux and night <10 lux). Night sound levels were 40-90 db.Clinical implicationsSleep disturbance was highly prevalent. Increased awareness of sleep disorders is needed. Modifiable environmental factors on the ward were implicated, therefore increased awareness and a change of approach to sleep disturbance in in-patient psychiatry is recommended.Declaration of interestNone.