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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Sleep Apnea: A Stealthy Cause of Depression


November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School


It seems like a minor problem, even an amusing one: A bedmate complains about his or her partner's snoring. Laughs follow when someone imitates the racket that regularly intrudes on sleep. But the problem may not be so funny. In many cases, it can literally be depressing.

As many as one-fifth of people with depression may suffer from a sleep-related breathing disorder called sleep apnea. People with depression are about five times as likely as people without depression to have a sleep-related breathing disorder.

Let's take a look at what this problem is and why it might be an important one to pay attention to.

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What is Sleep Apnea?

Apnea means "without breathing." No matter what the cause — an obstruction or faulty signaling from the part of the brain that controls breathing — people with apnea stop breathing for 30 seconds or less. This is temporarily suffocating. Oxygen levels drop and carbon dioxide builds up. The sleeper wakes up, gasping loudly for air until blood oxygen levels return to normal.

At its worst, this cycle may repeat itself hundreds of times each night. Yet the sleeper may be completely unaware. Anyone listening is likely to dismiss the problem as snoring that is merely annoying.

The most common form of sleep apnea is obstructive sleep apnea, so named because it is associated with blocked air passages. Enlarged tonsils or other throat tissue may cause the blockage. The problem only occurs during sleep, when the body is more relaxed so the airway narrows or collapses.

Sleep apnea affects one of every 25 men and one of every 50 women. These rates rise with age. It's more common in people who are overweight.

Sleep apnea, however, is a significant medical problem, with important consequences. People with the condition:

  • Get very sleepy during the day
  • Have many more traffic accidents than people without the condition
  • Have a higher risk for stroke, heart attack and heart failure because of the extra strain that lack of oxygen places on the heart

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The Apnea-Depression Connection

Obstructive sleep apnea also appears to increase the risk for depression. One research team found that among 1,400 randomly-selected people, those with even a mild sleep-related breathing disorder were 60% more likely than unaffected people to be depressed.

There is also some evidence that a breathing disorder can make an existing depression worse. If a person's depression isn't responding to treatment, it could be that sleep apnea is an aggravating factor. The reverse is also true: Treating obstructive sleep apnea can help to improve depressed mood and reduce depressive symptoms in some people.

Talk to your doctor if you suspect that interrupted breathing is causing problems while you sleep. Your doctor will probably evaluate your heart health. After asking about your sleep pattern, he or she may examine your neck, mouth and throat for any narrowing. Sometimes a specialist in ear, nose, and throat medicine must do this examination. Finally, you may need a special nighttime sleep study, which monitors your breathing patterns and sleep stages throughout the night.

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How To Treat Sleep Apnea

If you are diagnosed with sleep apnea, your doctor may recommend the most studied treatment for obstructive sleep apnea. It's called "continuous positive airway pressure" or CPAP. The air pressure makes your airway less likely to collapse. Between 60% and 80% of people benefit from using a CPAP device.

CPAP involves wearing a special mask over your mouth and nose while you sleep. Most people need time to adjust to the device and coaching to learn how to use it comfortably. Some people may experience pressure sores, nasal congestion, air leakage or claustrophobia with a CPAP. These challenges lead people to stop using the CPAP.

Fortunately, CPAP devices are much less cumbersome now than they used to be. Users can choose from a variety of mask styles, which make for a better fit. Lighter and quieter devices can provide warmed, humidified air, which reduces nasal congestion, skin dryness and dry mouth. Newer machines offer a gradual pressure buildup or pressure that automatically adjusts (AutoPAP). Such improvements make the treatment easier.

Be aware that these devices are expensive: They range from several hundred dollars to nearly $1,000. The newer AutoPAP and bi-level devices cost even more. Medicare and other insurance plans provide some coverage, but it's wise to read the details about your plan's deductibles and restrictions.

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Lifestyle Changes

Certain lifestyle changes may help relieve sleep apnea. Being depressed, however, can affect your motivation and energy to make these changes.

Here are some things to consider doing before you invest in a CPAP machine:

  • Being overweight makes the mechanics of breathing more difficult, so losing weight — if you can do it — is a good idea.

 

  • If you get more exercise and follow a healthy diet, you will not only feel better, but your body will work better in many ways, including breathing during sleep.

 

  • Sleeping on your side instead of your back may take pressure off the air passages.

 

  • Since alcohol, sedatives and muscle relaxants can aggravate the underlying mechanical problem, it may help to avoid or limit your use of these substances.

Another option is a dental device that fits in the mouth to reposition the lower jaw and tongue. Sometimes it will successfully prop the airway open. Such devices are easier to use than CPAP, but are less helpful if you have severe sleep apnea.

If none of these approaches is effective, you may consider surgery to correct the source of the blockage. If tissue at the back of the mouth and throat has loosened or grown too large, a surgeon may be able to remove excess tissue and clear the airway. Or adjusting the upper or lower jaw may improve air flow.

Surgery does offer the possibility of a cure, but it is not a sure cure. Some patients improve, but many don't. Older patients heal slowly and may encounter more complications, such as infections and difficulty swallowing. In some cases, symptoms get worse. A decision about surgery should only be made after reviewing all possible options with a sleep specialist.

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The Value of a Good Night's Sleep

More and more, scientists are learning that a good night's sleep is essential to staying healthy and living a good life. Mental health professionals are still interested in what you dream about, but they are increasingly focusing their attention on the basic value of deep, restful sleep.

Even if you don't have sleep apnea, getting enough sleep is bound to make you healthier and boost your mood. It can boost your energy, enable your powers of concentration and learning, and enhance both your productivity and your ability to take pleasure in leisure activity.

If you're someone who tries to get along with less than seven or eight hours of sleep per night, consider getting more sleep. What you lose in waking hours will probably be made up in improved fitness and an enhanced quality of life.

But if you sleep for eight or more hours per night and you don't wake up rested — or if you are keeping the household awake with your snoring — it's worth speaking to your doctor. All you have to lose is your depression.

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Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.

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