The presence of insomnia and depression contributes to the acceptance of an initial treatment trial of continuous positive airway pressure therapy in patients with obstructive sleep apnea

Abstract

The presence of comorbid insomnia and sleep apnea (COMISA) reduces the initial acceptance of continuous positive airway pressure (CPAP) therapy in 39-58% of patients with obstructive sleep apnea (OSA). Depressive disorders are reported in 5 to 63% of patients with OSA. Here we studied the co-occurrence of depression and insomnia in OSA patients and its impact on treatment acceptance in a real-life controlled trial.

Methods: In this prospective, uncontrolled study, participants were recruited from January to December 2018, among adult patients who visited our sleep lab. Participants underwent polysomnography study and completed the Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), and Zung Depression Rating Scale (ZDRS). All subjects were categorized into 8 groups: no OSA/no depression (apnea-hypopnea index [AHI] < 5/h, n = 34), mild OSA/no depression (AHI = 5-14/h, n = 22), moderate OSA/no depression (AHI = 15-29/h, n = 44), severe OSA/no depression (AHI ≥ 30/h, n = 45), no OSA/mild depression (AHI < 5/h, n = 31), mild OSA/mild depression (AHI = 5-14/h, n = 24), moderate OSA/mild depression (AHI = 15-29/h, n = 31), and severe OSA/mild depression (AHI ≥ 30/h, n = 40).

Results: Over the one-year period, 272 participants (200 men, mean age 52.9 ± 13.0 years, BMI 33.6 ± 7.2 kg/m²) were enrolled. When the above 8 groups were subcategorized into the presence or absence of insomnia, we found no differences in CPAP trial acceptance between subgroups except in patients from the mild depression/severe OSA/insomnia subgroup who denied CPAP therapy more frequently (chi-squared test p = 0.016). We found, with a moderate efficiency indicated by the ROC curve, that patients with AHI > 15/h, AIS ≥ 11, and ZDRS > 44 were more likely to refuse an initial trial of CPAP treatment because of COMISA and depression (ROC curve area = 0.710, p = 0.049).

Conclusion: This study demonstrates that it is important to recognize a depressive mood disorder in patients with moderate/severe OSA and COMISA as the coexistence of these comorbidities impairs the rate of initial acceptance of CPAP treatment. Additionally, our study suggests the cut-off values from the AIS and ZDRS questionnaires to help lead clinicians to an early diagnostic evaluation of COMISA patients for the presence of depressive mood disorder.

Keywords: Continuous positive airway pressure; Depression; Insomnia; Obstructive sleep apnea; Zung scale of depression.