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Sleep apnea can cause symptoms of apparent clinical depression which may respond quickly to treatment of the sleep disorder. A knowledge of the intellectual and emotional impact of sleep apnea may be important in making a correct differential diagnosis. Unfortunately, many physicians, psychiatrists, and psychologists may be unaware of this connection which may lead to apparent symptoms of depression. If there is a possibility that a patient's depression is caused by sleep apnea, they should undergo evaluation and, if necessary, receive treatment for their sleep disorder. In addition, people with sleep apnea may need support in addressing emotional aspects of treatment and recovery. Informed, trained therapists can provide essential therapy and support to the patient and the patient's family in the recovery process.
The impact of sleep apnea and snoring on sleep and health in the individual and for the public should not be ignored. According the National Commission on Sleep Disorders Research: "Forty million Americans are chronically ill with various sleep disorders...Sleep apnea alone is the cause of excessive daytime sleepiness experienced by almost 20 million Americans... Overwhelming evidence from testimony and specific surveys suggests that the vast majority of Americans with sleep disorders remain undiagnosed and untreated. ... " (Report of the National Commission on Sleep Disorders Research, Wake up America: A National Sleep Alert, Executive Summary and Report, January 1993.)(hereafter cited as NCSDR)
"Obstructive sleep apnea is an illness characterized by snoring, partial or complete cessation of breathing during sleep, reductions in blood oxygen levels, severe sleep fragmentation, and excessive daytime sleepiness. Researchers and clinicians have recognized sleep apnea as one of the most common sleep disorders and with perhaps the greatest medical and social impact on society in terms of morbidity and mortality. The syndrome strikes both sexes and all races, ages, socioeconomic strata, and ethnic groups, though it is less common in women prior to menopause, and may be more common in blacks than in whites." (NCSDR)
"The potential consequences of obstructive sleep apnea are significant and include hypertension, coronary heart disease, myocardial infarction, pulmonary hypertension, congestive hear failure, stroke, neuropsychiatric problems, cognitive impairment, sexual disfunction, and injury due to accidents. Finally the Commission estimates that cardiovascular deaths attributable to obstructive sleep apnea alone may be as high as 38,000 annually."(NCSDR)
"In the United States, 11,845,000 people between the ages of 30-60 are estimated to have obstructive sleep apnea; nearly one-quarter of them (3,029,000) experience the disorder at a moderate or severe level. The prevalence of obstructive sleep apnea may be much higher in specific subgroups. ... For the approximately 31 million Americans who are age 65 and older, the best estimate of obstructive sleep apnea is 7,440,000, with 46 percent at the moderate or severe level." (NCSDR)
Recent studies show that among employed people 30 to 60 years old, at least 2 percent of the women and 4 percent of the men may have treatable sleep apnea syndrome, while 24 percent of the men and 9 percent of the women showed disturbed breathing during sleep. (Terry Young et. al. in the New England Journal of Medicine, April 1993). An editorial by Eliot Phillipson, MD in the same issue of NEJM proclaimed sleep apnea as "a major public health problem."
Diagnosis is made on the basis of the clinical picture, patient and spouse reports, and an overnight polysomonogram done in the laboratory or even at home. Effective treatment eliminates snoring and apnea. The success of treatment is measured by the reduction of respiratory disturbance to normal levels, by the elimination of symptoms like fatigue and depression, and the patient's subjective feeling of well-being. The "gold standard" treatment accepted by physicians and others trained in sleep disorders medicine is the continuous application of positive air pressure through a mask during sleep (Continuous Positive Airway Pressure--CPAP). The additional air pressure keeps the airway from collapsing. Since this permits normal breathing to continue during sleep, normal sleep patterns emerge, sleep becomes restorative, and the patient feels better. The impact is often immediate and dramatic although the patient may need to continue therapy permanently. Weight loss, surgery and other interventions may also have their place in treatment.
Even a basic understanding of sleep apnea can be the basis for awareness and referral. A patient presenting with fatigue, depression, or problems in social relationships might have a primary problem of sleep apnea. If so, treatments appropriate for depression may miss the mark. If snoring, gasps, or pauses in breathing during sleep are reported, referral to an expert in sleep disorders for evaluation may be appropriate. A simple questionnaire may be all that is needed to pinpoint suspicious symptoms.
Psychologists and psychiatrists can play an important role in the treatment of sleep apnea. With appropriate training in sleep disorders, they can play a part in the sleep laboratory or in the clinic.
The patient with sleep apnea faces tremendous social and emotional challenges in accepting therapy. A significant number of patients fail to comply with treatment, sometimes because they may lack appropriate emotional support and are unable to adjust to their new status. Family members and colleagues may not understand or accept the positive changes in the patient's personality. And the patient and those close to him or her must come to grips with the loss of functioning for years before treatment. Finally, if symptoms of depression occur in a patient with known sleep apnea, appropriate treatment may require looking at both the treatment for sleep apnea--is it effective?--and at the possibility of depression. While there are support groups and patient-centered organizations which can be very important to patients and their families, professional intervention and support may also be needed.
The therapeutic skills of the psychologist, psychiatrist, social worker or other helping professional can assist the patient and family to succeed in treatment and achieve a full rehabilitation.
© 1995 Jerry Halberstadt and New Technology Publishing, Inc. An earlier version of this article was published in December, 1994 in The InterPsych Newsletter, a monthly Internet publication from INTERPSYCH -The Internet Mental Health Organization, whose aim is promoting international scholarly collaboration on inter-disciplinary research and intervention efforts in the field of psychopathology. It is republished by agreement with Interpsych.
Jerry Halberstadt is a publisher who suffered from sleep apnea syndrome for many years before being diagnosed and treated. He has served as chair for an educational conference on sleep apnea for physicians and the public and has co-authored Sleep Apneathe Phantom of the Night, a sleep apnea handbook for patients and professionals.
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