Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression

Diagnostic accuracy of screening questionnaires for obstructive sleep apnea in psychiatric patients

BACKGROUND

Obstructive sleep apnea (OSA) is prevalent among psychiatric patients and can exacerbate psychiatric conditions. Screening for OSA in this population is challenging due to overlapping symptoms and adherence issues. This study evaluated the diagnostic accuracy of the STOP-Bang, BOAH, GOAL, NoSAS, and No-Apnea screening questionnaires in psychiatric patients.

METHODS

In this observational cohort study, consecutive psychiatric patients admitted to a single tertiary care center between June 1, 2016 and December 31, 2022 were screened using the STOP-Bang questionnaire and additional data on parameters of the other questionnaires were collected. Polygraphy was performed using the Somnocheck micro CARDIO® system to record the Apnea-Hypopnea Index (AHI). Diagnostic accuracy was evaluated using receiver operating characteristic (ROC) curve, sensitivity, and specificity analysis.

RESULTS

Among 128 patients (median age 61.5 [IQR, 52.3-73.0] years; 77 [60.2 %] men), the No-Apnea questionnaire achieved the highest sensitivity for any OSA (AHI ≤5) at 96.00 % (95 % CI, 89.35 %-98.58 %; AUC, 0.68), followed by GOAL at 92.00 % (95 % CI, 83.78 %-96.27 %; AUC, 0.59) and STOP-Bang at 90.67 % (95 % CI, 81.85 %-95.26 %; AUC, 0.66). The specificities of all questionnaires were low, ranging from 15.09 % (STOP-Bang; 95 % CI, 8.35 %-25.90 %) to 50.94 % (BOAH; 95 % CI, 38.65 %-63.13 %).

CONCLUSION

The STOP-Bang, GOAL, and No-Apnea questionnaires effectively identify psychiatric patients at risk for OSA, though their low specificity underscores the necessity for confirmatory diagnostics, such as polygraphy. The No-Apnea score, which relies only on objective variables, may offer particular benefits in psychiatric settings.

Prevalence and risk factors of obstructive sleep apnea in depression: an observational retrospective study

Background

A substantial number of previous studies have concentrated on the prevalence of depression among patients with obstructive sleep apnea (OSA). However, research regarding the prevalence of OSA among patients with depression remains relatively scarce. The aim of this study was to determine the prevalence of OSA among patients with depression and to identify the associated risk factors.

Method

A single-center retrospective chart review was conducted. The research focused on patients diagnosed with depression who were referred for a polysomnogram (PSG) during a one-year period. Patients were diagnosed with obstructive sleep apnea (OSA) if their apnea-hypopnea index (AHI) was ≥5. Using the PSG monitoring results, patients were classified into two distinct groups: the OSA group, consisting of 50 patients, and the non-OSA group, which included 109 patients. An in-depth analysis was subsequently conducted on the sleep architecture and factors associated with the risk of OSA.

Results

Among the 159 depression patients who met the subject criteria, 31.4% were diagnosed with OSA. Statistically significant differences were observed between the OSA group and the non-OSA group in terms of sex, body mass index (BMI), smoking status, and lipid levels (all p<0.05). The PSG monitoring results indicated that both the duration of non-rapid eye movement stage 3 (N3) sleep and the percentage of N3 sleep relative to total sleep time (N3/TST) were markedly lower in the OSA group than in the non-OSA group, with a statistically significant difference (p<0.01). Statistically significant differences were observed between the two groups regarding the number of awakenings, arousal index (ArI), mean oxygen saturation, oxygen saturation nadir, and oxygen desaturation index (all p<0.01). Multiple logistic regression analysis indicated that advanced age (odds ratio [OR]=1.034, 95% confidence interval [CI]: 1.004-1.065, p=0.024), female sex (OR=0.378, 95% CI: 0.171-0.837, p=0.016), low-density lipoprotein cholesterol (LDL-C) (OR=1.946, 95% CI: 1.026-3.692, p=0.041), and BMI≥25.0 kg/m² (OR=3.434, 95% CI: 1.411-8.360, p=0.007) were factors associated with OSA among patients with depression.

Conclusion

OSA was prevalent among patients with depression. Risk factors for OSA included male sex, advancing age, a BMI≥25.0 kg/m², and elevated LDL-C levels.

Poor Sleep is Common in Treatment-Resistant Late-life Depression and Associated With Poorer Antidepressant Response: Findings From the OPTIMUM Clinical Trial

BACKGROUND

Adults with treatment-resistant late-life depression (TRLLD) have high rates of sleep problems; however, little is known about the occurrence and change in sleep during pharmacotherapy of TRLLD. This analysis examined: (1) the occurrence of insufficient sleep among adults with TRLLD; (2) how sleep changed during pharmacotherapy; and (3) whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep.

METHODS

Secondary analysis of data from 634 participants age 60+ years in the OPTIMUM clinical trial for TRLLD. Sleep was assessed using the sleep item from the Montgomery-Asberg Depression Rating Scale at the beginning (week-0) and end (week-10) of treatment. The analyses examined whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep during depression treatment.

RESULTS

About half (51%, n = 323) of participants reported insufficient sleep at baseline. Both persistent insufficient sleep (25%, n = 158) and worsened sleep (10%, n = 62) during treatment were associated with antidepressant nonresponse. Participants who maintained sufficient sleep (26%, n = 164) or who improved their sleep (n = 25%, n = 158) were three times more likely to experience a depression response than those with persistent insufficient sleep or worsened sleep.

CONCLUSION

Insufficient sleep is common in TRLLD and it is associated with poorer treatment response to antidepressants.

Portable polygraphic device (Somnocheck micro CARDIO®) provides accurate diagnostic information in psychiatric patients at risk for obstructive sleep apnoea: an observational cohort study

BACKGROUND

Symptoms of obstructive sleep apnoea (OSA) overlap significantly with those of psychiatric disorders, making accurate diagnosis of OSA challenging within psychiatric settings. Diagnosing OSA in psychiatric patients is crucial because untreated OSA can exacerbate psychiatric symptoms, reduce treatment efficacy, and impair overall quality of life. This study aimed to determine the diagnostic accuracy of a readily accessible procedure for psychiatric patients in a real-world clinical setting by comparing the Somnocheck micro CARDIO® (SCm) portable cardiorespiratory polygraphy device with the gold standard polysomnography (PSG).

METHODS

This observational cohort study included consecutive psychiatric patients at intermediate to high risk for OSA based on screening with the STOP-Bang questionnaire, admitted to a single tertiary care centre between June 1, 2016 and December 31, 2022. The Apnoea-Hypopnoea-Index (AHI), Apnoea-Index (AI), Oxygen-Desaturation-Index (ODI), and minimum oxygen saturation were measured sequentially by SCm and PSG.

RESULTS

A total of 57 patients were analysed (median age 62.0 [Interquartile Range (IQR), 51.5-72.5] years; 34 [59.6%] men). Regarding AHI, no significant differences (AHI measured by PSG, median, 16.6 [IQR, 6.2-26.7] vs. AHI measured by SCm, median, 14.9 [IQR, 10.0-22.8]; p = 0.812; r = 0.71) were found between SCm and PSG. AI, ODI and minimum oxygen saturation differed significantly between SCm and PSG. Using optimised cut-off values (any OSA: AHISCm ≥ 9.25), SCm showed high sensitivity (0.894) and high specificity (0.800) for the diagnosis of OSA, with an area under the receiver operating characteristic curve of 0.877.

CONCLUSIONS

This study found that the SCm portable device was accurate in identifying psychiatric patients with OSA. AHI measurement by SCm provided reliable diagnostic performance in comparison with the gold standard polysomnography. These findings support the integration of polygraphic measurements into the routine sleep assessment of psychiatric patients. Early and accurate diagnosis of OSA in this population can significantly improve the management of both sleep disorders and psychiatric conditions, potentially enhancing overall treatment outcomes and quality of life for these patients.

Depression and comorbid obstructive sleep apnea: Association between positive airway pressure adherence, occurrence of self-harm events, healthcare resource utilization, and costs

OBJECTIVE

Previous studies have shown that treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy in patients with depression may improve depression symptoms and response to antidepressant therapy. We investigated the association between PAP therapy adherence, self-harm events, healthcare resource utilization (HCRU), and costs over 2 years in a national sample of patients with pre-existing depression and newly diagnosed comorbid OSA.

METHODS

Administrative claims data were linked to objective PAP therapy usage. Inverse probability treatment weighting was used to compare outcomes over 2 years across PAP adherence levels. The predicted numbers of emergency room (ER) visits and hospitalizations by adherence level were assessed using risk-adjusted generalized linear models.

RESULTS

37,459 patients were included. Relative to non-adherent patients, consistently adherent patients had fewer self-harm events (0.04 vs 0.05, p < 0.001) after 1 year, and significantly (all p < 0.001) fewer ER visits (0.66 vs 0.86) and all-cause hospitalizations (0.13 vs 0.17), and lower total ($11,847 vs $11,955), inpatient hospitalization ($1634 vs $2274), and ER visit ($760 vs $1006) costs per patient in the second year of PAP therapy. Consistently adherent patients showed lower risk for hospitalizations and ER visits.

LIMITATIONS

Using observational claims data, we were unable to assess clinical characteristics including sleep, sleepiness, and daytime symptoms, or important social determinants of health. We were limited in assessing care received outside of the included health plans.

CONCLUSION

Consistent adherence to PAP therapy over 2 years was associated with improved HCRU outcomes for patients with pre-existing depression newly diagnosed with comorbid OSA.

Treatment-Resistant Late-Life Depression: A Review of Clinical Features, Neuropsychology, Neurobiology, and Treatment

Major depression is common in older adults (≥ 60 years of age), termed late-life depression (LLD). Up to 30% of these patients will have treatment-resistant late-life depression (TRLLD), defined as depression that persists despite two adequate antidepressant trials. TRLLD is challenging for clinicians, given several etiological factors (eg, neurocognitive conditions, medical comorbidities, anxiety, and sleep disruption). Proper assessment and management is critical, as individuals with TRLLD often present in medical settings and suffer from cognitive decline and other marks of accelerated aging. This article serves as an evidence-based guide for medical practitioners who encounter TRLLD in their practice.

Insomnia and treatment-resistant depression

Depression and sleep disturbance are related closely with bidirectional relationship. The heterogenic diagnostic criteria of major depressive disorder composed by the myriad combination of symptoms including sleep disturbance. Insomnia is an identifiable risk factor for depression and the treatment of insomnia might be able to prevent subsequent major depressive episodes which draws psychiatrists' attention to the interface of psychiatry and sleep medicine field. It is important to identify occult sleep disturbance in patients with treatment-resistant depression to improve treatment outcome. New tools to objectively measure sleep at home environment represent a great march in clinical care and research modalities but need further validation before they can be applying widespread at sleep and depression intersection. Careful evaluation and measurement of the phenotype and nature of sleep disturbance will continue to advance understanding of the biological bases of psychiatric disorders and the connections with sleep.

[Current Status of and Progress in Research on Obstructive Sleep Apnea and Comorbid Depressive Disorders]

Obstructive sleep apnea (OSA) and depressive disorders are common diseases in adults and they share in common many clinical symptoms, including sleep disturbance, fatigue, lack of concentration and cognitive function impairment. OSA and depressive disorders also share some common pathophysiological changes, including increased activity of the hypothalamic-pituitary-adrenal (HPA) axis, chronic low-grade inflammation, oxidative stress, and changes in gut microbiota and neurotransmitters, which may contribute to the comorbidity of OSA and depressive disorders. In the case of comorbid OSA and depressive disorders, OSA and depressive disorders may affect and exacerbate each other, thereby increasing the severity of diseases, entailing greater risk of cardiovascular and metabolic diseases, and causing greater difficulty in treatment. Herein, we summarized the latest research findings on the epidemiology, possible mechanisms, harms, and treatment of comorbid OSA and depressive disorders. This review may help improve clinicians' understanding of the comorbidity of OSA and depression disorders, thereby promoting early screening, prompt diagnosis and treatment, and improved prognosis. Further studies are needed for better understanding of the effect of the comorbidity of OSA and depressive disorders and treatment on cardiometabolic diseases.

The Evolving Nexus of Sleep and Depression

Sleep disturbances and depression are closely linked and share a bidirectional relationship. These interconnections can inform the pathophysiology underlying each condition. Insomnia is an established and modifiable risk factor for depression, the treatment of which offers the critical opportunity to prevent major depressive episodes, a paradigm-shifting model for psychiatry. Identification of occult sleep disorders may also improve outcomes in treatment-resistant depression. Sleep alterations and manipulations may additionally clarify the mechanisms that underlie rapid-acting antidepressant therapies. Both sleep disturbance and depression are heterogeneous processes, and evolving standards in psychiatric research that consider the transdiagnostic components of each are more likely to lead to translational progress at their nexus. Emerging tools to objectively quantify sleep and its disturbances in the home environment offer great potential to advance clinical care and research, but nascent technologies require further advances and validation prior to widespread application at the interface of sleep and depression.

Does continuous positive airways pressure treatment improve clinical depression in obstructive sleep apnea? A randomized wait-list controlled study

BACKGROUND

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder that is associated with a range of adverse daytime sequelae, including significantly higher rates of clinical depression than is seen in the general community. Improvements in depressive symptoms occur after treatment of the primary sleep disorder, suggesting that comorbid depression might be an intrinsic feature of OSA. However, there are limited data on whether treatment for OSA in patients diagnosed with clinical depression improves mood symptoms meaningfully enough to lead to the remission of the psychiatric diagnosis.

METHODS

N = 121 untreated OSA patients were randomized to either continuous positive airway pressure (CPAP) treatment or waitlist control, and depressive symptoms, sleepiness and clinical depression (using a structured clinical interview) were assessed at baseline and 4 months. Linear and logistic regression analyses were conducted, controlling for baseline scores, stratification factors and antidepressant use.

RESULTS

Depressive symptoms (odds ratio [OR] = -4.19; 95% confidence interval [CI] = -7.25, -1.13; p = .008) and sleepiness (OR = -4.71; 95% CI = -6.26, -3.17; p < .001) were significantly lower at 4 months in the CPAP group compared to waitlist. At 4 months, there was a significant reduction in the proportion of participants in the CPAP group meeting criteria for clinical depression, compared to the waitlist controls (OR = 0.06, 95% CI = 0.01, 0.37; p = .002).

CONCLUSION

Treatment of OSA may be a novel approach for the management and treatment of clinical depression in those with comorbid sleep disordered breathing. Larger trials of individuals with clinical depression and comorbid OSA are needed.

Reduced Plasma Estradiol Levels are Associated with Sleep Apnea in Depressed Peri- and Post-Menopausal Women

OBJECTIVE

This study aimed at investigating the correlation between estradiol and sleep apnea among women with major depressive disorders during the perimenopausal and postmenopausal periods.

METHODS

A total of 84 perimenopausal and postmenopausal women diagnosed with depression, and who had been subjected to whole-night polysomnography (PSG) were retrospectively studied. They were assigned into two groups based on the presence of OSA (apnea-hypopnea index (AHI)≥5) (OSA vs non-OSA). The correlation between estradiol levels and apnea-hypopnea index were assessed by logistic regression models after adjusting for age, body mass index (BMI), Hamilton Depression Rating Scale (HAMD), Pittsburgh Sleep Quality Index (PSQI), apnea frequency and progesterone.

RESULTS

Among the 84 patients, 45.23% had OSA. Estradiol levels were significantly elevated in non-OSA than in OSA patients (p<0.05). Univariate analysis revealed that elevated estradiol levels are associated with reduced odds of OSA (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.875-0.966, p = 0.001). Multivariate analyses showed that low estradiol levels (OR = 0.859, 95% CI 0.826-0.991, p = 0.031), higher HAMD scores (OR = 1.212, 95% CI 1.012-1.453, p = 0.037), higher apnea frequency (OR = 2.493, 95% CI 1.389-4.473, p = 0.002) and higher BMI (OR=1.635, 95% CI 1.136-2.353, p = 0.008) are correlated with OSA.

CONCLUSION

The ratio of depressed perimenopausal to postmenopausal women comorbid OSA was high. Higher BMI, low estradiol levels, high apnea frequency and high HAMD scores were correlated with OSA diagnosis and could be potential diagnostic markers for OSA in depressed perimenopausal and postmenopausal women. Reduced estradiol levels were correlated with an increased risk of OSA among depressed perimenopausal and postmenopausal women.

Prevalence of obstructive sleep apnea in suicidal patients with major depressive disorder

In this paper, we report the rate of previously undiagnosed obstructive sleep apnea (OSA) in a randomized clinical trial (RCT) of suicidal patients with major depressive disorder (MDD). One hundred and twenty-five suicidal adults with MDD were recruited into a RCT. None were suspected to have OSA. Fourteen percent met diagnostic criteria for OSA. The Apnea Hypopnea Index (AHI) was predicted by increasing age, male sex, and higher Body Mass Index. However, neither the degree of daytime sleepiness nor the degree of insomnia predicted AHI severity. A high degree of suspicion is warranted for OSA in suicidal patients with MDD, and for patients with treatment-resistant depression. ClinicalTrials.gov identifier: NCT01689909.

Brief behavioral treatment for insomnia in older adults with late-life treatment-resistant depression and insomnia: a pilot study

Objective

Brief Behavioral Treatment for Insomnia (BBTI) is an efficacious treatment of insomnia in older adults. Behavioral treatments for insomnia can also improve depression. However, it is unknown if BBTI is feasible or has an effect in patients with insomnia and late-life treatment resistant depression (LLTRD). The aims of this study were two-fold, to test: 1) the feasibility (defined by acceptability and retention rates) of BBTI and 2) the therapeutic potency of BBTI on symptoms of insomnia and depression.

Methods

Eleven older Veterans with LLTRD and insomnia were recruited in a randomized control trial to receive immediate (4-weeks of BBTI followed by 3-weeks of phone call check-ins and a final in-person 8-week assessment) or delayed (3-weeks of treatment as usual [wait-list control] followed by 4-weeks of BBTI and a final in-person 8-week assessment) BBTI. The primary outcome measures included the Patient Health Questionnaire (minus the sleep item) and the Insomnia Severity Index.

Results

BBTI was found to be feasible in older Veterans with insomnia and LLTRD; all participants recommended BBTI and retention rates were 90.9%. There was no difference in treatment effect between the immediate BBTI and delayed BBTI groups at week 4. After both groups (immediate and delayed) received BBTI, improvements were seen in both insomnia (d = 1.06) and depression (d = 0.54) scores.

Conclusions

BBTI is a feasible treatment for insomnia in older adults with LLTRD. BBTI may be an effective adjunctive treatment for depression. Larger adequately-powered trials are required to confirm these preliminary findings.

Effect of insomnia treatments on depression: A systematic review and meta-analysis

BACKGROUND

Insomnia is frequently co-morbid with depression, with a bidirectional relationship between these disorders. There is evidence that insomnia-specific interventions, such as cognitive behavioral therapy for insomnia, may lead to improvements in depression. The purpose of this systematic review and meta-analysis is to determine whether treatment of insomnia leads to improved depression outcomes in individuals with both insomnia and depression.

METHODS

We conduct a systematic review and meta-analysis to explore the effect of treatment for insomnia disorder on depression in patients with both disorders.

RESULTS

Three thousand eight hundred and fifteen studies were reviewed, and 23 studies met inclusion criteria. Although all of the studies suggested a positive clinical effect of insomnia treatment on depression outcomes, most of the results were not statistically significant. Although the interventions and populations were highly variable, the meta-analysis indicates moderate to large effect size (ES) improvement in depression as measured with the Hamilton Depression Rating Scale (ES = -1.29, 95%CI [-2.11, -0.47]) and Beck Depression Inventory (ES = -0.68, 95%CI [-1.29, -0.06]).

CONCLUSIONS

These results support that treating insomnia in patients with depression has a positive effect on mood. Future trials are needed to identify the subtypes of patients whose depression improves during treatment with insomnia-specific interventions, and to identify the mechanisms by which treating insomnia improves mood.

Effect of Metabolic Syndrome on Late-Life Depression: Associations with Disease Severity and Treatment Resistance

BACKGROUND/OBJECTIVES

Metabolic syndrome (MetS) is the co-occurrence of obesity and metabolic derangements. Prior research implicates MetS in prolongation of the course of depression in older adults, but its effect on antidepressant response is unknown in this population. The objective was to determine whether MetS and related metabolic dyscrasias are associated with decreased rate of remission from depression in older adults treated pharmacologically for depression.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Three academic medical centers in North America.

PARTICIPANTS

Adults aged 60 and older (mean age 69.1) with major depressive disorder (MDD) (N = 435).

INTERVENTION

Open-label, protocolized treatment with extended-release venlafaxine for 12 or more weeks.

MEASUREMENTS

Time to remission from depression, with remission defined as a Montgomery-Åsberg Depression Rating Scale (MADRS) score of 10 or less at last two visits.

RESULTS

Two hundred twenty-two participants (51%) met criteria for MetS at baseline; MetS was associated with greater severity (MADRS score) and chronicity of depression at baseline. Remission was achieved in 182 participants (42%). In the unadjusted analysis, MetS was associated with prolonged time to remission (hazard ratio for remission = 0.71, 95% confidence interval = 0.52-0.95), but this relationship was not significant in the adjusted model; greater number of MetS components and lower high-density lipoprotein cholesterol had similar effects. Only diastolic blood pressure (DBP) was a significant predictor of time to remission before and after adjustment, with higher DBP predicting longer time to remission. Insulin sensitivity did not predict time to remission.

CONCLUSION

The presence of MetS in older adults with depression was associated with greater symptom severity and chronicity of depression, which appears to have accounted for the poorer antidepressant response observed in those with MetS. Additionally, our preliminary finding of an association between higher DBP and poorer antidepressant response bears further examination and replication.