CPAP-induced mania in bipolar disorder: a case report

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.

Medication of comorbidities in females with sleep-disordered breathing during long-term CPAP therapy

BACKGROUND

Treating sleep disordered breathing (SDB) with nasal continuous positive airway pressure (CPAP) may reduce mortality, but the studies on the effect on medication use are few. Women tend to have more mild sleep apnoea and partial airway obstruction and are therefore expected to have less co-morbidity. The purpose of this study was to evaluate the effect of CPAP therapy on medication use in women as overall medication, and in different subcategories of diseases, and to evaluate the impact of nocturnal airway obstruction type as partial or complete.

METHODS

From the database of the Department of Pulmonary Diseases in Turku University Hospital from 1994 to 1998, 601 consecutive females with SDB were enrolled, and the type of SDB was evaluated. All were offered CPAP therapy. The medication use measured as defined daily doses (DDD) in overall medication and in nine subcategories were collected three years before and three years after CPAP initiation.

RESULTS

In final analyses, 182 women were included. In CPAP users (n = 66), comorbidities were more frequent and DDDs higher overall, in asthma, in chronic obstructive pulmonary disease, and in severe mental disorders, both before and after CPAP initiation. The medication use was similar regardless of the type of SDB. The change in medication use was similar as in controls.

CONCLUSIONS

CPAP therapy did not decrease medication use in three-year follow-up. However, possibly continuous rise in medication use was prevented, as the change in medication use was similar in controls. Complete and partial obstruction had similar effects.

Dépistage et prise en charge de l’apnée du sommeil, un traitement du trouble bipolaire

Malgré les efforts fournis ces dernières années, le bilan de la prise en charge des patients bipolaires reste toujours insatisfaisant, tant du point de vue du retard diagnostique (8 à 10 ans en moyenne [1]) que des rechutes thymiques (50 % à 1 an [1]) et de la suicidalité, mais aussi concernant la morbidité cardiovasculaire (on rappellera que la principale cause de décès chez ces patients reste à ce jour les accidents cardiovasculaires). Face à ce constat, une nouvelle approche multidisciplinaire se développe depuis quelques années [2]. Dans ce nouveau paradigme faisant appel bien entendu à la psychiatrie mais aussi à l’endocrinologie ou encore la cardiologie, la médecine du sommeil pourrait tenir un rôle de premier plan si l’on en juge par les comorbidités retrouvées aussi bien en périodes critiques qu’en périodes « dites » intercritiques. Ainsi, est-il convenu que les épisodes thymiques entraînent des troubles du sommeil, mais aussi que certains troubles du sommeil (rythmes irréguliers, insomnie, apnées…) sont des facteurs de rechutes thymiques. La force de l’association statistique pourrait, par ailleurs, nous permettre de considérer que certains troubles du sommeil sont à considérer comme une dimension du trouble bipolaire. De nombreuses études (avec malheureusement des faiblesses méthodologiques) retrouvent ainsi une association troublante entre troubles bipolaires et SAS, qui concernerait même près de la moitié des patients bipolaires [3]. Devant les difficultés diagnostiques et thérapeutiques évoquées précédemment, et si l’on parvient à confirmer qu’environ la moitié des bipolaires est apnéique (étude en cours dans notre établissement de psychiatrie), un dépistage systématique du SAOS chez des sujets suspectés de bipolarité ou résistants à une prise en charge psychiatrique « standard » permettrait une optimisation des soins (amélioration des troubles du sommeil, traitement au moins partiel de l’épisode thymique [4], diminution du risque de rechute thymique, prévention cardiovasculaire, recommandations sur le choix des psychotropes).

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 and psychiatric disorders: a systematic review

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with psychiatric pathology. Psychiatric comorbidity in OSA may affect patient quality of life and adherence to CPAP. A focused evaluation of OSA in highly selected groups of primarily psychiatric patients may provide further insights into the factors contributing to comorbidity of OSA and psychopathology. The goal of this study is to examine the prevalence and treatment of OSA in psychiatric populations.

METHODS

A systematic review following the PRISMA guidelines was conducted to determine the prevalence of OSA in schizophrenia and other psychotic disorders, mood disorders, and anxiety disorders, and to examine potential interventions. The PubMed, EMBASE, and PsycINFO databases were searched (last search April 26, 2014) using keywords based on the ICD-9-CM coding for OSA and the DSM-IV-TR diagnostic groups.

RESULTS

The search retrieved 47 records concerning studies of OSA in the selected disorders. The prevalence studies indicate that there may be an increased prevalence of OSA in individuals with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), despite considerable heterogeneity and a high risk of bias. There was insufficient evidence to support increased OSA in schizophrenia and psychotic disorders, bipolar and related disorders, and anxiety disorders other than PTSD. Studies of treatment of OSA indicate an improvement in both OSA and psychiatric symptoms. CPAP adherence was reduced in veterans with PTSD.

CONCLUSIONS

OSA prevalence may be increased in MDD and PTSD. In individuals with OSA and psychiatric illness, treatment of both disorders should be considered for optimal treatment outcomes.

Sleep-disordered breathing and psychiatric disorders

Sleep-disordered breathing, the commonest form of which is obstructive sleep apnoea (OSA) is increasingly recognised as a treatable cause of morbidity. It shares many risk factors with psychiatric disorders including behaviours such as smoking and physical comorbidity. Many symptoms of the two overlap, leaving OSA often undetected and undertreated. In the few studies that assess the two, OSA is commonly comorbid with depression (17-45%) and schizophrenia (up to 55%) and possibly bipolar. There is some limited evidence that treating OSA can ameliorate psychiatric symptoms. Some psychotropics, such as narcotics, cause sleep-disordered breathing (SDB), whilst weight-inducing neuroleptics may exacerbate it. An extreme form of SDB, sudden infant death syndrome (SIDS), is a risk in mothers with substance abuse. Being aware of these common comorbidities may help improve psychiatric patient's treatment and quality of life.