Original Research

Effects of Insomnia and Depression on CPAP Adherence in a Military Population

Fed Pract. 2019 March;36(3):134-139

References

1. Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(7):471-483.

2. Epstein LJ, Kristo D, Strollo PJ, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.

3. Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep-related breathing disorders in adults. Sleep. 2006;29(3):381-401.

4. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver T. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011;15(6):343-356.

5. Luyster FS; Buysse DJ; Strollo PJ. Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med. 2010;6(2):196-204.

6. Wickwire EM, Smith MT, Birnbaum S, Collop NA. Sleep maintenance insomnia complaints predict poor CPAP adherence: a clinical case series. Sleep Med. 2010;11(8):772-776

7. Pieh C, Bach M, Popp R, et al. Insomnia symptoms influence CPAP compliance. Sleep Breath. 2013;17(1):99-104.

8. Nguyên XL, Chaskalovic J, Rakotonanahary D, Fleury B. Insomnia symptoms and CPAP compliance in OSAS patients: a descriptive study using data mining methods. Sleep Med. 2010;11(8):777-784.

9. Yilmaz E, Sedky K, Bennett DS. The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis. J Clin Sleep Med. 2013;9(11):1213-1220.

10. Chen YH, Keller JK, Kang JH, Hsieh HJ, Lin HC. Obstructive sleep apnea and the subsequent risk of depressive disorder: a population-based follow-up study. J Clin Sleep Med. 2013;9(5):417-423.

11. Kessler RC, Berglund P, Demler O, et al; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003:289(23):3095-3105

12. Harris M, Glozier N, Ratnavadivel R, Grunstein RR. Obstructive sleep apnea and depression. Sleep Med Rev. 2009;13(6):437-444.

13. Schwartz D, Kohler W, Karatinos G. Symptoms of depression in individuals with obstructive sleep apnea may be amendable to treatment with continuous positive airway pressure. Chest. 2005;128(3):1304-1309

14. Law M, Naughton M, Ho S, Roebuck T, Dabscheck E. Depression may reduce adherence during CPAP titration trial. J Clin Sleep Med. 2014;10(2):163-169.

15. Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med. 2012;8(5):501-506

16. Collen JF, Lettieri CJ, Hoffman M. The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med. 2012;8(6):667-672.

17. Caldwell A, Knapik JJ, Lieberman HR. Trends and factors associated with insomnia and sleep apnea in all United States military service members from 2005 to 2014. J Sleep Res. 2017;26(5):665-670.

18. Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297-307.

19. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychological Measurement. 1977;1(3):385-401.

20. Krakow B, Melendrez D, Lee SA, Warner TD, Clark JO, Sklar D. Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath. 2004;8(1):15-29.

21. Björnsdóttir E, Janson C, Sigurdsson JF, et al. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013;36(12):1901-1909.

22. Glidewell RN, Renn BN, Roby E, Orr WC. Predictors and patterns of insomnia symptoms in OSA before and after PAP therapy. Sleep Med. 2014;15(8):899-905.

23. Edwards C, Mukherjee S, Simpson L, Palmer LJ, Almeida OP, Hillman DR. Depressive symptoms before and after treatment of obstructive sleep apnea in men and women. J Clin Sleep Med. 2015;11(9):1029-1038.

24. Bopparaju S, Casturi L, Guntupalli B, Surani S, Subramanian S. Anxiety and depression in obstructive sleep apnea: Effect of CPAP therapy and influence on CPAP compliance. Presented at: American College of Chest Physicians Annual Meeting, October 31-November 05, 2009; San Diego, CA. Chest. 2009;136(4, meeting abstracts):71S.

25. Wells RD, Freedland KE, Carney RM, Duntley SP, Stepanski EJ. Adherence, reports of benefits, and depression among patients treated with continuous positive airway pressure. Psychosom Med. 2007;69(5):449-454.

26. Orr JE, Smales C, Alexander TH, et al. Treatment of OSA with CPAP is associated with improvement in PTSD symptoms among veterans. J Clin Sleep Med. 2017;13(1):57-63.

Discussion

Our study did not provide evidence that self-reported depressive and insomnia symptoms, as measured by the CES-D and ISI, can serve as useful predictors of short and long-term CPAP adherence in a sample of active-duty and retired military. OSA severity, as measured by the AHI, was the only promising predictor of CPAP adherence at 3 months.

Insomnia has been shown to improve with the use of CPAP. In a pilot study, Krakow and colleagues investigated the use of CPAP, oral appliances, or bilateral turbinectomy on patients with OSA and chronic insomnia.²⁰ Objective measures of insomnia improved with 1 night of CPAP titration. Björnsdóttir and colleagues evaluated the long-term effects of positive airway pressure (PAP) treatment on 705 adults with middle insomnia.²¹ They found after 2 years of PAP treatment combined with cognitive behavioral therapy for insomnia, patients had reduced symptoms of middle insomnia. It is possible that persistent insomnia is associated with more severe OSA which was not studied in our population.²²

As reported in other studies, it is possible that patients with depressive symptoms can improve with CPAP use, suggesting that depression and CPAP use are not totally unrelated. Edwards and colleagues studied the impact of CPAP on depressive symptoms in men and woman. They found that depressive symptoms are common in OSA and markedly improve with CPAP.²³ Bopparaju and colleagues found a high prevalence of anxiety and depression in patients with OSA but did not influence CPAP adherence.²⁴

The results of this study differ from some previous findings where depression was found to predict CPAP adherence.¹⁰This may be due in part to differences in the type of instrument used to assess depression. Wells and colleagues found that baseline depressive symptoms did not correlate with CPAP adherence and that patients with greater CPAP adherence had improvement in OSA and depressive symptoms.²⁵ Furthermore, patients with residual OSA symptoms using CPAP had more depressive symptoms, suggesting that it is the improvement in OSA symptoms that may be correlated with the improvement in depressive symptoms. Although soldiers with PTSD may have reduced CPAP adherence, use of CPAP is associated with improvement in PTSD symptoms.^11,26

Limitations

This study had several limitations, including a small sample size. Study patients were also from a single institution, and the majority of patients had mild-to-moderate OSA. A multicenter prospective study with a larger sample size that included more severe patients with OSA may have shown different results. The participants in this study were limited to members from the active-duty and retired military population. The findings in this population may not be transferrable to the general public. Another study limitation was that the ISI and the CES-D were only administered prior to the initiation of CPAP. If the CES-D and ISI were administered at the 3- and 12-month follow-up visits, we could determine whether short and long-term CPAP improved these symptoms or whether there was no association between CPAP adherence with insomnia and depressive symptoms. Another limitation is that we did not have access to information about potential PTSD symptomatology, which has been associated with reduced CPAP adherence and is more common in a military and veteran population.¹¹