Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis

Abstract

Background: Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms.

Methods and findings: We performed a systematic review and meta-analysis of randomized controlled trials that examined the effect of CPAP or MADs on depressive symptoms in patients with OSA. We searched Medline, EMBASE, the Cochrane Central Registry of Controlled Trials, and PsycINFO from the inception of the databases until August 15, 2014, for relevant articles. In a random effects meta-analysis of 19 identified trials, CPAP treatment resulted in an improvement in depressive symptoms compared to control, but with significant heterogeneity between trials (Q statistic, p<0.001; I(2) = 71.3%, 95% CI: 54%, 82%). CPAP treatment resulted in significantly greater improvement in depressive symptoms in the two trials with a higher burden of depression at baseline (meta-regression, p<0.001). The pooled standardized mean difference (SMD) in depressive symptoms with CPAP treatment in these two trial populations with baseline depression was 2.004 (95% CI: 1.387, 2.621), compared to 0.197 (95% CI: 0.059, 0.334) for 15 trials of populations without depression at baseline. Pooled estimates of the treatment effect of CPAP were greater in parallel arm trials than in crossover trials (meta-regression, p = 0.076). Random effects meta-analysis of five trials of MADs showed a significant improvement in depressive symptoms with MADs versus controls: SMD = 0.214 (95% CI: 0.026, 0.401) without significant heterogeneity (I(2) = 0%, 95% CI: 0%, 79%). Studies were limited by the use of depressive symptom scales that have not been validated specifically in people with OSA.

Conclusions: CPAP and MADs may be useful components of treatment of depressive symptoms in individuals with OSA and depression. The efficacy of CPAP and MADs compared to standard therapies for depression is unknown. Please see later in the article for the Editors' Summary.

Figure 1. PRISMA flow diagram .

All medical databases were searched on the same date. Abstract, full-text review, and data extraction were conducted in duplicate by M. P. and C. E. B. APA, American Psychiatric Association; ATS, American Thoracic Society; APSS, Associated Professional Sleep Societies; CENTRAL, Cochrane Central Registry of Controlled Trials.

Figure 2. CPAP studies forest plot.

Data were calculated by a random effects model. Studies were stratified by baseline depression score. Boxes are SMDs, and lines are 95% CIs. The vertical solid line represents no difference between CPAP and control. Values to the right of the solid line favor CPAP benefit. Pooled SMDs and 95% CIs are represented by the diamond shapes.

Figure 3. MAD studies forest plot.

Data were calculated by a random effects model. Boxes are SMDs, and lines are 95% CIs. The vertical solid line represents no difference between MAD and control. Values to the right of the solid line favor MAD benefit. Pooled SMD and 95% CI is represented by the diamond shape.