Gender differences in the effect of comorbid insomnia symptom on depression, anxiety, fatigue, and daytime sleepiness in patients with obstructive sleep apnea

Mastery is central: an examination of complex interrelationships between physical health, stress and adaptive cognition, and social connection with depression and anxiety symptoms

Background

Research has established the link between physical health, stress and cognition, and social connection with depression and anxiety. Nevertheless, an understanding of the comorbidity of depression and anxiety symptoms and their complex interrelationships with relevant factors remains still limited. This study investigated the complex pattern of interplay between depression and anxiety symptoms and pertinent physical, cognitive, and social factors and potential gender differences.

Methods

Using a sample of 600 middle-aged men and women, depression and anxiety as well as physical health, perceived stress and mastery, and social connection were assessed. The network structure of depression and anxiety symptoms and risk and resilience factors were characterized by examining interrelationships and the centrality indices of Strength and Bridge Strength. Gender differences were examined using the Network Comparison Test.

Results

Perceived stress and mastery were central bridge factors influencing comorbid depression and anxiety symptoms, and perceived stress, anhedonia, and mastery exhibited strong inter-connections to each other. The connections of physical health-anhedonia and sleep disturbance-irritability were stronger in men than in women, while social connection with family was linked to interpersonal problems only in women.

Conclusions

The results underscore that prevention and interventions targeting reducing perceptions of stress and promoting mastery would prevent onset or recurrence of depression and anxiety symptoms among middle-aged men and women. Engaging in behavioral activities to maintain physical health and ensuring adequate sleep could be particularly beneficial for men in reducing overall symptom severity.

Restless legs syndrome in patients with obstructive sleep apnea: Association between apnea severity and symptoms of depression, insomnia, and daytime sleepiness

OBJECTIVE

To determine if the prevalence and severity of restless legs syndrome (RLS) varies with apnea severity and analyze differences between the sexes in terms of comorbid RLS with symptoms of depression, insomnia, and daytime sleepiness in patients with obstructive sleep apnea (OSA).

METHODS

Symptoms of depression, insomnia, and daytime sleepiness were defined as Patient Health Questionnaire-9 score ≥10, Insomnia Severity Index score ≥15, and Epworth Sleepiness Scale score ≥11. Multivariate logistic and linear regression analyses were conducted.

RESULTS

In 707 adults with OSA (85.1% males), 16.1% (n = 114) had comorbid RLS. The prevalence of RLS was markedly lower in those with moderate and severe OSA than in those with mild OSA. Similarly, the odds of RLS significantly decreased with increasing apnea-hypopnea index. After controlling for age and sex, in patients with comorbid RLS, the International RLS Study Group Rating Scale scores were negatively correlated with apnea-hypopnea index and a nadir peripheral oxygen saturation during sleep. The presence of RLS was more likely to be associated with symptoms of depression, insomnia, and daytime sleepiness after controlling for confounding variables, but only in men.

CONCLUSIONS

RLS is frequently noted in combination with OSA, with a female preponderance. The severities of OSA and RLS may be negatively associated. In patients with OSA, sex-related differences in terms of comorbid RLS with symptoms of depression, insomnia, and daytime sleepiness warrant further investigations.

Latent profile analysis of depression in US adults with obstructive sleep apnea hypopnea syndrome

Objective

This study used latent profile analysis to explore the level of depression among US adults with obstructive sleep apnea hypopnea syndrome (OSAHS) symptoms and to identify different latent categories of depression to gain insight into the characteristic differences between these categories.

Methods

The data of this study were obtained from the National Health and Nutrition Examination Survey (NHANES) database, and the subjects with OSAHS symptoms were aged 18 years and older. The latent profile analysis (LPA) method was used to fit the latent depression categories in subjects with OSAHS symptoms. The chi-square test, rank sum test, and binary logistic regression were used to analyze the influencing factors of depression subgroups in subjects with OSAHS symptoms.

Results

Three latent profiles were identified: low-level (83.7%), moderate-level (14.5%) and high-level (1.8%) depression. The scores of 9 items in the high-level depression group were higher than those in the other two groups. Among them, item 4 "feeling tired or lack of energy" had the highest score in all categories.

Conclusion

Depression in subjects with OSAHS symptoms can be divided into low-level, moderate-level and high-level depression. There are significant differences among different levels of depression in gender, marital status, PIR, BMI, smoking, general health condition, sleep duration and OSAHS symptom severity.

The relationship between locus of control and pre-competitive anxiety in highly trained soccer players

Introduction

Previous studies have not considered the potential association between locus of control and precompetitive anxiety in elite soccer players. Accordingly, this cross-sectional study examined The prediction of locus of control on precompetitive anxiety in highly trained cadet soccer players.

Objective

Based on a literature review, our research question was: can the locus of control be considered as an explanatory element of precompetitive anxiety?

Methods

Thirty-five Tunisian highly trained soccer players licensed from two regional soccer clubs aged between 15 and 16 years participated in the resent study. All participants were evaluated using the Competitive State Anxiety Inventory-2 (CSAI-2) and the Internal-External Locus of Control Scale. The relationship between measures of anxiety, self-confidence and the locus of control scores were analyzed using Pearson's product-moment correlation coefficient. Further, multiple linear stepwise multiple regression models were calculated to determine the most robust predictors of the locus of control.

Results

Based on our findings, the regression analysis explains up to 21.3% of the total variation of our independent variable (locus of control) and explains only 21.3% of the variability of our dependent variable somatic anxiety. Furthermore, locus of control explains 61.9% of the variability in self-confidence.

Conclusion

The locus of control can be used for the detection and selection of young athletic talent to identify individuals with the best psychological aptitude to cope with psychological problems related to sports performance. Preparing highly trained soccer players on how to deal with their anxiety could prevent them from becoming overwhelmed when they feel powerless to change their situation during competition.

The association between sleep architecture, quality of life, and hypertension in patients with obstructive sleep apnea

OBJECTIVE

The aim of this study was to investigate the association between hypertension and overnight polysomnography measures of sleep duration, sleep architecture, and quality of life (QoL) in patients with obstructive sleep apnea (OSA).

METHODS

Participants were patients suspected of having OSA with or without hypertension. All patients underwent overnight polysomnography and completed the Epworth Sleepiness Scale (ESS), Self-Rating Anxiety Scale, Self-Rating Depression Scale, and 12-item Short-Form Health Survey.

RESULTS

Of 128 patients (mean age 46.2 ± 12.5 years), 53% had hypertension. The average total sleep duration was 344 min (standard deviation 90) or 5.7 h and sleep efficiency was < 70%. There was no significant difference between patients with OSA with/without hypertension in total sleep duration, sleep architecture, anxiety, depression, ESS scores, or QoL. In patients with OSA, nocturnal minimum oxygen saturation was significantly negatively correlated with bodily pain and physical component summary (PCS) scores; mean nocturnal saturation was negatively correlated with bodily pain and social function; anxiety showed a significant negative correlation with role emotional; and depression was significantly negatively correlated with physical function, role physical, general health, role emotional, PCS, and mental component summary (MCS) scores. In the group with OSA and hypertension, N3 duration was negatively correlated with social function, mental health, and MCS scores. Anxiety was significantly negatively correlated with physical function, role physical, vitality, mental health, role emotional, PCS, and MCS scores. Depression was significantly negatively correlated with physical function, role physical, vitality, mental health, role emotional, PCS, and MCS scores. In patients with mild, moderate, and severe OSA, QoL was associated with depression. In mild OSA, PCS was correlated with ESS and anxiety. In moderate OSA, MCS was correlated with apnea-hypopnea index scores. In severe OSA, MCS and PCS were correlated with anxiety.

CONCLUSIONS

There were no significant associations between the presence of hypertension and total sleep duration, sleep architecture, or QoL in patients with OSA. However, hypertension may affect the influencing factors of QoL in patients with OSA. Further cohort studies are needed to confirm these findings.

Comorbid insomnia and sleep apnea in children: a preliminary explorative study

Insomnia and sleep-disordered breathing (SDB) are prevalent sleep disorders. These disorders can therefore be concurrently present - comorbid insomnia and sleep apnea (COMISA). The prevalence of COMISA in the paediatric age range is unclear. As such, phenotypic constructs should help better define this comorbid condition if it exists in children and improve both diagnostic sensitivity and ultimately clinical care outcomes. We aimed to evaluate the frequency of insomnia in children and adolescents referred for evaluation of sleep symptoms suggestive of SDB in one initial (Cohort#1) and verify such findings in an independent cohort (Cohort#2) using a retrospective cross-sectional approach in patients aged 9-19 years presenting at a sleep centre to be evaluated for symptoms of SDB. Cohort #1 comprised 50 consecutive children (58% males; mean [SD] age 13.6 [3.3] years; median [interquartile range, IQR] Epworth Sleepiness Scale score 10 [6-12]) who were evaluated using validated SDB and insomnia questionnaires. Cohort#2 was extracted from electronic medical records and included 384 polysomnographically evaluated children (mean [SD] age 12.9 [3.6] years; mean [SD] body mass index z score 1.27 [0.28]; median Epworth Sleepiness Scale score 9.7 [4-17]). In Cohort #1, 56% were at high risk of SDB, 36% had insomnia alone, and 18% were at high risk of COMISA. The prevalence of COMISA in Cohort #2 was 16%, 72% had SDB alone, and 12% had insomnia alone. In both cohorts, COMISA manifested as increased propensity for sleepiness and fatigue during both waking and daytime. Thus, the presence of COMISA is frequent in the paediatric age range and accompanied by a more prominent symptomatic phenotype.

Age and sex differences on the association between anxiety disorders and obstructive sleep apnea: A nationwide case-control study in Taiwan

AIM

The aim of this study was to examine the association between anxiety disorders and obstructive sleep apnea (OSA).

METHODS

This is a population-based, retrospective case-control study using Taiwan's nationwide database. We included patients with OSA aged ≥12 years, diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 327 and 780. Each enrolled patient with OSA needed to undergo a polysomnography examination within 1 year pre- or post-OSA occurrence. Patients with OSA and controls were selected in a 1:4 ratio. Patients with anxiety disorders (ICD-9-CM code 300) were diagnosed by board-certified psychiatrists and required to visit the outpatient clinic at least three times per year. Multivariate logistic regression and interaction analyses were used to evaluate the objective association.

RESULTS

This study enrolled 7987 and 31 948 participants with and without OSA, respectively. A significant difference in anxiety exposure was observed only pre-OSA diagnosis but not post-OSA diagnosis. Compared with patients without anxiety disorders: (i) those with anxiety disorders had an adjusted odds ratio (aOR) of ≈1.864 in OSA comorbidity (aOR = 1.864; 95% confidence interval [CI] = 1.337-2.405); and (ii) subgroup analysis showed a significant interaction that anxiety patients of male sex, aged 18 to 44 years, aged 45 to 64 years, and hypertension had a higher aOR in OSA comorbidity (aOR = 2.104 [95% CI = 1.436-2.589], aOR = 1.942 [95% CI = 1.390-2.503], aOR = 2.179 [95% CI = 1.564-2.811], and aOR = 2.092 [95% CI = 1.497-2.706], respectively).

CONCLUSION

The study revealed a higher ratio of previous anxiety exposure in patients with OSA. Compared with those without anxiety, anxiety patients of male sex, aged 18 to 64 years, and with hypertension had a higher risk of OSA comorbidity.

Sex Differences in Excessive Daytime Sleepiness Among Patients With Obstructive Sleep Apnea

BACKGROUND AND PURPOSE

To identify sex differences in daytime sleepiness associated with apnea severity and periodic limb movements during sleep (PLMS) in subjects with obstructive sleep apnea (OSA).

METHODS

This study used the Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), and Sleep Hygiene Index (SHI) in logistic regression analyses with interaction terms. Severe OSA, excessive daytime sleepiness (EDS), and PLMS were defined as an apnea-hypopnea index of ≥30, an ESS score of ≥11, and a periodic limb movements index of >15, respectively.

RESULTS

The 1,624 subjects with OSA (males, 79.1%) comprised 45.3%, 38.2%, and 16.4% with severe OSA, EDS, and PLMS, respectively. Multiple logistic regression without interaction terms showed that sex, severe OSA, and PLMS were not significantly associated with EDS. However, significant interactions were noted between sex and severe OSA and PLMS in EDS in both crude and adjusted models (all p values<0.05). In the adjusted model, severe OSA was associated with EDS in males (p=0.009) but not in females. PLMS were more likely to be associated with EDS in females (p=0.013), whereas PLMS were less likely to be associated with EDS in males (p=0.041). The models were adjusted by the BDI score, SHI, and presence of medical comorbidities.

CONCLUSIONS

There are significant sex differences in subjective daytime sleepiness in subjects with severe OSA and PLMS. Severe OSA and PLMS may influence daytime sleepiness more in males and females, respectively.

Sleep disordered breathing symptoms are associated with depressive symptoms: A longitudinal study of Chinese adolescents

BACKGROUND

Little is known about the prospective association between sleep disordered breathing (SDB) and depressive symptoms in Chinese adolescents. This study examined the independent predictive role of SDB symptoms in depressive symptoms in a large sample of adolescents.

METHODS

A total of 11831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort and 7072 adolescents who were resurveyed 1 year later were included for the analyses. Adolescents completed a self-administered questionnaire about demographics, mental health, sleep problems, and family environment. SDB symptoms were assessed by 3 items about loud snoring, breathing pauses, and snorting/gasping. The Chinese Youth Self-Report anxious/depressed subscale was used to assess depressive symptoms.

RESULTS

In the cross-sectional analyses, 11.8% adolescents had depressive symptoms, and elevated frequency of SDB symptoms were significantly associated with depressive symptoms. In the longitudinal study, 4.5% of adolescents had persistent depressive symptoms, the incidence rate of depressive symptoms at 1-year follow-up was 6.5%, and elevated frequency of any SDB symptoms (often: OR=2.23, 95%CI:1.50-3.32) at baseline was significantly associated with incident depressive symptoms after adjusting for potential confounders. The associations between SDB symptoms and depressive symptoms were similar for boys and girls.

LIMITATION

SDB symptoms and depressive symptoms were measured by self-report.

CONCLUSION

SDB symptoms are an independent and significant predictor of depressive symptoms in adolescents. Further research is needed to understand the biological mechanisms between SDB and mood dysregulation in adolescents.

The relationships between obstructive sleep apnea and psychiatric disorders: a narrative review

Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Its prevalence tends to increase worldwide. Untreated sleep apnea is associated with a higher risk of metabolic diseases, cardiovascular diseases, stroke, road accidents, and death, but also it is suggested that it increases the risk of mental disorders.

Method: The literature review was based on a search of articles on Medline, Pubmed, and Google Scholar from 2003 to 2021 using the keywords: obstructive sleep apnea; mental disorders; cognitive functions; affective disorders; depression; bipolar disorder; schizophrenia; psychotic disorders. The analysis included original studies, meta-analysis, and review articles.

Discussion: The result obtained from researches published so far does not allow for drawing unequivocal conclusions. There is a lot of bias present in study protocols and inclusion/exclusion criteria. Nonetheless, it seems that some disorders have a better proven correlation with OSA. Cognitive impairment, depression, and anxiety disorders are linked to OSA not only in terms of the overlapping of symptoms but also of a causal relationship. Psychotic disorders and bipolar disorders connections with OSA are confirmed, but they are not yet well understood. All correlations are found to be possibly bidirectional.

Conclusion: 1. Multiple lines of evidence increasingly point towards a bidirectional connection between OSA and mental disorders, and the cause and effect relationship between these two groups of disorders requires further research.

2. Due to reports of an increased risk of OSA with antipsychotic drugs, caution should be exercised when initiating therapy with this type of drug in patients with known risk factors for it.

3. Screening for OSA in psychiatric patients should be introduced as OSA can increase cognitive impairment, affective, and psychotic symptoms.

Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

Comorbid insomnia and sleep apnea: characterization of the syndrome and understanding its associations with comorbid sleep conditions

PURPOSE

Obstructive sleep apnea (OSA) is traditionally associated with excessive daytime sleepiness. Insomnia is characterized by hyperarousal, and is seen as a predominant feature in a subgroup of patients with OSA. The aim of this study was to describe the prevalence of comorbid insomnia and sleep apnea (COMISA) in a sleep apnea population and to characterize its features.

METHODS

This was a chart review of patients who underwent overnight polysomnography (PSG). All patients completed questionnaires with the Epworth Sleepiness Scale (ESS), and symptoms of insomnia and other sleep-related comorbidities. Patients with OSA on the PSG were included.

RESULTS

A total of 296 patients with OSA were included, of which 80% reported at least 1 major symptom of insomnia: 57% reported sleep onset insomnia, 68% sleep maintenance insomnia, and 48% had early morning awakenings. COMISA (OSA plus 2 or more major symptoms of insomnia) was seen in 63%. These patients were more likely to report an abnormal ESS score, gastroesophageal reflux (GER), and restless legs (RL) than those without; no difference was seen in self-reported sleep bruxism. Among the patients with COMISA, 85% reported at least 1 representative symptom of psychophysiological insomnia (PPI); each of the 5 PPI symptoms was present in at least 40% of patients with COMISA.

CONCLUSIONS

Insomnia is extremely prevalent in our population of patients with OSA, accompanied by daytime sleepiness and symptoms of PPI, GER, and RL. Further study is needed to determine the interactions between symptoms and OSA treatments in these patients.

Depressive Symptoms in Comorbid Obstructive Sleep Apnea and Insomnia: An Integrative Review

The purpose of this integrative review was to synthesize evidence concerning the relationship between comorbid obstructive sleep apnea and insomnia (OSA+I), and depressive symptoms. OSA and insomnia are common sleep disorders, recently comorbid OSA+I has been recognized as prevalent in adults. Although each sleep disorder increases the risk and severity of depressive symptoms, the effect of comorbid OSA+I on depressive symptoms remains unclear. A systematic search of PubMed, CINAHL, and PsycINFO identified 15 data-based studies. All the studies were observational with either a cross-sectional (n = 14) or a case-control design (n = 1). Study quality was assessed. Most of the studies (n = 14) indicated that comorbid OSA+I had an additive role on depressive symptoms. Insomnia appeared to have a more important role than OSA in increasing the severity of depressive symptoms in persons with comorbid OSA+I.

Excessive Daytime Sleepiness in Depression and Obstructive Sleep Apnea: More Than Just an Overlapping Symptom

Excessive daytime sleepiness (EDS) is a significant public health concern, with obstructive sleep apnea (OSA) being a common cause, and a particular relationship exists with the severity of depression. A literature search on OSA, depression, and EDS was performed in PubMed. The chosen evidence was limited to human studies. Available evidence was systematically reviewed to ascertain the association of EDS with depression and OSA according to the general population and some specific population subgroups. In addition, effectiveness of continuous positive airway pressure (CPAP) was analyzed as a standard therapy for improving EDS and depression in patients with OSA. In the general population, patients with OSA, and some other subpopulations, the review contributed to: (1) delineating the prevalence of EDS; (2) substantiating the relationship of EDS and depression; (3) presenting the relationship between EDS and OSA; and (4) revealing that the duration of CPAP is crucial for its therapeutic effects in improving EDS and depressive symptoms in patients with OSA.

Sex differences in subjectively reported symptoms of obstructive sleep apnea in community-dwelling adults with type 2 diabetes

BACKGROUND

Reports of sex differences in self-reported mood, sleep quality, daytime function, and excessive daytime sleepiness in people with obstructive sleep apnea (OSA) have been inconsistent. The purpose of this study was to investigate sex differences in these subjective sleep outcomes in participants with type 2 diabetes (T2D) either at high risk for OSA or diagnosed with OSA.

METHODS

Measures included OSA severity by apnea-hypopnea index (AHI) and self-reported questionnaires: Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), functional outcomes of sleep quality questionnaire (FOSQ), and the profile of mood states (POMS). Relevant individual, social, and health determinants were included as covariates.

RESULTS

A total of 350 participants with T2D [Mean A1C 8.0% (SD ±1.8)] had mean age 56.5 (SD ±10.5) and were balanced by sex (51% men) and race (60% white, 40% non-white). Reports of sleep quality and daytime function were worse in women than in men (p <0.05), whereas men had more severe OSA than women (p <0.05). In fully adjusted models, there was no moderation by sex in the relations between AHI and the sleep outcome measures. AHI showed a significant association with ESS but not PSQI, FOSQ, or POMS.

CONCLUSION

In participants with T2D at high risk for or diagnosed with OSA, excessive daytime sleepiness was independently associated with OSA severity, but not self-reported sleep quality, daytime function, or mood. While women reported worse outcomes associated with sleep, these outcomes were not associated with OSA severity.

Differences in electroencephalographic spectra during pre-sleep wakefulness, N1, and R sleep between comorbid insomnia and obstructive sleep apnea

PURPOSE

The neuropsychobiological effects of the comorbidity of insomnia and obstructive sleep apnea are not well studied. Our objective was to compare electroencephalographic spectra of patients with comorbid insomnia and sleep apnea syndrome to those of patients with sleep apnea syndrome alone during pre-sleep wakefulness and the N1 and R sleep periods.

METHOD

We performed electroencephalography and polysomnography on 10 patients with comorbid insomnia and sleep apnea and 10 with only sleep apnea. Electroencephalography spectra analysis was performed for absolute power in clinical bands in six derivations.

RESULTS

Compared to sleep apnea patients, comorbid patients had lower sleep efficiency and total sleep time, higher beta-1 power in the left frontal and central derivations during pre-sleep wakefulness, higher delta power in the left frontal and central derivations during the N1 stage, and higher beta-2 power in the left frontal and central, and right central derivations during the R stage.

CONCLUSIONS

Data suggest that patients with insomnia and sleep apnea, compared to patients with only sleep apnea, presented higher left high-frequency rhythms during pre-sleep wakefulness and R sleep stage, and may be for increased emotional and cognitive-related activity, while in stage N1, presented higher left delta power, which suggest some slowing after sleep deprivation.

Diagnosis of obstructive sleep apnea in women: Is there any difference?- Experience from a tertiary care hospital of North India

Context:

Obstructive sleep apnea (OSA) considered classically to be a male-dominant disease, may have significant gender-based differences in clinical presentation and diagnosis.

Aims:

To evaluate gender-based differences in the clinical profile and polysomnographic features of Indian patients with OSA.

Settings and Design:

A prospective observational study was conducted over a period of 12 months involving adult ambulatory patients, referred for evaluation of OSA.

Methods and Materials:

Enrolled patients underwent detailed clinical evaluation followed by supervised polysomnography. Sleep studies were manually validated and analyzed.

Statistical Analysis Used:

Continuous variables were compared using two-tailed independent- sample t-test. For the univariate analysis, the Chi-square test was used.

Results:

Out of 150 enrolled patients, 94 (62.7%) were males (male-to-female: 1.7:1; age: 51.85 ± 12.60 years; BMI: 32.09 ± 5.53 kg/m²). Most common presenting features were excessive daytime somnolence, snoring, and easy fatiguability. Women with OSA were older than men. Insomnia and anxiety were significantly higher among females. Parameters defining sleep architecture were similar in both groups. Although obstructive apneas and hypopneas were similar, mean apnea hypopnea index was significantly higher (P < 0.05) in males compared to females with higher titratable continuous positive airway pressure.

Conclusions:

There are gender-specific differences in the clinical presentation of OSA due to various anatomical, physiological, and psychosocial factors. Their potential influence on the clinical features, natural history, and implications on treatment need further evaluation on a larger scale.

Is severe obstructive sleep apnea associated with less depressive symptoms?

PURPOSE

To investigate the relationship between obstructive sleep apnea (OSA) and symptoms of depression and anxiety in OSA patients.

METHODS

Symptoms were assessed using the Beck Depression Inventory (BDI) and the state part of the State-Trait Anxiety Inventory (STAI-S). BDI scores of ≥10 and STAI-S scores of ≥40 were considered to indicate the presence of depression and anxiety, respectively. Apnea severities measured using polysomnography were categorized into mild, moderate, and severe subgroups bounded by the 33rd and 66th percentiles of each polysomnographic parameter. Data were stratified by age, gender, and level of daytime sleepiness.

RESULTS

The study population comprised 795 adult patients (86.9% men). Symptoms of depression and anxiety were present in 46.2% and 49.2% of patients, respectively. Excessive daytime sleepiness was present in 40.0% of patients and did not differ depending on the level of apnea severity. Results of crude logistic regression analyses indicated that depressive symptoms were more prevalent in patients with mild OSA than those with severe OSA, regardless of the categorizing method. These results remained statistically significant following adjustment for several confounding factors. These relationships were similar but less prominent in measures of anxiety. In the sub-analyses, such negative associations between severity of OSA and depressive symptoms tended to be observed only in patients with daytime sleepiness.

CONCLUSIONS

Symptoms of depression and anxiety were found to be more prevalent in patients with mild OSA than those with severe OSA. Excessive daytime sleepiness was shown to affect the severity of depressive symptoms.

Prevalence and risk factors of people at-risk of obstructive sleep apnea in a rural community of Odisha, India: a community based cross-sectional study

BACKGROUND

Obstructive sleep apnea (OSA) is a progressive sleep disordered breathing condition characterized by repeated episodes of upper airway collapse during sleep. Despite being the most common sleep apnea, it often remains undiagnosed and untreated, especially in rural communities. There is a paucity of literature estimating the prevalence of the disease and associated risk factors from the rural population of Odisha.

METHODS

It is a cross-sectional study that was conducted in a rural community of Odisha, India to find out the prevalence of people living with the risk of OSA. Multi-staged sampling was done. Participants were evaluated using the Berlin questionnaire (BQ) after obtaining informed consent. Data were analyzed using SPSS with the significance level set at 95%. Univariate and multivariate analysis was done to evaluate the risk factors associated with the condition.

RESULTS

Out of 200 community dwellers surveyed using the BQ, 25% had a high likelihood of OSA. Among these high risk subjects, snoring was reported by 70%, excessive daytime sleepiness by 50%. Out of those who were at risk of OSA, 28% were smokers and 48% reported alcohol use. The associated risk factors were age >35 years (OR = 4.5, 95% CI = 1.4-13.8, p < 0.05), BMI ≥ 25 kg/m² (aOR = 3.5, 95% CI = 1.2- 10.5, p < 0.05), alcoholism (aOR = 4.5, 95% CI = 1.8-11.1, p = 0.001), and hypertension (aOR = 11.5, 95% CI = 4.7-28, p < 0.001). The prevalence was not affected by the type of diet (vegetarian vs non-vegetarian), use of tobacco or tea consumption.

CONCLUSION

OSA is highly prevalent in the rural community of Odisha. Independent risk factors associated with such subjects were obesity, regular alcohol consumption, and hypertension. Further prevalence studies are recommended.

Men and women with chronic insomnia disorder and OSAS: Different responses to CPAP

Objective

To evaluate the response to CPAP in patients with chronic insomnia disorder (CID) with OSAS in an unselected patient population including all OSAS severity groups. As a secondary objective, we also wanted to evaluate the differences between patients that improve insomnia symptoms with CPAP and patients that do not improve, specifically evaluating possible gender differences.

Methods

Retrospective study of patients with a diagnosis of OSAS treated with CPAP and CID at the first clinical visit, selected from a database of an outpatient sleep clinic of University Hospital.

Results

From a database of total of 827 patient, 90 patients were identified with OSAS and CID (53.3% women). Middle / moderate OSAS was diagnosed in 68.9% and severe OSA in 31.1%. Most patients (61.1%) improved insomnia symptoms after CPAP therapy. In the responders group, 58.2% had initial insomnia, 63.6% middle insomnia and 12.7% late insomnia. Responders to CPAP were more frequently women (women 61.8%, men 38.2%, p = 0.035) and there was no other difference between responders and non-responders. On subgroup analysis, this difference was significant only in severe OSAS (women 88.9%, men 31.6%, p = 0.013).

Conclusion

In most patients with CID and OSA, there is a consistent reduction of insomnia symptoms with the CPAP use. This factor emphasizes the importance of performing PSG in CID. Insomnia in men with severe OSAS responds less frequently to CPAP suggesting that in these cases the insomnia phenotype is less dependent on the respiratory symptoms.

Mechanisms of reduced sleepiness symptoms in heart failure and obstructive sleep apnea

Patients with both heart failure and obstructive sleep apnea often have poor, repeatedly disrupted sleep, and yet they frequently do not complain of excessive daytime sleepiness. Understanding this lack of perceived sleepiness is crucial for the case identification and treatment of obstructive sleep apnea in the heart failure population at high risk of this disease, especially given the association between untreated obstructive sleep apnea and mortality among patients with heart failure. In this review, we present epidemiologic evidence concerning the lack of sleepiness symptoms in heart failure and obstructive sleep apnea, explore possible mechanistic explanations for this relationship, assess the benefits of treatment in this population, discuss implications for clinical practice and explore directions for future research.

Current Treatment of Comorbid Insomnia and Obstructive Sleep Apnea With CBTI and PAP-Therapy: A Systematic Review

Insomnia and obstructive sleep apnea (OSA) are often both present in patients with sleep-disordered-breathing (SDB). The coexistence of the two disorders shows an increase in cumulative morbidity and an overall greater illness severity. There is still considerable controversy regarding management decisions in this group of patients. This systematic review focused on more recent evidence regarding treatment of patients presenting with both clinical entities of comorbid insomnia and OSA (COMISA) in terms of their management, especially using combinations of positive airway pressure [PAP, namely aPAP, cPAP, adaptive servo-ventilation (ASV)] and CBTi as well as each one of these two modalities alone. As a conclusion it is necessary to specifically target distinct combinations of both insomnia (initial, middle, late) and OSA (mild, moderate, severe) phenotypes. The present review gives reason to assume that both CBTi and PAP-therapy are necessary. However, it appears that distinct treatment patterns may suit different COMISA phenotypes.

Women with both sleep problems and snoring show objective impairment of sleep

OBJECTIVE

Combined insomnia and obstructive sleep apnea has been the focus of considerable research with respect to its health effects. A related issue is whether sleep disturbances in combination with snoring might exert effects on objective sleep variables in the non-clinical general population. The purpose of the present study was to investigate the polysomnographical characteristics of individuals who had sought medical help for both disturbed sleep and for snoring. No previous work of this type has been carried out.

METHOD

For this study we used a representative set of data of 384 women with one night of in-home PSG. We identified those individuals who had sought medical help for sleep problems (SL), individuals that had sought help for snoring (SN), as well as those that had sought help for either both (Combined), or for neither (Control).

RESULTS

Our results yielded an N of 46, 16, 21, and 301 individuals, respectively. A one-factor analysis of variance showed significant main effects on N1% (F = 10.2, p < 0.001), N3% (F = 2.7, p < 0.05), AHI/h (F = 5.5, p < 0.001), and a delta power measure (F = 3.8, p < 0.05). The combined group showed significantly higher levels than the other groups for N1% (29% vs < 21%), AHI/h (19/h vs < 10/h) and lower levels for N3%, and a measure of delta power. Reported sleep quality measures did not show the same pattern, since the highest/lowest value were found for either the group presenting snoring alone or sleep problems alone.

CONCLUSION

We concluded that individuals who had sought help for both insomnia and snoring showed impaired sleep in terms of PSG and that this was not reflected in ratings of sleep or health. This suggests that simultaneous sleep disturbances and snoring may potentiate each other to cause impaired sleep, yet the mechanism still needs to be elucidated.

Comorbid Insomnia With Obstructive Sleep Apnea: Clinical Characteristics and Risk Factors

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and chronic insomnia are two common sleep disorders and both are considered independent risk factors for heart disease. The aim of this study was to investigate the prevalence of comorbid insomnia with OSA and to compare its clinical characteristics with those of OSA without insomnia.

METHODS

Patients who visited two tertiary university hospital sleep centers were screened. Those with a diagnosis of OSA using polysomnography were divided into two groups based on their scores on the Korean version of the Insomnia Severity Index (ISI-K): OSA with insomnia (OSA+I) (ISI-K score ≥ 15) and OSA without insomnia (OSA-I) (ISI-K score < 15). Subjective symptoms were evaluated using sleep questionnaires including ISI-K. Demographic and clinical characteristics of OSA+I and OSA-I were compared.

RESULTS

Out of 476 patients with OSA, 139 (29.2%) had significant insomnia. Patients in the OSA+I group had a higher percentage of females (35.3% versus 19.6%, P < .001) and have higher rates of heart disease (19.4% versus 8.6%, P < .001). OSA+I group showed lower quality of life, lower quality of sleep, higher sleep propensity, and higher depression as measured by the Korean versions of the Short-Form 36-Item Health Survey, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Beck Depression Inventory, respectively. There were no significant differences in adherence to continuous positive airway pressure between the groups.

CONCLUSIONS

There is a high prevalence of comorbid insomnia with OSA (29.2%), consistent with previous findings in Western studies. Comorbid insomnia with OSA may constitute a cumulative risk factor for cardiovascular disease. These findings warrant further investigation into the mechanisms involved in its pathogenesis and devising more efficient treatments.

Gender differences in sleep disorders in the US military

OBJECTIVES

The purpose of this study is to compare sleep disorders between male and female military personnel. Comorbid behavioral health disorders and chronic pain were also studied in relation to sleep disorders.

DESIGN

We conducted a retrospective review of military personnel who underwent a sleep medicine evaluation and an in-laboratory attended polysomnography. Initial sleep questionnaires, demographics, polysomnographic variables, and comorbid disorders of interest were reviewed and compared for each sex.

SETTING

All patients were referred to the Wilford Hall Ambulatory Surgical Center Sleep Disorders Center for evaluation of sleep disturbance.

PARTICIPANTS

Our cohort consisted of 209 military personnel with 51.7% men. The cohort was relatively young with a mean age of 34.3 years. Men had a significantly higher body mass index at 29.4 vs 27.3 in women.

RESULTS

Insomnia was diagnosed in 72 women and 41 men (P< .001), whereas obstructive sleep apnea (OSA) was diagnosed in 92 men and 50 women (P< .001). Depression and anxiety were more common in women. Women had an average of 1.76 ± 1.36 comorbid conditions compared with 1.08 ± 1.19 in men. In patients diagnosed with both insomnia and OSA, women were more likely to have post-traumatic stress disorder, depression, and anxiety. Neither the Epworth Sleepiness Scale (12.8 ± 4.88) nor the Insomnia Severity Index (16.9 ± 5.33) differed between sexes.

CONCLUSIONS

Gender-related differences in sleep disorders are present in active-duty personnel. Behavioral health disorders were frequent comorbid disorders, and women diagnosed with both insomnia and OSA manifested greater psychiatric comorbidity. The frequent association between sleep and behavioral health disorders in military personnel requires further study.

Quality of life, depression and dietary intake in Obstructive Sleep Apnea patients

BACKGROUND

The aim of this study was to analyze the association between depression, quality of life and dietary intake in newly diagnosed Obstructive Sleep Apnea (OSA) patients.

METHODS

From 153 eligible patients suffering from sleep disturbances, 64 met inclusion and exclusion criteria. The polysomnography was used for OSA diagnosis. The quality of life (QOL) was assessed by WHOQOL-BREF questionnaire, self-reported chronotype by morningness-eveningness questionnaire and level of depression by Beck's Depression Inventory. Blood pressure and parameters of glucose and lipid metabolism were assessed by routine methods. The dietary intake was evaluated by 24-hr dietary recalls.

RESULTS

Significantly negative associations were found between depression inventory and QOL. Better QOL for physical health and social relationships was observed in the "definitely morning" chronotype. The "morning type" of patients was positively related to the intake of fat, monounsaturated fatty acids and vitamin B12. Correlations between QOL and diastolic blood pressure, HDL-cholesterol, TG, fasting glucose, as well as protein and vitamin B6 intake were found.

CONCLUSIONS

In conclusion, both chornotype and depression influence QOL in OSA patients where morning type is associated with better physical health and social relationships and increase in depression index deteriorate physical health, psychological and social relationship QOL domains. QOL as well as depression and chornotype are also influenced by selected cardio-metabolic factors and dietary intake.

Subjective apnoea symptoms are associated with daytime sleepiness in patients with moderate and severe obstructive sleep apnoea: a retrospective study

OBJECTIVES

Most previous studies have failed to show a relation between daytime sleepiness and apnoea severity in patients with obstructive sleep apnoea (OSA). We determined the relation between daytime sleepiness and subjective and objective apnoea severity in newly diagnosed patients with moderate-to-severe OSA.

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary referral centre.

PARTICIPANTS

A total of 559 adults with newly diagnosed moderate and severe OSA.

MAIN OUTCOME MEASURES

Daytime sleepiness was evaluated using the Epworth Sleepiness Scale (ESS). Subjective and objective apnoea severities were assessed using the Sleep Breathing Scale (SBS) and polysomnography respectively. Sleep quality and depressive symptoms were evaluated using Medical Outcomes Study-Sleep Scale and Beck Depression Inventory (BDI) respectively.

RESULTS

The mean ESS score was 9.8 (SD 5.0). ESS score was correlated with SBS score (P < 0.001), apnoea-hypopnoea index (AHI) (P = 0.027), minimal oxygen saturation (MinSaO2 ) (P = 0.021), body mass index (BMI) (P = 0.007) and BDI score (P < 0.001). Linear regression analysis showed that higher SBS (P = 0.005) and BDI scores (P < 0.001) were associated with higher ESS score after controlling for gender, BMI and AHI. Apnoea-hypopnoea index, MinSaO2 and BMI were not independently related to ESS score.

CONCLUSIONS

Daytime sleepiness was related to subjective OSA symptoms but not objective apnoea severity measured by polysomnography in patients with moderate-to-severe OSA. These findings suggest the usefulness of the subjective apnoea severity as an indicator of OSA disease severity.

Quality of life in patients with obstructive sleep apnea: Relationship with daytime sleepiness, sleep quality, depression, and apnea severity

The aim of this study was to investigate the relative contributions of daytime sleepiness, sleep quality, depression, and apnea severity to mental and physical quality of life (QoL) in obstructive sleep apnea (OSA) patients. This was a cross-sectional study. Participants were adults diagnosed with OSA. Medical Outcomes Study-Short Form 36 (SF-36), Epworth Sleepiness Scale (ESS), Medical Outcomes Study-Sleep Scale, and Beck Depression Inventory (BDI) were used. The factors predicting the physical and mental QoL were evaluated using multiple linear regression analysis. Seven hundred ninety three OSA patients participated in the study. The average age was 48.9 years (SD = 11.7 years). The mean apnea-hypopnea index (AHI) was 29.5 hour(-1) (SD = 20.6 hour(-1)). The SF-36 scores were 72.6 (SD = 18.5). The BDI, sleep quality, and age were related to both mental and physical QoL. However, ESS, minimal arterial oxygen saturation, gender, and body mass index were associated with the physical but not mental QoL. The BDI was the strongest predictor of both physical and mental QoL. AHI was related to neither physical nor mental QoL. The potential factors affecting QoL are different between physical and mental dimensions of QoL. Depressive mood was the strongest predictor of both the physical and mental QoL.

The influence of personality traits on perception of pain in older adults – Findings from the Swedish National Study on Aging and Care – Blekinge study

Background and aims

The experience of pain may vary in accordance with personality traits and individual characteristics. Neuroticism is demonstrated to constitute a vulnerability factor among younger and middle-aged pain patients. The combination of openness and neuroticism is associated with high anxiety/depression scores among adult individuals with chronic conditions. The aim of this study was to investigate possible associations between pain and the personality dimensions of neuroticism, extroversion, openness, agreeableness and conscientiousness among persons aged 60 years and older. An additional aim was to explore whether such associations are equally gender expressed.

Methods

The Swedish National Study on Aging and Care includes a randomly selected sample from the National Population Register. The data collection was conducted at four research centres and was approved by the Ethics Committees of Lund University and the Karolinska Institutet, Stockholm, Sweden. The Blekinge sample includes 1402 individuals, aged 60–96 years, of whom 769 (55%) reported pain. A total of 2312 individuals had been invited to participate. The reason for non-participation was registered. Participants underwent medical examination and testing by research personnel, conducted in two sessions, each of which lasted about 3 h. A questionnaire was completed between the two sessions. Pain was self-reported and based on the question: Have you had ache/pain during the last 4 weeks? Information on personality traits was obtained by means of the personality SGC1 questionnaire; a 60-item Swedish version of Costa & McCrae’s FFM questionnaire. Personality traits were then tested based on gender by means of multivariate forward logistic regression in models adjusted for age, insomnia, financial status and educational level.

Results

When adjusting for covariates among women, neuroticism had a small but significant odds ratio of experiencing pain (OR 1.05, CI 1.02–1.08). Insomnia had the highest odds ratio (OR 2.19, CI 1.52–3.15) followed by low education (OR 1.59, CI 1.07–2.36), while belonging to the younger part of the older adult cohort was also associated with pain (OR 1.02, CI 1.005–1.04). In men, neuroticism (OR 1.03, CI 1.002–1.06) followed by openness (OR 1.03 CI 1.001–1.07) had a small but significant odds ratio of experiencing pain. Insomnia had the highest odds ratio (OR 1.98, CI 1.24–3.15).

Conclusions

Personality traits and pain were related among the older adults but there were gender differences. The relationship between pain and neuroticism in women was about the same in strength as the relation between pain and neuroticism/openness in men. Both sexes suffer from insomnia. The relationship between personality traits and pain was only affected to a minor extent by insomnia.

Implications

There is a need to increase awareness of the impact of personality as well as to provide improved treatment for pain and insomnia in older people.

Does race-ethnicity moderate the relationship between CPAP adherence and functional outcomes of sleep in US veterans with obstructive sleep apnea syndrome?

BACKGROUND

Little is known about the association of race-ethnicity and the relationship of continuous positive airway pressure (CPAP) adherence with functional outcomes of sleep in American samples with obstructive sleep apnea syndrome (OSAS). This retrospective study examines whether race-ethnicity moderates the relationship between CPAP adherence and functional outcomes of sleep in OSAS.

METHODS

Over 4 months, consecutive OSAS patients had CPAP data downloads and completed questionnaires (demographics, Functional Outcomes of Sleep Questionnaire [FOSQ], Epworth Sleepiness Scale [ESS], Insomnia Severity Index [ISI]) at the Miami VA sleep center. Medical diagnoses and polysomnography data were obtained from medical record. CPAP adherence was measured as mean daily hours of use. Hierarchical regression modeling was used to explore the differential impact of race-ethnicity and CPAP adherence on functional outcomes of sleep.

RESULTS

Two hundred twenty-seven veterans (93% male, age 59 ± 11 years) were included; 142 (63%) participants self-reported as white or Hispanic, and 85 participants (37%) as black. Hierarchical regression analyses failed to show main effects for race-ethnicity or CPAP use and FOSQ scores; however, the interaction of race-ethnicity with CPAP adherence was significantly associated with the total FOSQ (p = 0.04), Social (p = 0.02), and Intimacy (p = 0.01) subscale scores. For blacks, in adjusted analyses, CPAP adherence was positively associated with Social and Intimacy FOSQ subscales; however, no significant relationship was noted between CPAP use and FOSQ scores in whites/Hispanics.

CONCLUSIONS

Race-ethnicity may moderate the relationship between CPAP adherence and some functional outcomes of sleep; however, further studies are needed.

Relationship between pain and Quality of Life—Findings from the Swedish National Study on Aging and Care—Blekinge study

Background and aims

The influence of pain as well as Quality of Life (QoL) varies in accordance with biological, social, psychological and existential factors. This study investigates the influence of such factors on the relationship between pain and QoL among older adults from a gender perspective.

Methods

The Swedish National Study on Aging and Care (SNAC-Blekinge) baseline sample comprised 1402 individuals aged 60–96 years, of whom 769 (55%) reported pain. The participants were invited by a letter to take part in the study, which was carried out by research staff in two sessions of three hour each. Participants gave informed consent and completed a questionnaire between the two sessions. The reason for non-participation was registered among subjects who declined the invitation. Pain and insomnia were self-reported. Data on age, gender and if living alone or not were collected from the questionnaire. Co-morbidity was obtained from electronic patients records for a period of up to two years prior to participating in the SNAC study. SoC was measured by a translated short form from the original twenty-nine question instrument. QoL, was estimated using the HRQL Medical Outcome Study-Short Form (SF 12). In a model, pain, age, sex, insomnia, co-morbidity, living alone, sense of coherence (SOC), household economy, education and QoL were calculated through multivariate logistic regression.

Results

Among women, pain was found to have the highest OR (odds ratio) for low QoL [OR 2.27 (CI 1.36–3.78)], followed by low economic status [OR 1.75 (CI 1.08–2.84)], co-morbidity [OR 1.24 (CI 1.05–1.46)], low SOC [OR 1.08 (CI 1.06–1.10)] and lower age [OR 1.05 (CI 1.02–1.08)]. In men, insomnia was found to be the main contributor to low QoL [OR 1.86 (CI 1.04–3.33)], followed by low SOC [OR 1.08 (CI 1.05–1.11)] and lower age [OR 1.04 (CI 1.01–1.07)].

Conclusions

Pain has a strong relationship with low QoL among elderly women. Insomnia is associated with low QoL among men who suffer less from pain. Thus the main result is a striking gender difference: Elderly women suffer from pain, elderly men suffer from insomnia.

Implications

It is importanttotake accountof sex, age, sleep problems, co-morbidity, SOC and economic status in order to understand the relationship between pain and QoL among older adults.

Cardiovascular and psychiatric morbidity in obstructive sleep apnea (OSA) with insomnia (sleep apnea plus) versus obstructive sleep apnea without insomnia: a case-control study from a Nationally Representative US sample

PURPOSE

To evaluate cardiovascular and psychiatric morbidity in patient visits with obstructive sleep apnea (OSA) with insomnia (OSA+Insomnia) versus OSA without insomnia (OSA-Insomnia) in a nationally representative US sample.

METHODS

A retrospective case-control study of epidemiologic databases (National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey) representing an estimated ± standard error (SE) 62,253,910 ± 5,274,747 (unweighted count=7234) patient visits with diagnosis of OSA from 1995-2010, was conducted. An estimated 3,994,104 ± 791,386 (unweighted count=658) were classified as OSA+Insomnia and an estimated 58,259,806 ± 4,849,800 (unweighted count=6576) as OSA-Insomnia. Logistic regression analysis was carried out using OSA+Insomnia versus OSA-Insomnia as the dependent variable, and age (>50 years versus ≤ 50 years), sex, race ('White' versus 'non-White'), essential hypertension, heart failure, ischemic heart disease, cardiac dysrhythmia, cerebrovascular disease, diabetes, obesity, hyperlipidemia, depressive, anxiety, and adjustment disorders (includes PTSD), hypersomnia and all medications used as independent variables. All comorbidities were physician diagnosed using the ICD9-CM.

RESULTS

Among patient visits with OSA, an estimated 6.4%± 0.9% also had insomnia. Logistic regression analysis revealed that the OSA+Insomnia group was significantly more likely to have essential hypertension (all ICD9-CM codes 401) (OR=1.83, 95% CI 1.27-2.65) and provisionally more likely to have cerebrovascular disease (ICD9-CM codes 430-438) (OR=6.58, 95% CI 1.66-26.08). The significant OR for cerebrovascular disease was considered provisional because the unweighted count was <30.

CONCLUSIONS

In a nationally representative sample, OSA+Insomnia was associated significantly more frequently with essential hypertension than OSA-Insomnia, a finding that has not been previously reported. In contrast to studies that have considered patient self-reports of psychological morbidity, the absence of a significant association with psychiatric disorders in our study may be indicative of the fact that we considered only physician-rated psychiatric syndromes meeting ICD9-CM criteria. Our findings among the OSA+Insomnia group are therefore most likely conservative.