Obstructive sleep apnea and psychiatric disorders: a systematic review

Obstructive Sleep Apnea Severity is Directly Related to Suicidal Ideation in Posttraumatic Stress Disorder

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and obstructive sleep apnea (OSA). There are no studies of OSA diagnosed by sleep study and SI in patients with PTSD.

METHODS

Forty consenting civilians with PTSD (38 female, mean ± standard deviation age: 44.60 ± 12.73) underwent a Level 3 home sleep apnea test (WatchPAT200; Itamar Medical, Israel). OSA severity was measured with the respiratory disturbance index (RDI) (number of apneas, hypopneas and respiratory effort related arousals per hour). SI was measured with Items 9, 35, 39, and 50 of the Brief Symptom Inventory (BSI). Other patient-rated measures included the Beck Depression Inventory, second edition (BDI-II), PTSD Checklist for DSM-5 (PCL-5), and the Pittsburgh Sleep Quality Index PTSD Addendum modified to include only Items 1c, 1e, 1f, and 1g that address nightmares.

RESULTS

The RDI (r = .757, P < .001) and oxygen desaturation index (r = .633, P < .001) were directly correlated to SI. Multiple regression analysis using SI as the dependent variable and patient-rated measures as independent variables revealed only RDI (β = .480, t = 4.167, P < .001) and BDI-II (β = .469, t = 3.375, P = .002) as predictors of SI, with adjusted R2 = 0.718. In patients with RDI < 30 events/h (n = 37) correlation of SI with RDI (r = .511, P = .001) but not ODI (r = .312, P = .060) remained significant. Multiple regression analysis (when RDI < 30 events/h) revealed only BDI-II (β = .603, t = 3.492, P = .002), and not RDI (β = .247, t = 1.723, P = .096) as a significant predictor of SI.

CONCLUSIONS

OSA severity in PTSD was directly related to SI. Depression was a significant mediator in the relationship between RDI and SI, with OSA-related intermittent hypoxemia possibly contributing to this relationship only in severe OSA.

Nonadherence to CPAP Associated With Increased 30-Day Hospital Readmissions

STUDY OBJECTIVES

The primary objective of this study was to determine if nonadherence to continuous positive airway pressure (CPAP) is associated with increased 30-day all-cause, cardiovascular-cause, and pulmonary-cause hospital readmissions.

METHODS

Retrospective cohort study at a Veterans Affairs hospital of patients with obstructive sleep apnea (OSA) who were hospitalized from January 1, 2007 to December 31, 2015. Odds ratio of 30-day readmission was calculated for all-cause, cardiovascular-cause, and pulmonary-cause readmissions. Logistic regression model was used to evaluate odds of nonadherent versus adherent group while adjusting for age, sex, body mass index, living situation, race, comorbidities, and medication adherence.

RESULTS

Out of 2,077 records reviewed, 345 patients (183 adherent and 162 nonadherent) met our inclusion criteria. The adherent group had a total of 215 initial admissions, and the nonadherent group had a total of 268 index admissions. Thirty-day all-cause readmission rate was significantly higher in the nonadherent group, with an adjusted odds ratio (OR) of 3.52 (95% confidence interval [CI], 2.04-6.08, P < .001). Thirty-day cardiovascular-cause readmission rate was significantly higher in the nonadherent group, with an adjusted OR of 2.31 (95% CI, 1.11-4.78, P = .024). Difference in 30-day pulmonary-cause readmissions was not statistically significant, with an adjusted OR of 3.66 (95% CI, 0.41-32.76, P = .25).

CONCLUSIONS

Nonadherence to CPAP is associated with increased 30-day all-cause and cardiovascular-cause readmission in patients with OSA. Ensuring CPAP adherence is crucial in addressing general and cardiovascular-related healthcare utilization and morbidity in patients with OSA.

COMMENTARY

A commentary on this article appears in this issue on page 161.

Association of estradiol with sleep apnea in depressed perimenopausal and postmenopausal women: a preliminary study

OBJECTIVE

Women's risk of obstructive sleep apnea (OSA) increases substantially during and after the menopausal transition, when depression risk is also elevated, raising the possibility that estrogen withdrawal contributes to OSA vulnerability, in turn contributing to mood disturbance. We examined the association between estradiol levels and OSA in depressed peri- and postmenopausal women.

METHODS

Thirty depressed peri-/postmenopausal women (mean body mass index [BMI] 30.82 kg/m) without known OSA completed routine polysomnography concurrent with serum estradiol levels. Estradiol in women with apnea-hypopnea indices (AHI) ≥15 indicating moderate-to-severe OSA was compared against those with AHI less than 15 using logistic regression adjusting for age and BMI.

RESULTS

Thirteen women (43%) had AHI ≥15 (median AHI 21.6). Estradiol levels were lower (P = 0.02) in those with OSA (median 19, interquartile range 9-25 pg/mL) than without OSA (median 29, interquartile range 19-66 pg/mL). On univariate analysis, higher estradiol was associated with reduced odds of OSA (odds ratio 0.95, 95% CI 0.90-0.99, P = 0.04). After adjusting for age and BMI, estradiol levels remained associated with lower odds of OSA (odds ratio 0.90), but the association was no longer statistically significant (95% CI 0.76-1.05, P = 0.18). Montgomery Åsberg Depression Rating Scale scores did not differ between those with and without OSA.

CONCLUSIONS

These preliminary results suggest that, in addition to higher BMI and age, lower estradiol may be associated with increased OSA risk in depressed women during the peri- and postmenopause, raising the possibility that estradiol withdrawal associated with menopause influences upper-airway patency in women.

Sleep disturbances in women with polycystic ovary syndrome: prevalence, pathophysiology, impact and management strategies

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder affecting the reproductive, metabolic and psychological health of women. Clinic-based studies indicate that sleep disturbances and disorders including obstructive sleep apnea and excessive daytime sleepiness occur more frequently among women with PCOS compared to comparison groups without the syndrome. Evidence from the few available population-based studies is supportive. Women with PCOS tend to be overweight/obese, but this only partly accounts for their sleep problems as associations are generally upheld after adjustment for body mass index; sleep problems also occur in women with PCOS of normal weight. There are several, possibly bidirectional, pathways through which PCOS is associated with sleep disturbances. The pathophysiology of PCOS involves hyperandrogenemia, a form of insulin resistance unique to affected women, and possible changes in cortisol and melatonin secretion, arguably reflecting altered hypothalamic-pituitary-adrenal function. Psychological and behavioral pathways are also likely to play a role, as anxiety and depression, smoking, alcohol use and lack of physical activity are also common among women with PCOS, partly in response to the distressing symptoms they experience. The specific impact of sleep disturbances on the health of women with PCOS is not yet clear; however, both PCOS and sleep disturbances are associated with deterioration in cardiometabolic health in the longer term and increased risk of type 2 diabetes. Both immediate quality of life and longer-term health of women with PCOS are likely to benefit from diagnosis and management of sleep disorders as part of interdisciplinary health care.

The Relationship between Diabetes-Related Complications and Obstructive Sleep Apnea in Type 2 Diabetes

This study explored the relationship between obstructive sleep apnea (OSA) and the presence of any diabetes-related complications in type 2 diabetes and whether this was mediated by hypertension. Secondly, the relationship between OSA severity and estimated glomerular filtration rate (eGFR) was investigated. A total of 131 patients participated. OSA was diagnosed using a home monitor, and severity was measured by apnea-hypopnea index (AHI) and oxygen desaturation index (ODI). OSA was found in 75.6% of the participants, 40.5% with moderate-to-severe degree. Any diabetes-related complications (retinopathy, neuropathy, nephropathy, or coronary artery disease) were present in 55.5%, and 70.2% of the participants had hypertension. Mediation analysis indicated that, compared to those with mild or no OSA, those with moderate-to-severe OSA were 3.05 times more likely to have any diabetes-related complications and that this relationship was mediated by the presence of hypertension. After adjusting for confounders, ODI (B = -0.036, p = 0.041), but not AHI, was significantly associated with lower eGFR. In conclusion, moderate-to-severe OSA was related to the presence of any diabetes-related complications in type 2 diabetes, and the relationship was mediated by hypertension. The severity of intermittent hypoxia was associated with lower eGFR. Whether OSA treatment will delay or reduce diabetes-related complications should be investigated.

Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in major depression: a observational and retrospective study on 703 subjects

Background

Several studies have investigated the prevalence and risk factors of depression in subjects with obstructive sleep apnea syndrome. However, few studies have investigated the prevalence and risk factors for obstructive sleep apnea syndrome in major depression. The aim of this study was to examine the prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in a large sample of individuals with major depression.

Methods

Data from 703 individuals with major depression recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. An apnea-hypopnea index of ≥15 events per hour was used as cut-off score for moderate to severe obstructive sleep apnea syndrome. Logistic regression analyses were conducted to examine clinical and demographic risk factors of moderate to severe obstructive sleep apnea syndrome in major depression.

Results

The prevalence of moderate to severe obstructive sleep apnea syndrome in major depression is 13.94%. Multivariate logistic regression analysis revealed that male gender, snoring, excessive daytime sleepiness, lower insomnia complaint, presence of metabolic syndrome, age ≥ 50 years, BMI >30 kg/m², ferritin >300 μg/L, CRP >7 mg/L and duration of sleep ≥8 h were significant risk factors of moderate to severe obstructive sleep apnea syndrome in major depression.

Conclusion

Moderate to severe obstructive sleep apnea syndrome is a common pathology in major depression. The identification of these different risk factors advances a new perspective for more effective screening of moderate to severe obstructive sleep apnea syndrome in major depression.

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Recent studies have called attention to the need for enhancing treatment outcome in trauma-focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic-related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA-positive and 276 OSA-negative veterans were identified. Generalized estimating equations were used to compare between-group differences in weekly self-reported PTSD symptomatology. The OSA-positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = -0.657). Additionally, OSA-positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA-positive veterans without access to CPAP (B = -0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence-based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.

Neuropathic Pain in Low Back-Related Leg Pain Patients: What Is the Evidence of Prevalence, Characteristics, and Prognosis in Primary Care? A Systematic Review of the Literature

This systematic review synthesizes literature describing prevalence, characteristics, and prognosis of low back-related leg pain (LBLP) patients with neuropathic pain in primary care and/or similar settings. Inclusion and exclusion criteria were developed and used by independent reviewers to screen citations for eligibility. The initial search yielded 24,948 citations; after screening 12 studies were included. Neuropathic pain was identified using case ascertainment tools (n = 5), clinical history with examination (n = 4), and using LBLP samples assumed neuropathic (n = 3). Neuropathic pain prevalence varied from 19% to 80%. There was consistent evidence for higher back-related disability (n = 3), poorer health-related quality of life (n = 2), and some evidence for more severe depression (n = 2), anxiety (n = 3), and pain intensity (n = 4) in patients with neuropathic pain. Results were less consistent when cases were identified through clinical history with examination than those identified using case ascertainment tools. Prognosis (n = 1) of LBLP patients with neuropathic pain was worse compared with those without, in all outcomes (leg pain intensity, leg and back-related disability, self-reported general health) except back pain intensity. No studies described prognostic factors. This systematic review highlights the evidence gap in neuropathic pain in LBLP in primary care, especially with respect to prognosis.

PERSPECTIVE

Patients with LBLP may have neuropathic pain. This systematic review emphasizes the paucity of evidence describing the characteristics and prognosis of neuropathic pain in this patient population. Future research investigating prognosis of these patients with neuropathic pain is likely to contribute to better understanding and management.

Omega-3 Index and Obstructive Sleep Apnea: A Cross-Sectional Study

STUDY OBJECTIVES

Erythrocyte levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (Omega-3 Index) were previously found to be associated with obstructive sleep apnea (OSA) at very low levels (< 5.0%) in only one epidemiologic study. OSA has comorbidities, such as arterial hypertension, heart failure, or major depression, also associated with a low Omega-3 Index. These comorbidities can be improved by increasing intake of EPA and DHA, and thus the Omega-3 Index, preferably to its target range of 8% to 11%. Symptoms of OSA might improve by increasing the Omega-3 Index, but more research is needed.

METHODS

In our sleep laboratory, 357 participants with OSA were recruited, and data from 315 participants were evaluated. Three categories of OSA (none/ mild, moderate, severe) were defined based on apnea-hypopnea index. Anthropometrics and lifestyle characteristics (smoking, alcohol, fish intake, omega-3 supplementation) were recorded. Erythrocyte fatty acid compositions were assessed with the HS-Omega-3 Index methodology.

RESULTS

The mean Omega-3 Index in all 3 categories of OSA was 5.7%, and no association with OSA was found. There were more male participants with severe OSA (79.7%, P = .042) than females, and participants with severe OSA had a significantly higher body mass index (32.11 ± 6.39 kg/m², P = .009) than participants with mild or moderate OSA. Lifestyle characteristics were not significantly different.

CONCLUSIONS

In contrast to our hypothesis, an Omega-3 Index of 5.7% was not associated with OSA severity. Previously, an Omega-3 Index < 5.0% was associated. Although our results suggest aiming for an Omega-3 Index > 5.7% in an intervention trial with EPA and DHA in OSA, comorbidities of OSA suggest a target range of 8% to 11%.

Sleep and Dreaming in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

Sleep disturbances are core features of posttraumatic stress disorder (PTSD). This review aims to characterize sleep disturbances, summarize the knowledge regarding the relationships between trauma exposure and sleep difficulties, and highlight empirically supported and/or utilized treatments for trauma-related nightmares and insomnia.

RECENT FINDINGS

Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

Lifestyle and Occupational Stress: A Potential Risk Factor for Obstructive Sleep Apnea in Nonobese Male Subjects

PURPOSE

To record the incidence of obstructive sleep apnea (OSA) in nonobese male subjects and investigate the coexistence of lifestyle stress, sleep deprivation, and upper airway inflammation.

MATERIALS AND METHODS

552 patients were assessed during a survey of banks, government and corporate offices, recruitment agencies, and schools between January 2012 and January 2016. After applying the inclusion and exclusion criteria designed for this study, the number of patients tapered down to 120 patients who underwent diagnostic tests, viz. polysomnography, chemiluminiscence immunoassay, nephelometry, and upper airway endoscopy. This revealed the presence of OSA coexistent with elevated serum cortisol, C-reactive protein (CRP), and upper airway inflammation.

RESULTS

Polysomnography showed that 57 of 120 patients suffered from OSA. Objective evaluation of these patients exposed an undercurrent of lifestyle stress in 39 patients. CRP and serum cortisol were found to be significantly high (1.60 ± 0.52 and 7.20 ± 0.76 μg/dL, respectively) in 30 patients. Endoscopy revealed 18 patients with moderate, 7 with severe, and 5 with no upper airway inflammation.

CONCLUSION

The results of this study demonstrated that OSA was found to be prevalent in the cohort of nonobese male patients studied. Coexistence of lifestyle stress, sleep deprivation, and upper airway inflammation was revealed.

Depressive symptoms are associated with poor sleep quality rather than apnea-hypopnea index or hypoxia during sleep in patients with obstructive sleep apnea

PURPOSE

We examined factors, including the severity of obstructive sleep apnea (OSA), that were associated with depressive symptoms and excessive daytime sleepiness in OSA patients.

METHODS

We retrospectively reviewed data of 1203 subjects (861 men, mean age 48.2 years) who completed self-reported questionnaires and underwent polysomnography between September 2005 and May 2016 at the Center for Sleep and Chronobiology at Seoul National University Hospital. We compared scores on the Beck Depression Inventory (BDI) and Epworth sleepiness scale (ESS) between OSA and control groups. Analyses for OSA subgroups were classified by severity, and partial correlations were performed.

RESULTS

BDI scores were higher in the OSA than in the control group (12.3 ± 7.6 vs. 10.1 ± 6.2, p = 0.001). There were differences in ESS scores among the mild, moderate, and severe OSA subgroups (p < 0.001), but not in BDI scores (p = 0.236). After adjusting for age, gender, and BMI, BDI in the OSA group correlated positively with wake after sleep onset (WASO; p = 0.014) and sleep latency (SL; p < 0.001), negatively with total sleep time (TST; p < 0.001) and sleep efficiency (SE; p = 0.001), but not with the apnea-hypopnea index (AHI; p = 0.387) or average O₂ (p = 0.542). ESS in the OSA group correlated positively with TST (p < 0.001), SE (p < 0.001), and AHI (p < 0.001) and negatively with WASO (p = 0.010), SL (p < 0.001), and average O₂ (p < 0.001).

CONCLUSIONS

In this study, patients with OSA had more depressive symptoms than those without OSA. Daytime sleepiness in OSA patients was related to the severity of OSA as well as sleep propensity. However, depressive symptoms in OSA patients were associated with poor sleep quality rather than OSA severity. Depressive symptoms in OSA may be treated by modulating the sleep architecture and sleep quality.

Identifying Psychiatric Comorbidities for Obstructive Sleep Apnea in the Biomedical Literature and Electronic Health Record

Obstructive sleep apnea (OSA) is one of the most common diseases among Americans, affecting between 5 and 20% of the population. While there is existing evidence of numerous comorbid conditions, such as obesity, diabetes, and high blood pressure, the vast majority of this evidence has focused explicitly on cardiovascular morbidities and excluded any mental or behavioral disorders. The goal of this study was to examine psychiatric comorbidities of OSA in two types of sources: (1) biomedical literature in the MEDLINE/PubMed database (focusing on MeSH descriptors) and Semantic MEDLINE Database (SemMedDB; for semantic predications), and (2) electronic health record data in the MIMIC-III database. Approximately 300 unique psychiatric comorbidities were identified, ranked, and compared across MEDLINE/PubMed, SemMedDB, and MIMIC-III. The preliminary results highlight the potential of this multi-angled approach for suggesting opportunities for further investigation that may contribute to improving mental health in persons afflicted with OSA.

Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers: a study on 1311 subjects

Background

Several studies have investigated the prevalence and risk factors of insomnia in subjects with obstructive sleep apnea syndrome. However, few studies have investigated the prevalence and risk factors for obstructive sleep apnea syndrome in insomnia sufferers. Thus, the aim of this study was to examine the prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in a large sample of insomnia sufferers.

Methods

Data from 1311 insomnia sufferers who were recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. An apnea-hypopnea index of ≥15 events per hour was used as the cut-off score for moderate to severe obstructive sleep apnea syndrome. Logistic regression analyses were conducted to examine clinical and demographic risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Results

The prevalence of moderate to severe obstructive sleep apnea syndrome in our sample of insomnia sufferers was 13.88%. Multivariate logistic regression analysis revealed that male gender, snoring, excessive daytime sleepiness, lower maintenance insomnia complaint, presence of metabolic syndrome, age ≥ 50 & <65 years, age ≥ 65 years, BMI ≥ 25 & <30 kg/m², BMI >30 kg/m², and CRP >7 mg/L were significant risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Conclusion

Moderate to severe obstructive sleep apnea syndrome is a common pathology in insomnia sufferers. The identification of these different risk factors advances a new perspective for more effective screening of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Obstructive sleep apnoea is not a risk factor for incident hospitalised depression: a historical cohort study

We evaluated whether obstructive sleep apnoea (OSA) was related to the incidence of hospitalisation for depression, a robust end-point that is unlikely to result from misdiagnosis.

All adults referred with suspected OSA who underwent a diagnostic sleep study at a large urban academic hospital between 1994 and 2010 and were linked to provincial health administrative data between 1991 and 2015 were included. Cox regression analysis was used to investigate the association between OSA symptoms and severity and incident hospitalised depression, the primary outcome.

Over a median follow-up of 9.7 years, 136 (1.3%) out of 10 149 participants were hospitalised for depression. A significant crude effect of OSA symptoms (waking unrefreshed and impact on memory and concentration) on hospitalised depression became nonsignificant after controlling for confounders. Apnoea–hypopnoea index was not significantly associated with the outcome: adjusted hazard ratio (33 versus6 events·h−1) 1.13 (95% CI 0.91–1.40). Factors associated with hospitalised depression were female sex, younger age, use of hypnotics, alcoholism and unemployment.

In a large clinical cohort with suspected OSA, controlling for confounders, OSA symptoms and severity were not related to the risk of hospitalisation for depression, suggesting that previously reported links between OSA and depression may be due to overlapping diagnostic criteria. However, our findings cannot exclude a potential link between OSA and milder depression.

Sleep Apnea Symptoms and Cardiovascular Disease Risks among Haitian Medical Students

Sleep apnea is a prevalent sleep disorder that disproportionately affects blacks and has been previously studied among Caribbean-born blacks in Brooklyn, New York, but there has been negligible research in the Caribbean, specifically Haiti, and developing countries on this pressing health issue. A total of 373 medical students (mean age=20.6 years ± 2.3 years) from a medical school in Haiti participated in this study. Participants were administered a questionnaire assessing their sleep health and cardiovascular outcomes. The rate of sleep apnea symptoms was: snoring (13.2%), excessive daytime sleepiness (73.7%), and difficulty maintaining sleep (25.3%). Many reported falling asleep while watching television (68.2%) or while driving (7.8%). Based on logistic regression analysis, reported nocturnal breathing pauses was the most important predictor of the likelihood of reporting a history of cardiac disease (14.96; 95% CI=1.27–76.07). Findings suggest that more aggressive effort should be made to increase screening of sleep apnea among Haitians, thereby increasing the likelihood for early detection and treatment to reduce sleep-related risk of cardiovascular disease.

Functional reorganization in obstructive sleep apnoea and insomnia: A systematic review of the resting-state fMRI

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Resting state functional MRI studies is a promising non-invasive tool for better understanding of the pathophysiology of sleep disorders.

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The salience network is involved in hyperarousal and affective symptoms in insomnia.

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The posterior default mode network appears to underlie cognitive and depressive symptoms of obstructive sleep apnoea.

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Disruption of intrinsic networks have been demonstrated in major depression, which is a common co-morbidity of sleep disorders.

Functional neuroimaging techniques have accelerated progress in the study of sleep disorders. Considering the striking prevalence of these disorders in the general population, however, as well as their strong bidirectional relationship with major neuropsychiatric disorders, including major depressive disorder, their numbers are still surprisingly low. This review examines the contribution of resting state functional MRI to current understanding of two major sleep disorders, insomnia disorder and obstructive sleep apnoea. An attempt is made to learn from parallels of previous resting state functional neuroimaging findings in major depressive disorder. Moreover, shared connectivity biomarkers are suggested for each of the sleep disorders. Taken together, despite some inconsistencies, the synthesis of findings to date highlights the importance of the salience network in hyperarousal and affective symptoms in insomnia. Conversely, dysfunctional connectivity of the posterior default mode network appears to underlie cognitive and depressive symptoms of obstructive sleep apnoea.

Complications of anesthesia during electroconvulsive therapy due to undiagnosed obstructive sleep apnea: A case-study

This is a case description of two patients with bipolar affective disorder, who presented complications, possibly due to underlying, undiagnosed obstructive sleep apnea syndrome (OSAS), during anesthesia for electroconvulsive therapy (ECT). The first patient, just after receiving the second ECT, developed tachypnea with spasm of the upper airways and severe oxygen desaturation He was intubated and transferred to the medical intensive care unit where he was extubated 15 h later. The second patient, just after the eighth ECT, developed tachycardia and severe hypertension. He was transferred to the recovery room where he received oxygen therapy via nasal cannula and amlodipine. Both patients in the diagnostic polysomnographic tests which followed revealed a moderate to high apnea - hypopnea index (AHI) and distortion of sleep architecture. These cases highlight the need to assess for OSAS patients who receive ECT, especially if they exhibit peri-anesthesia complications.

Obstructive sleep apnea and dermatologic disorders

Obstructive sleep apnea (OSA) is present in at least 2% of women and 4% of men, and its prevalence is increasing, because a major predisposing factor for OSA is a high body mass index. Psoriasis has the most strongly substantiated link with OSA, where the relationship may be bidirectional. Dermatologic disorders may be comorbid with OSA due to several factors: (i) the heightened proinflammatory state in OSA, which can occur independent of body mass index, and may exacerbate inflammatory dermatoses; (ii) intermittent hypoxemia may promote neovascularization and tumor growth in certain cancers, such as melanoma; (iii) obesity, present in majority of OSA patients, can be associated with a heightened proinflammatory state; (iv) upper airway obstruction due to local tumors or soft tissue swelling due to physical urticaria or angioedema; (v) acute nasal congestion in the atopic patient with allergic rhinitis; (vi) dermatologic disorders associated with other OSA risk factors (eg, acanthosis nigricans and metabolic syndrome); and (vii) a high sympathetic tone (eg, in atopic dermatitis) and resultant sleep fragmentation contributing to upper airway instability during sleep. In many instances, the dermatology patient with OSA may have other medical and psychiatric comorbidities that are also associated with increased OSA risk.

Risk of obstructive sleep apnea and excessive daytime sleepiness in hospitalized psychiatric patients

OBJECTIVES

This study evaluated the risk of developing obstructive sleep apnea (OSA) and excessive daytime sleepiness (EDS) in hospitalized psychiatric patients at the American University of Beirut Medical Center (AUB-MC). Factors associated with OSA and EDS occurrence in this sample were also examined.

METHODS

The Berlin questionnaire and the Epworth sleepiness scale; which respectively evaluate OSA and EDS symptoms, were administered to individuals hospitalized at an acute psychiatric treatment unit at the AUB-MC between the dates of January 2014 and October 2016. Additional data collected included general demographics, psychiatric diagnoses, and questionnaires evaluating depression and anxiety symptoms. Statistical analyses utilizing SPSS were performed to determine the prevalence of OSA and EDS, as well as their respective associations with patient profiles.

RESULTS

Our results showed that 39.5% of participants were found to have a high risk of sleep apnea and 9.9% of the participants were found to have abnormal daytime sleepiness. The risk of developing OSA was associated with a higher body mass index (BMI) (P=0.02), and depression severity (patient health questionnaire 9 score) (P=0.01). Increasing severity of depressive symptoms was associated with a higher risk of sleep apnea (P=0.01). BMI (odds ratio [OR] =5.97, 95% confidence interval [CI] 1.89-18.82) and depression severity (OR =4.04, 95% CI 1.80-9.07) were also found to be predictors of OSA. The psychiatric diagnoses of the participants were not found to have a significant association with the risk of sleep apnea.

CONCLUSION

The risk of OSA is increased among hospitalized psychiatric patients, and this condition can have detrimental effects on psychiatric patients. OSA appears to be under-recognized in this population, psychiatrists should screen for OSA in hospitalized psychiatric patients and refer them for diagnostic testing or treatment when indicated.

Chronobiology, sleep-related risk factors and light therapy in perinatal depression: the "Life-ON" project

BACKGROUND

Perinatal depression (PND) has an overall estimated prevalence of roughly 12 %. Untreated PND has significant negative consequences not only on the health of the mothers, but also on the physical, emotional and cognitive development of their children. No certain risk factors are known to predict PND and no completely safe drug treatments are available during pregnancy and breastfeeding. Sleep and depression are strongly related to each other because of a solid reciprocal causal relationship. Bright light therapy (BLT) is a well-tested and safe treatment, effective in both depression and circadian/sleep disorders.

METHODS

In a 3-year longitudinal, observational, multicentre study, about 500 women will be recruited and followed-up from early pregnancy (10-15 gestational week) until 12 months after delivery. The primary aim of the present study is to systematically explore and characterize risk factors for PND by prospective sleep assessment (using wrist actigraphy, polysomnography and various sleep questionnaires) and bloodbased analysis of potential markers during the perinatal period (Life-ON study). Secondary aims are to explore the relationship between specific genetic polymorphisms and PND (substudy Life-ON1), to investigate the effectiveness of BLT in treating PND (substudy Life-ON2) and to test whether a short term trial of BLT during pregnancy can prevent PND (substudy Life-ON3).

DISCUSSION

The characterization of specific predictive and risk factors for PND may substantially contribute to improve preventive medical and social strategies for the affected women. The study results are expected to promote a better understanding of the relationship between sleep disorders and the development of PND and to confirm, in a large sample of women, the safety and efficacy of BLT both in prevention and treatment of PND.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02664467 . Registered 13 January 2016.

Emerging co-morbidities of obstructive sleep apnea: cognition, kidney disease, and cancer

Obstructive sleep apnea (OSA) causes daytime fatigue and sleepiness, and has an established relationship with cardiovascular and metabolic disease. Recent years have seen the emergence of an evidence base linking OSA with an increased risk of degenerative neurological disease and associated cognitive impairment, an accelerated rate of decline in kidney function with an increased risk of clinically significant chronic kidney disease (CKD), and with a significantly higher rate of cancer incidence and death. This review evaluates the evidence base linking OSA with these seemingly unrelated co-morbidities, and explores potential mechanistic links underpinning their development in patients with OSA, including intermittent hypoxia (IH), sleep fragmentation, sympathetic excitation, and immune dysregulation.

The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000-2010

STUDY OBJECTIVES

A large proportion of individuals affected by sleep disorders are untreated and susceptible to accidents, injuries, long-term sequelae (e.g., risk of cardiovascular disease, cancer, psychiatric disorders), and increased mortality risk. Few studies have examined the scope and magnitude of sleep disorder diagnoses in the United States (US) or factors influencing them. Veterans are particularly vulnerable to factors that elicit or exacerbate sleep disorders.

METHODS

This serial cross-sectional study characterized secular trends in diagnosed sleep disorders among veterans seeking care in US Veterans Health Administration facilities over an eleven-year span (FY2000-2010, n = 9,786,778). Electronic medical records from the national Veterans Administration Informatics and Computing Infrastructure database were accessed. Cases were defined using diagnostic codes specified by the American Academy of Sleep Medicine. Age-adjusted annual prevalence was summarized by sex, race, combat exposure, body mass index, and comorbid diagnoses (cardiovascular disease, cancer, mental disorders).

RESULTS

Sleep apnea (47%) and insomnia (26%) were the most common diagnoses among patients with any sleep disorder. There was a six-fold relative increase in total sleep disorder prevalence over the study period. Posttraumatic stress disorder, which tripled over the same time period, was associated with the highest prevalence of sleep disorders (16%) among the comorbid conditions evaluated.

CONCLUSIONS

The results indicate a growing need for integration of sleep disorder management with patient care and health care planning among US veterans.

COMMENTARY

A commentary on this article appears in this issue on page 1331.

Structural and functional neural adaptations in obstructive sleep apnea: An activation likelihood estimation meta-analysis

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The right basolateral amygdala, the hippocampus and the right insular cortex are important nodes in obstructive sleep apnea (OSA).

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Functional characterization of these regions suggested associated dysfunction of emotional, sensory, and limbic processes in OSA.

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Connectivity analysis demonstrated that these regions are part of a joint network comprising the anterior insula, posterior-medial frontal cortex and thalamus.

Obstructive sleep apnea (OSA) is a common multisystem chronic disorder. Functional and structural neuroimaging has been widely applied in patients with OSA, but these studies have often yielded diverse results. The present quantitative meta-analysis aims to identify consistent patterns of abnormal activation and grey matter loss in OSA across studies. We used PubMed to retrieve task/resting-state functional magnetic resonance imaging and voxel-based morphometry studies. Stereotactic data were extracted from fifteen studies, and subsequently tested for convergence using activation likelihood estimation. We found convergent evidence for structural atrophy and functional disturbances in the right basolateral amygdala/hippocampus and the right central insula. Functional characterization of these regions using the BrainMap database suggested associated dysfunction of emotional, sensory, and limbic processes. Assessment of task-based co-activation patterns furthermore indicated that the two regions obtained from the meta-analysis are part of a joint network comprising the anterior insula, posterior-medial frontal cortex and thalamus. Taken together, our findings highlight the role of right amygdala, hippocampus and insula in the abnormal emotional and sensory processing in OSA.

Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review

People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.

Obstructive sleep apnea and schizophrenia: A systematic review to inform clinical practice

BACKGROUND

Risk factors for obstructive sleep apnea (OSA) are common in people with schizophrenia. Identification and treatment of OSA may improve physical health in this population; however there are no guidelines to inform screening and management.

OBJECTIVES

Systematic review to determine, in people with schizophrenia and related disorders: the prevalence of OSA; the prevalence of OSA compared to general population controls; the physical and psychiatric correlates of OSA, associations between antipsychotic medications and OSA; the impact of treatment of OSA on psychiatric and physical health; and the diagnostic validity of OSA screening tools.

DATA SOURCES

Medline, EMBASE, ISI Web of Science and PsycINFO electronic databases. Cohort, case-control and cross-sectional studies and RCTs reporting on prevalence of OSA in subjects with schizophrenia and related disorders were reviewed.

RESULTS

The prevalence of OSA varied between 1.6% and 52%. The prevalence of OSA was similar between people with schizophrenia and population controls in two studies. Diagnosis of OSA was associated with larger neck circumference, BMI>25, male sex and age>50years. There were no data on physical or psychiatric outcomes following treatment of OSA. The diagnostic utility of OSA screening tools had not been investigated.

CONCLUSION

OSA may be prevalent and potentially under-recognized in people with schizophrenia. Further research is required to determine utility of OSA screening tools, the relationships between antipsychotic medications and OSA and any benefits of treating OSA. We propose a strategy for the identification of OSA in people with schizophrenia and related disorders.

Developing a brief depression screen and identifying associations with comorbid physical and psychological illness in Australian Gulf War veterans

OBJECTIVE

Major depression occurs frequently in veterans, and is associated with comorbid psychological and physical disorders and poorer quality of life. Depression can be difficult to detect in primary care, while lengthy assessment instruments can deter use. Our study aimed to develop a brief depression screen that could be used by veterans and caregivers, and then to compare the association between the brief screen and comorbidities and quality of life with that of a longer instrument.

METHODS

Our dataset comprised 1204 male Royal Australian Navy veterans of the 1990/91 Gulf War. Depressive symptoms were assessed using the General Health Questionnaire (GHQ-12), health-related quality of life by the Short-Form Health Survey (SF-12), major depression and comorbid psychiatric diagnoses such as posttraumatic disorder (PTSD) using Diagnostic and Statistical Manual (DSM-IV) criteria. Comorbid physical illnesses including musculoskeletal disorders, chronic fatigue and diabetes were examined.

RESULTS

A brief depression screen of three key self-reported symptoms was identified. Veterans with major depression present according to the screen were over four times more likely to have multisymptom illness or PTSD, and almost twice as likely to have musculoskeletal disorders. Having depression according to the brief screen and having at least one other physical or psychological condition was associated with poorer quality of life. Similar results were obtained for a longer screen based on all GHQ-12 items.

CONCLUSION

A 3 item depression screen performed as well as a 12 item one in identifying major depression, comorbid physical and psychological illness and poorer quality of life in veterans.

Primary Sleep Disorders

Primary sleep disorders include those not attributable to another medical or psychiatric condition: insomnia disorder, hypersomnolence disorder, narcolepsy, obstructive sleep apnea hypopnea syndrome, central sleep apnea syndrome, and the parasomnias. They are commonly encountered and are comorbid with many psychiatric disorders. It is important to recognize these disorders and be comfortable treating them or to know when to refer to a sleep disorders center and sleep specialist. Treatment of a comorbid sleep disorder can improve the overall quality of life, symptoms in mood disorders, and symptoms of excessive daytime sleepiness, and decrease cardiovascular morbidity and mortality.

Management of obstructive sleep apnea in edentulous patients: an overview of the literature

Purpose

A high prevalence of obstructive sleep apnea (OSA) is seen in edentulous individuals. Treatment options for edentulous OSA patients however are limited with continuous positive airway pressure therapy (CPAP) remaining the current therapy of choice. As CPAP is associated with high non-adherence rates and oral appliance therapy requiring sufficient dentition, there is a clinical need for effective treatment strategies aimed at edentulous OSA patients. The purpose of this study was to present a thorough overview of the literature regarding (1) the effects of nocturnal denture wearing on OSA, (2) the outcomes of oral appliance therapy, and (3) surgical treatment in edentulous OSA patients.

Methods

A computer-assisted literature search was performed in the MEDLINE database on “edentulism” and “obstructive sleep apnea.” The search yielded a total of 34 original articles.

Results

A total of 20 studies were included after exclusion of non-relevant, duplicate, and non-English publications, comprising 4 randomized clinical trials, 12 case reports, and 4 cohort or cross-sectional studies. The outcomes of these studies were addressed in detail concerning nocturnal wearing of dentures, oral appliance therapy, and surgical treatment.

Conclusion

Currently, there is no consensus in the literature on the effects of nocturnal wearing of dentures on OSA. Several studies report the successful use of oral appliance therapy, including implant-retained mandibular advancement devices (MADs), in selected cases of edentulous patients with varying stages of OSA. Little evidence is available regarding outcomes of surgical procedures in edentulous patients. Based on the results of this literature overview, the paucity of effective evidence-based treatment strategies for edentulous OSA patients indicates the further need of clinical studies to improve clinical management.

Obstructive sleep apnea: management considerations in psychiatric patients

Psychiatric disorders and obstructive sleep apnea (OSA) are often comorbid. However, there is limited information on the impact of psychotropic medications on OSA symptoms, on how to manage psychiatric pharmacotherapy in patients presenting with OSA, or on the effectiveness and challenges of OSA treatments in patients with comorbid mental illness. As such, the objective of this article is to provide an overview of some epidemiological aspects of OSA and treatment considerations in the management of OSA in individuals with comorbid psychiatric disorders. Predefined keywords were used to search for relevant literature in electronic databases. Data show that OSA is particularly prevalent in patients with psychiatric disorders. The medical care that patients with these comorbidities require can be challenging, as some of the psychiatric medications used by these patients may exacerbate OSA symptoms. As such, continuous positive airway pressure continues to be the first-line treatment, even in patients with psychiatric comorbidity. However, more controlled studies are required, particularly to determine continuous positive airway pressure compliance in patients with mental illness, the impact of treating OSA on psychiatric symptoms, and the impact of the use of psychotropic medications on OSA symptoms.

Obstructive sleep apnea in psychiatric outpatients. A clinic-based study

Psychiatric diseases and symptoms are common among patients with obstructive sleep apnea (OSA). However, only a few studies have examined OSA in psychiatric patients. At the outpatient clinic of the Uusikaupunki Psychiatric Hospital, Finland, we used a low referral threshold to a diagnostic sleep study. An ambulatory cardiorespiratory polygraphy was performed in 114 of 221 patients. 95 patients were referred by the psychiatric clinic and 19 were examined in other clinical settings. We reviewed the medical files and retrospectively assessed the prevalence of OSA and the effect of gender, age, obesity, hypertension, type 2 diabetes, alcohol abuse, and symptoms suggesting OSA. 58 of the 221 patients (26.2%), 30 of 85 men (35.3%) and 28 of 136 women (20.6%), had OSA as determined by an apnea-hypopnea index (AHI) of 5/h or more. 20 patients (12 men and 8 women) had moderate or severe OSA (AHI ≥ 15/h). 46 patients (including 11 patients with moderate or severe OSA) were identified in the psychiatric clinic. In univariate analysis, a high body mass index, male gender, hypertension, snoring, and a history of witnessed apneas during sleep were associated with the presence of OSA. In multivariate analysis, a history of witnessed apneas did not remain significant. Age, type 2 diabetes, alcohol abuse, excessive daytime sleepiness (EDS), and fatigue did not associate with the presence of OSA. Our findings suggest that in psychiatric outpatients OSA is common but underdiagnosed. Presentation is often atypical, since many patients with OSA do not report witnessed apneas or EDS.

Psoriasis and sleep disorders: A systematic review

Psoriasis is an immune-mediated chronic inflammatory disorder which manifests as dermatologic lesions, and psoriatic arthritis (PsA) in about 30% of cases. Psoriasis is associated with multiple comorbidities including metabolic syndrome, hypertension, diabetes, cardiovascular events, obesity and psychiatric disorders, which can all affect the course of sleep disorders. A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified 33 studies. There is an increased prevalence of obstructive sleep apnea (OSA) with 36%-81.8% prevalence in psoriasis versus 2%-4% in the general population. There was also an increase in the prevalence of restless legs syndrome of 15.1%-18% in psoriasis versus 5%-10% in European and North American samples. The wide variety of insomnia criteria used in studies resulted in an insomnia prevalence of 5.9%-44.8% in psoriasis, which is insufficient to show an elevated prevalence when the general population has a 10% prevalence of chronic insomnia and 30-35% prevalence of transient insomnia. There is evidence that symptoms of insomnia in psoriasis are directly mediated by pruritus and pain. Treatments that decrease the cutaneous symptoms in psoriasis were successful in mitigating insomnia, but did not show improvements in OSA where the relationship with psoriasis is multifactorial.

Sleep Apnea and Risk of Panic Disorder

PURPOSE

Epidemiological studies have identified a trend in the development of depressive and anxiety disorders following a diagnosis of sleep apnea. The relationship between sleep apnea and subsequent panic disorder, however, remains unclear.

METHODS

Using a nationwide database, the Taiwan National Health Insurance Research Database, patients with sleep apnea and age-, sex-, income-, and urbanization-matched control patients who did not have sleep apnea were enrolled between 2000 and 2010. Patients with a prior diagnosis of panic disorder before enrollment were excluded. The 2 cohorts were observed until December 31, 2010. The primary endpoint was occurrence of newly diagnosed panic disorder.

RESULTS

A total of 8,704 sleep apnea patients and 34,792 control patients were enrolled. Of the 43,496 patients, 263 (0.60%) suffered from panic disorder during a mean follow-up period of 3.92 years, including 117 (1.34%) from the sleep apnea cohort and 146 (0.42%) from the control group. The Kaplan-Meier analysis revealed a predisposition of patients with sleep apnea to develop panic disorder (log-rank test, P <.001). After multivariate adjustment, the hazard ratio for subsequent panic disorder among the sleep apnea patients was 2.17 (95% confidence interval, 1.68-2.81; P <.001).

CONCLUSIONS

Sleep apnea appears to confer a higher risk for future development of panic disorder.

Distinguishing schizophrenia from posttraumatic stress disorder with psychosis

PURPOSE OF REVIEW

Co-occurrence of psychotic symptoms with symptoms typically thought of as posttraumatic stress disorder (PTSD) is well known, and there has been considerable debate whether this represents a psychotic subtype or a comorbid psychotic disorder.

RECENT FINDINGS

Psychotic symptoms typical of schizophrenia occur with a higher than expected frequency in PTSD. A large genome-wide association study (GWAS) has identified a collection of genes associated with PTSD, and these genes overlap with those identified as increasing the risk of developing schizophrenia.

SUMMARY

Up to 70% of returning veterans experience symptoms of PTSD. These individuals also fall within the peak age range for the onset of schizophrenia. PTSD with psychosis may occur for several reasons: trauma increases one's risk for schizophrenia and PTSD; patients with schizophrenia have a higher incidence of PTSD and may present with characteristic psychotic symptoms overlapping with psychosis in schizophrenia. Secondary to symptom overlap, there may be substantial misdiagnosis of psychotic disorders as PTSD, or nonidentification of a comorbid psychotic disorder. This overlap calls into question traditional diagnostic boundaries with implications for initial and long-term treatment of PTSD and psychosis. This review will discuss the recent literature relating to the association of PTSD with schizophrenia.