Popular in Psychology

Most Cited

The adapted mind

Dalhousie University Jerome Barkow

Psychology

Consumers’ pursuit of material and experiential purchases

Cornell University Tom Gilovich

Experimental Psychology

Time to investigate human visual shape perception

University of Montreal Martin Arguin

Most Cited

James S. Jackson and the program for research on Black Americans

Harvard University David R. Williams

Psychology

Violence and Mental Illness: Rethinking Risk Factors and Enhancing Public Safety

Duke University Eric Elbogen

Cognitive Psychology

Cognitive remediation – where are we now and what should we do next?

King's College London Til Wykes

Cognitive Psychology

Harnessing Plasticity in the Atypical Developing Brain using Neurostimulation

University of Surrey Roi Cohen Kadosh

Discerning depressive symptoms in patients with obstructive sleep apnoea

View more insights in Social Sciences - Psychology - Cognitive Psychology

View more figures from University of Western Australia

View the page of Romola Bucks

Read the Study

Next in Cognitive Psychology

A quasi-comprehensive exploration of the mechanisms of spatial working memory

Liqiang Huang | The Chinese University of Hong Kong

How the Social Becomes the Biological: The Interaction Between the Genome and the Environment

Gillian Einstein | University of Toronto

The assessment of depression in obstructive sleep apnea (OSA) is confounded by the overlap in symptoms between the disorders. Romola Bucks suggests nonoverlapping depressive symptoms may be useful discriminators of clinical depression amongst patients with untreated, symptomatic OSA.

Image courtesy of interviewee. March 13, 2024

Log-in or Sign-up to Faculti
Currently viewing this subject insight as a guest. You have insight(s) remaining for this month. Login to view 8000+ figures on the platform.

Generating Workspace...

Export as PDF

The transcript discusses obstructive sleep apnea (OSA), a sleep-related breathing disorder characterized by partial or complete blockage of the airway, leading to interrupted breathing during sleep. This video video condition can have negative effects on both physical and mental health, particularly increasing the prevalence of depression among those affected.

The speaker, a psychologist, focuses on the mental health impacts of OSA, especially the relationship between sleep apnea symptoms and the symptoms of depression, leading to questions about whether depression rates in individuals with OSA are overestimated. They note that overlapping symptoms of OSA and depression, such as fatigue and irritability, complicate diagnosis and treatment.

The discussion highlights a study investigating the effects of Continuous Positive Airway Pressure (CPAP) therapy on depression in individuals with OSA. The study tracked participants' depression scores over a 12-week CPAP treatment period. Findings indicated that CPAP treatment generally led to improvements in depression symptoms, particularly in those with overlapping symptoms related to OSA. However, non-overlapping symptoms of depression, which are more characteristic of depression itself (like hopelessness and guilt), showed less improvement.

Key findings included:
1. Both overlapping and non-overlapping depression symptoms improved with CPAP use, but the improvement was greater for overlapping symptoms.
2. The extent of CPAP usage correlated with reductions in depression scores, especially for overlapping symptoms, indicating that adherence to the treatment is essential for improving mental health.

The speaker concluded that CPAP effectively alleviates overlapping symptoms of depression in OSA but may not address the more severe non-overlapping depressive symptoms, suggesting that individuals with significant non-overlapping symptoms may require additional treatments, such as medication or cognitive-behavioral therapy. The speaker proposed the need for an OSA-specific depression scale to better assess and address the mental health needs of patients with sleep apnea.

Language:

Export as PDF

X-TIMESTAMP-MAP:LOCAL=00:00:00.000,MPEGTS=900000

00:00.365 --> 00:01.405
Obstructive sleep apnea.

00:01.565 --> 00:05.005
OSA is a breathing disorder that happens during sleep.

00:05.665 --> 00:08.565
And what a pa basically happens is that the upper airway

00:09.315 --> 00:11.725
partially or completely obstruct, so it kind

00:11.725 --> 00:13.165
of collapses and smushes down.

00:13.215 --> 00:15.565
Think standing on a, on a hose pipe.

00:16.225 --> 00:19.565
And as a result, when you are trying to breathe in

00:19.825 --> 00:23.125
and breathe out in normal respiration, normal breathing,

00:23.665 --> 00:26.325
the airway is obstructed, partial your holy,

00:26.385 --> 00:28.085
and you can't get the air in

00:28.145 --> 00:30.005
and you can't breathe out the carbon dioxide.

00:30.275 --> 00:33.445
This is spectacularly bad for the body and the brain.

00:33.945 --> 00:37.485
And usually what happens is the individuals,

00:37.485 --> 00:39.765
will wake up either wholly

00:39.765 --> 00:42.325
or partially from deeper stages to lighter stages of sleep,

00:42.345 --> 00:44.805
or actually wake up completely to restart breathing.

00:45.025 --> 00:47.925
If you're sleeping in the bed next to someone with OSA,

00:48.065 --> 00:52.565
you will hear them go like this as they restart breathing,

00:52.705 --> 00:55.325
and there might be periods of silence or snoring before that

00:55.825 --> 00:58.565
and it can happen hundreds of times a night.

00:59.185 --> 01:01.005
And we have a metric of

01:01.005 --> 01:03.365
how severe your apnea is called the a HI,

01:03.785 --> 01:06.365
and it basically is the number of times you partially

01:06.365 --> 01:08.645
or completely obstruct, and that obstructs

01:08.645 --> 01:09.925
and drop your airflow

01:09.925 --> 01:13.085
and drops your blood oxygen levels below a acquired level

01:13.705 --> 01:15.365
for at least 10 seconds at a time.

01:16.265 --> 01:17.805
And that's the number of times per hour

01:17.805 --> 01:19.085
of sleep is the a HI.

01:19.465 --> 01:20.605
And, you know,

01:20.685 --> 01:24.565
a mild a HI would be about five times, an hour.

01:25.025 --> 01:27.485
You, you don't breathe properly for 10 or more seconds.

01:28.445 --> 01:31.685
Moderate might be, 15 times an hour, severe 30

01:31.905 --> 01:33.085
or more times an hour.

01:33.085 --> 01:35.805
And there are people who can spend as much as half

01:35.825 --> 01:37.645
of the night not breathing properly.

01:37.785 --> 01:39.405
So this is a significant disorder.

01:40.505 --> 01:42.805
Now, the context of the study is that

01:43.375 --> 01:46.325
sleep apnea is associated with a whole lot of physical

01:46.425 --> 01:48.005
and mental health difficulties.

01:48.005 --> 01:50.165
And I'm a psychologist, so I'm particularly interested in

01:50.165 --> 01:52.125
the mental consequences of apnea.

01:53.465 --> 01:56.005
And I'm particularly interested in,

01:56.505 --> 02:00.485
the effects on mental health, particularly depression,

02:00.635 --> 02:02.085
because it turns out

02:02.155 --> 02:05.085
that depression is more common in people

02:05.085 --> 02:08.525
with sleep apnea than it is in the general public, by,

02:08.625 --> 02:09.805
by a significant margin.

02:11.565 --> 02:13.545
And of course that's really critical

02:13.545 --> 02:16.785
because depression itself is associated with lots

02:16.785 --> 02:17.905
of negative consequences

02:18.165 --> 02:20.825
and may interfere with somebody's ability to engage

02:20.855 --> 02:23.145
with treatment for sleep apnea.

02:23.145 --> 02:24.385
So there's a vicious cycle.

02:25.685 --> 02:29.505
Um, but the problem is, is that depression is made up

02:29.705 --> 02:33.665
of constellation of different kinds of symptoms, some

02:33.665 --> 02:38.185
of which are also symptoms of sleep apnea in and of itself.

02:38.245 --> 02:42.025
So there is overlap between the symptoms of depression

02:42.085 --> 02:43.665
and the symptoms of sleep apnea.

02:44.895 --> 02:48.515
So one of the critical questions is, is are we

02:49.375 --> 02:52.355
overestimating the prevalence of depression and sleep apnea?

02:52.775 --> 02:55.635
And when we treat depression symptoms in sleep apnea,

02:55.975 --> 02:57.955
are we actually treating the depression

02:58.135 --> 03:01.205
or are we treating the, the, the symptoms of sleep apnea

03:01.205 --> 03:03.365
that happen to overlap and look like depression?

03:03.415 --> 03:06.605
There was very little re at all asking the question of

03:06.705 --> 03:08.965
of whether,

03:09.415 --> 03:11.845
there is a difference following sleep,

03:11.845 --> 03:14.045
AP treatment in depression,

03:14.275 --> 03:16.965
symptom improvement depending on the type of symptom

03:16.965 --> 03:18.365
that you've got, whether they're

03:18.365 --> 03:19.405
overlapping or not overlapping.

03:19.465 --> 03:21.605
So there's most studies basically ask the question,

03:21.715 --> 03:24.925
does CPAP treat depression in sleep apnea?

03:25.505 --> 03:28.645
Now, CPAP, it just in case most people will know,

03:28.645 --> 03:30.165
but just in case, is a, is a treatment

03:30.165 --> 03:32.405
where you wear a mask over the nose or mouth

03:32.945 --> 03:34.805
and it applies, blows.

03:34.805 --> 03:37.605
There's a machine that blows air,

03:38.035 --> 03:41.405
through a pipe into the mask, that helps

03:41.505 --> 03:43.365
to keep the airway open.

03:44.105 --> 03:47.805
So it helps to keep the, the, the air flowing into,

03:47.875 --> 03:49.285
into the lungs, which is really important.

03:49.825 --> 03:51.605
So most studies have just asked,

03:51.605 --> 03:53.325
does CPA treat depression in the answers?

03:53.385 --> 03:54.445
Yes, it does, right?

03:54.905 --> 03:56.405
But we wanted to know, we wanted

03:56.405 --> 04:00.615
to know a different question to the extent

04:00.615 --> 04:03.215
that an individual actually uses the therapy

04:03.215 --> 04:05.815
because not everybody does use it perfectly.

04:06.605 --> 04:09.695
What is the effect of that therapy on depression symptoms?

04:09.695 --> 04:11.775
And particularly, is there a different effect

04:11.775 --> 04:15.055
of CPAP on overlapping and non-overlapping symptoms?

04:15.755 --> 04:17.975
So let me explain to you what I mean by overlapping

04:17.975 --> 04:20.015
and non-overlapping, just to be a little bit more concrete.

04:20.805 --> 04:22.945
The kinds of symptoms that you see in OSA

04:22.975 --> 04:24.505
that could look like depression

04:24.665 --> 04:26.025
'cause you also see them in depression,

04:26.685 --> 04:30.505
are things like the behavioral consequences, like a loss

04:30.505 --> 04:35.185
of libido, changes in menstrual symptoms, mental

04:35.245 --> 04:38.265
and physical, slowing, what we call psychomotor retardation.

04:39.085 --> 04:41.545
Uh, tension and irritability, really common,

04:41.605 --> 04:43.025
as we all know, when you don't sleep.

04:43.965 --> 04:46.265
Um, physical anxiety symptoms.

04:46.265 --> 04:49.545
So kind of trembling in the tummy, heart palpitations,

04:49.545 --> 04:52.345
that kind of thing, sleep difficulties, which of course,

04:52.605 --> 04:55.825
you know, you get in both, loss of energy

04:56.085 --> 04:58.185
and some changes in co in thinking.

04:58.245 --> 05:00.345
So people feeling they're a bit slower mentally,

05:00.535 --> 05:01.665
they can't think as clearly,

05:01.665 --> 05:03.025
they can't problem solve as clearly.

05:03.565 --> 05:05.825
And you can see why that could be both a symptom

05:05.845 --> 05:08.265
of depression and a symptom of of sleep apnea.

05:08.265 --> 05:10.385
If you don't sleep well, if your brain's not getting an hypo

05:10.385 --> 05:12.225
oxygen, of course you're not gonna think as clearly,

05:12.805 --> 05:15.345
but it, that's not necessarily the case

05:15.345 --> 05:16.425
that you're also depressed.

05:16.685 --> 05:18.465
So those are the overlapping symptoms.

05:19.285 --> 05:21.825
And the non-overlapping symptoms are things that

05:22.245 --> 05:23.785
as a psychologist, I think of as kind

05:23.785 --> 05:28.145
of more cardinal features, the depression like agitation,

05:29.015 --> 05:32.665
loss of weight and appetite, depressed mood,

05:32.855 --> 05:34.825
feeling like everything is terrible

05:35.045 --> 05:38.505
and nothing is can can, can never get better, hopeless,

05:38.585 --> 05:42.145
helpless, guilt, suicidal thinking,

05:42.375 --> 05:44.105
changes in insight and awareness

05:44.885 --> 05:47.185
or the opposite actually a kind of feeling

05:47.205 --> 05:48.905
of disconnection from your feelings

05:48.905 --> 05:51.025
that you don't really feel anything is real.

05:51.145 --> 05:52.305
A sort of derealization

05:52.845 --> 05:55.385
and hypochondriasis are kind of complaining of lots

05:55.385 --> 05:56.945
of physical problems when actually is there.

05:57.425 --> 06:00.245
And they are very different qualitatively to the first set

06:00.245 --> 06:01.285
that I've just described.

06:01.905 --> 06:03.885
But they are all symptoms of depression.

06:05.355 --> 06:08.215
And the problem is, is that in all the previous trials

06:08.565 --> 06:13.015
that have looked at whether CPAP, treats depression,

06:13.485 --> 06:16.655
they've used a range of different measures

06:16.655 --> 06:18.855
with different numbers and different proportions

06:18.855 --> 06:21.335
of those overlapping and non-overlapping sym

06:21.505 --> 06:22.615
items or symptoms.

06:23.395 --> 06:26.255
And actually we, a previous paper we did,

06:26.435 --> 06:28.455
was a meta-analysis of the prevalence

06:28.455 --> 06:30.535
of depression in sleep apnea.

06:30.635 --> 06:33.975
And we found a direct relationship between how many

06:34.535 --> 06:35.655
symptoms in a scale.

06:35.875 --> 06:37.935
So the proportion of symptoms in a scale

06:37.935 --> 06:41.655
that were overlapping a direct relationship between that

06:42.035 --> 06:43.295
and the prevalence of depression.

06:43.355 --> 06:46.735
Simply put, if you used a scale with very high numbers

06:46.735 --> 06:49.695
of overlapping symptoms, you reported a higher prevalence

06:49.695 --> 06:52.255
of depression in your sample than if you lose to scale

06:52.365 --> 06:54.255
with lower, numbers

06:54.355 --> 06:56.055
or proportions of overlapping symptoms.

06:56.555 --> 06:59.335
So that suggests to me that our understanding of

06:59.365 --> 07:00.455
what is the true nature

07:00.455 --> 07:03.415
of depression in sleep apnea is quite muddled.

07:04.115 --> 07:05.295
It is challenging.

07:05.955 --> 07:07.895
And we could have a whole existential argument about, well,

07:08.735 --> 07:09.855
a depression symptom is a

07:09.855 --> 07:11.135
depression symptom, it's still a bad thing.

07:11.135 --> 07:13.575
And I would agree, but I do think if we are trying

07:13.575 --> 07:17.135
to work out, well, who needs more help than OSA

07:17.135 --> 07:18.335
to treat their depression, we need

07:18.335 --> 07:20.015
to know the answer to this question.

07:20.315 --> 07:22.695
So this is a 12 week single arm study.

07:22.795 --> 07:24.215
So we didn't have a control group

07:24.285 --> 07:26.895
because we were only interested in individual differences.

07:27.355 --> 07:29.815
So what happened within the individuals we studied,

07:29.955 --> 07:33.175
so everybody got CPAP, they had never had CPAP before.

07:34.115 --> 07:36.055
We had to exclude all the sorts of things

07:36.055 --> 07:39.855
that might've mi the water like psychosis and insomnia

07:40.035 --> 07:41.135
and central apnea,

07:41.135 --> 07:42.655
which is a different kind of sleep disorder.

07:43.515 --> 07:45.935
Um, people who couldn't speak English well enough

07:45.935 --> 07:47.855
to follow the questionnaires, that kind of thing.

07:48.595 --> 07:52.055
Um, and we basically, assessed them at baseline.

07:52.885 --> 07:55.695
They then went into 12 weeks of CPAP treatment

07:56.195 --> 08:00.095
and we assessed them at week three, week eight and week 13.

08:00.235 --> 08:02.455
So after the 12 weeks of CPAP treatment,

08:02.455 --> 08:06.575
and we used a questionnaire measure called the ham D

08:07.635 --> 08:09.495
and we used that because it allowed us

08:09.555 --> 08:12.495
to divide the symptoms into overlapping

08:12.515 --> 08:14.255
and non overlapping as I've described.

08:14.635 --> 08:16.015
And because there were different numbers

08:16.035 --> 08:18.015
of symptoms within the questionnaire

08:18.015 --> 08:20.895
that fit into those categories, we created two scores,

08:20.995 --> 08:23.095
but as, as a proportion of the number of items.

08:23.195 --> 08:25.215
So we produced percentage scores for those.

08:26.075 --> 08:29.575
We also just calculated the standard total score in raw

08:29.575 --> 08:31.415
points that you would expect to see.

08:32.715 --> 08:36.215
And what we wanted to do was to see whether,

08:37.245 --> 08:39.455
well obviously how depressed were they to begin with,

08:39.555 --> 08:42.175
and then what was the change in depression score over time

08:42.235 --> 08:44.015
and was it different between overlapping

08:44.195 --> 08:45.575
and non-overlapping symptoms?

08:46.555 --> 08:48.735
So we then did what's called growth curve modeling,

08:48.865 --> 08:50.735
which allows you to,

08:51.815 --> 08:54.575
describe the initial starting score at baseline

08:54.835 --> 08:57.885
and then a slope of change, a change function over time.

08:58.545 --> 09:00.645
And if I may, I could share a, an image

09:00.645 --> 09:02.845
with you when we're talking about the results that, that

09:03.365 --> 09:05.925
I think captures what I'm trying to describe in words.

09:06.545 --> 09:08.005
The first thing I think I want to say.

09:08.225 --> 09:10.965
And if you could just mentally combine those two lines

09:10.965 --> 09:13.165
that I'm showing you together, which are the overlapping

09:13.165 --> 09:14.725
and non-overlapping symptoms together,

09:14.785 --> 09:15.805
the first thing I wanted to say is

09:16.045 --> 09:17.165
everyone's depression improved.

09:18.065 --> 09:20.725
So on average they started at about 11 points

09:21.185 --> 09:24.485
and they went down about three, 3.2 points per visit,

09:24.665 --> 09:25.685
but it wasn't linear.

09:26.025 --> 09:28.885
So what you can see from those two separate slopes

09:28.885 --> 09:31.365
and imagine them smushed together, is that there was a,

09:31.805 --> 09:33.365
a faster change between baseline

09:33.365 --> 09:36.165
and week three than across the rest of the,

09:36.165 --> 09:37.525
the 12 weeks of treatment.

09:38.955 --> 09:41.925
What I think you can also see, I think it's really obvious

09:42.075 --> 09:45.645
that the solid line here is the overlapping symptoms

09:45.785 --> 09:48.085
and the dotted line is the non-overlapping symptoms.

09:48.585 --> 09:52.915
So what you'll see, first of all, is that everyone started

09:53.025 --> 09:56.955
with higher percentage scores are overlapping symptoms than

09:56.955 --> 09:59.995
non-overlapping symptoms, which is not surprising given

09:59.995 --> 10:01.635
that they're overlapping with OSA.

10:01.635 --> 10:05.875
So you would expect that and that both overlapping

10:05.875 --> 10:08.555
and non overlapping symptom scores improved over time

10:09.255 --> 10:10.995
and those changes were significant.

10:12.145 --> 10:15.475
What you'll also see is that the, the slope

10:15.495 --> 10:17.555
of change is much steeper,

10:18.105 --> 10:20.715
even though it still flattens off, it's much steeper overall

10:20.715 --> 10:21.835
for the overlapping symptoms.

10:21.835 --> 10:23.515
So they started at about 30%

10:23.855 --> 10:26.635
and they improved on average about 9% per visit.

10:26.695 --> 10:29.115
But again, it flattened off, off

10:29.115 --> 10:31.155
for the non-overlapping symptoms.

10:31.155 --> 10:34.395
They started at about, what was it,

10:34.455 --> 10:35.955
12 percentage points

10:35.955 --> 10:38.675
and went down by about three percentage points per visit.

10:38.805 --> 10:39.955
Again, flattening off.

10:40.695 --> 10:45.275
So yes, both kinds of symptoms improved with treatment,

10:45.455 --> 10:49.955
but overlapping more than non-overlapping, you might say.

10:49.955 --> 10:51.915
Well, so what, what we wanted to know was,

10:51.975 --> 10:53.595
is this a function of

10:53.695 --> 10:55.955
how much people actually engage with their therapy?

10:56.555 --> 10:58.995
'cause as I said, lots of people start CPAP,

10:58.995 --> 11:00.035
but don't continue it.

11:00.545 --> 11:01.795
Lots of people don't use it.

11:01.855 --> 11:03.675
The required number of hours a night.

11:03.675 --> 11:04.875
And the rough rule

11:04.875 --> 11:07.715
of thumb is if you use it fewer than four hours a night,

11:07.715 --> 11:08.995
you're probably not using it enough.

11:09.075 --> 11:10.915
I mean, you should really use it the whole night,

11:10.935 --> 11:13.355
but we kind of roughly say four hours

11:13.455 --> 11:15.395
or more is kind of better than less.

11:16.655 --> 11:18.435
So what we did was we looked

11:18.435 --> 11:21.555
to see whether there was a relationship between,

11:21.695 --> 11:26.635
how quickly people's depression improved within overlapping

11:26.635 --> 11:27.875
and non-overlapping symptoms

11:28.255 --> 11:30.115
and how much they used their CPAP.

11:30.615 --> 11:34.195
And there was, but only for the overlapping symptoms.

11:34.535 --> 11:37.435
So those people who use their CPAP device,

11:38.225 --> 11:40.195
more hours on average across the 12 weeks

11:40.375 --> 11:43.475
or more percentages of a greater percentage of nights

11:43.615 --> 11:45.475
for more than four hours, four

11:45.475 --> 11:49.355
or more hours had a steeper slope of decline.

11:49.375 --> 11:51.675
So you could imagine that this average is made up

11:51.675 --> 11:53.765
of a whole load of different trajectories.

11:53.915 --> 11:56.245
Each person gets their own slope function.

11:56.785 --> 12:00.445
So someone who uses their CPA more would have a steeper

12:00.445 --> 12:03.485
slope than someone who uses their C who use their CPAP less.

12:03.485 --> 12:05.285
And that association was significant.

12:05.625 --> 12:07.485
And that is, I think, a very interesting finding,

12:07.965 --> 12:10.965
particularly as it contrasts with the fact

12:10.965 --> 12:13.365
that there was no relationship between

12:13.425 --> 12:15.325
how much people use their CPA treatment

12:16.465 --> 12:18.685
and the change, the rate

12:18.685 --> 12:22.605
of change in non-overlapping depression symptoms.

12:23.415 --> 12:25.395
The first conclusion, I guess I want to draw is,

12:25.415 --> 12:27.475
is the good news story is this confirms

12:27.475 --> 12:30.515
that CPAP improves depression for everyone.

12:30.575 --> 12:32.435
And I think we don't wanna lose sight of

12:32.435 --> 12:34.195
that in the excitement about the differences.

12:35.565 --> 12:38.745
So the proportion who started out depressed,

12:38.965 --> 12:41.385
in a sense of they met criteria for mild

12:41.385 --> 12:44.745
or more severe depression was 63% and that went down to 24%.

12:44.745 --> 12:46.105
So that's a, that's a big change.

12:47.245 --> 12:49.385
Now you might say, well, that's just a placebo effect.

12:49.385 --> 12:51.265
There's no control group in this study

12:51.265 --> 12:53.305
because we weren't doing a randomized controlled trial.

12:54.165 --> 12:56.425
But placebo effects wouldn't explain the differences

12:56.425 --> 12:58.545
between non-overlapping and overlapping symptoms.

12:58.935 --> 13:02.985
They just wouldn't. So the second thing is to, you know,

13:02.985 --> 13:05.505
we conclude is that CPAP use does appear

13:05.505 --> 13:08.705
to improve overlapping symptoms more than non-overlapping,

13:08.885 --> 13:11.505
and in a way that is related to how much

13:11.525 --> 13:13.705
of the treatment people were using.

13:15.355 --> 13:17.535
So, good news story, if you're trying to say

13:17.535 --> 13:21.015
to your patient, you really need to use CPAP

13:21.135 --> 13:22.855
'cause it's gonna help your depression, and the more you use

13:22.855 --> 13:25.415
it, the more it will help your depression, right?

13:26.015 --> 13:27.975
Regardless of the type of depression symptom.

13:29.675 --> 13:32.175
But the relationship between CPAP use

13:32.195 --> 13:33.975
and depression was really only significant

13:33.995 --> 13:35.255
for overlapping symptoms.

13:36.395 --> 13:39.135
So if you were being really radical, you could conclude

13:39.245 --> 13:43.375
that CPAP doesn't treat depression, it only treats OSA

13:44.355 --> 13:47.415
I'm being provocative here for

13:47.415 --> 13:49.735
that is a conclusion you could draw, right?

13:51.115 --> 13:54.095
Um, because the symptoms that seem to be more persistent

13:54.625 --> 13:57.735
after CPAP treatment were the non-overlapping ones, the ones

13:57.735 --> 14:00.255
that as a psychologist I see as cardinal features

14:00.255 --> 14:02.455
of depression, the hopelessness, the helplessness,

14:02.475 --> 14:05.255
the guilt, the, the, you know, the negativity,

14:05.595 --> 14:07.255
the depressive mood, the kind of,

14:07.255 --> 14:08.815
it's all hopeless, helpless, worthless.

14:09.295 --> 14:12.735
I am a useless individual. Really, really strong symptoms.

14:14.525 --> 14:18.345
So it, if it could mean that CPAP doesn't treat

14:19.265 --> 14:22.935
depression in OSA, maybe what it means is, is

14:22.935 --> 14:24.255
that those people who have a lot

14:24.255 --> 14:28.095
of those non-overlapping symptoms need something else apart

14:28.095 --> 14:30.135
from CPAP to treat their depression.

14:30.135 --> 14:32.095
There's no doubt they need the CPA, right?

14:32.835 --> 14:34.335
For other reasons that I'm interested in,

14:34.335 --> 14:36.135
which is cognition thinking and memory skills.

14:36.155 --> 14:40.215
We know that you is terrible for thinking and memory skills.

14:40.595 --> 14:42.255
We know it's terrible for hypertension.

14:42.365 --> 14:43.855
It's a risk factor for diabetes.

14:44.355 --> 14:46.055
So you've got to have the CPAP,

14:46.915 --> 14:50.645
but if you are someone who is depressed and

14:50.755 --> 14:52.175
That depression has a lot

14:52.175 --> 14:56.175
of those non-overlapping features, then I think it means

14:56.175 --> 14:59.735
that you need something else, perhaps, medication,

14:59.735 --> 15:01.615
perhaps something like a cognitive behavioral

15:01.615 --> 15:03.015
therapy or CBT.

15:04.845 --> 15:08.915
The other thing that I think is a potential, kind

15:08.915 --> 15:10.995
of next step from this would be, well,

15:10.995 --> 15:13.515
maybe we should be designing an OAA

15:13.915 --> 15:15.115
specific depression scale.

15:16.665 --> 15:20.295
Because that way we might be able to actually talk about

15:20.365 --> 15:21.735
what is the true prevalence

15:21.735 --> 15:23.655
of depression in obstructive sleep apnea

15:24.155 --> 15:27.575
and how best to treat depression in sleep apnea.

15:27.575 --> 15:29.615
That isn't of the overlapping kind.

15:30.915 --> 15:34.875
And I haven't seen anyone yet take up the,

15:36.015 --> 15:37.275
the challenge of that

15:39.265 --> 15:40.595
because some people would say,

15:40.595 --> 15:42.555
well it doesn't matter if you're treating depression

15:42.715 --> 15:44.275
symptoms, you're treating depression, who cares?

15:44.975 --> 15:48.475
And others like me kind of go, but maybe it does.

15:48.775 --> 15:50.355
And I actually dunno the answer.

Understanding Obstructive Sleep Apnea and Depression

00:00:00 - Obstructive sleep apnea. OSA is a breathing disorder that happens during sleep. And what a pa basically happens is that the upper airway partially or completely obstruct, so it kind of collapses and smushes down. Think standing on a, on a hose pipe. And as a result, when you are trying to breathe in and breathe out in normal respiration, normal breathing, the airway is obstructed, partial your holy, and you can't get the air in and you can't breathe out the carbon dioxide. This is spectacularly bad for the body and the brain.
00:00:37 - will wake up either wholly or partially from deeper stages to lighter stages of sleep, or actually wake up completely to restart breathing. If you're sleeping in the bed next to someone with OSA, you will hear them go like this as they restart breathing, and there might be periods of silence or snoring before that and it can happen hundreds of times a night. And we have a metric of how severe your apnea is called the a HI, and it basically is the number of times you partially
00:01:08 - and drop your airflow and drops your blood oxygen levels below a acquired level for at least 10 seconds at a time. And that's the number of times per hour of sleep is the a HI. And, you know, a mild a HI would be about five times, an hour. You, you don't breathe properly for 10 or more seconds. Moderate might be, 15 times an hour, severe 30 or more times an hour. And there are people who can spend as much as half of the night not breathing properly.
00:01:40 - Now, the context of the study is that sleep apnea is associated with a whole lot of physical and mental health difficulties. And I'm a psychologist, so I'm particularly interested in the mental consequences of apnea. And I'm particularly interested in, the effects on mental health, particularly depression, because it turns out that depression is more common in people with sleep apnea than it is in the general public, by,
00:02:11 - And of course that's really critical because depression itself is associated with lots of negative consequences and may interfere with somebody's ability to engage with treatment for sleep apnea. So there's a vicious cycle. but the problem is, is that depression is made up of constellation of different kinds of symptoms, some of which are also symptoms of sleep apnea in and of itself. So there is overlap between the symptoms of depression
00:02:44 - So one of the critical questions is, is are we overestimating the prevalence of depression and sleep apnea? And when we treat depression symptoms in sleep apnea, are we actually treating the depression or are we treating the, the, the symptoms of sleep apnea that happen to overlap and look like depression? There was very little re at all asking the question of of whether, there is a difference following sleep, AP treatment in depression,

CPAP's Impact on Depression Symptoms Explored

00:03:16 - that you've got, whether they're overlapping or not overlapping. So there's most studies basically ask the question, does CPAP treat depression in sleep apnea? Now, CPAP, it just in case most people will know, but just in case, is a, is a treatment where you wear a mask over the nose or mouth and it applies, blows. There's a machine that blows air, through a pipe into the mask, that helps to keep the airway open. So it helps to keep the, the, the air flowing into,
00:03:49 - So most studies have just asked, does CPA treat depression in the answers? Yes, it does, right? But we wanted to know, we wanted to know a different question to the extent that an individual actually uses the therapy because not everybody does use it perfectly. What is the effect of that therapy on depression symptoms? And particularly, is there a different effect of CPAP on overlapping and non-overlapping symptoms? So let me explain to you what I mean by overlapping
00:04:20 - The kinds of symptoms that you see in OSA that could look like depression 'cause you also see them in depression, are things like the behavioral consequences, like a loss of libido, changes in menstrual symptoms, mental and physical, slowing, what we call psychomotor retardation. tension and irritability, really common, as we all know, when you don't sleep. physical anxiety symptoms. So kind of trembling in the tummy, heart palpitations,
00:04:52 - you know, you get in both, loss of energy and some changes in co in thinking. So people feeling they're a bit slower mentally, they can't think as clearly, they can't problem solve as clearly. And you can see why that could be both a symptom of depression and a symptom of of sleep apnea. If you don't sleep well, if your brain's not getting an hypo oxygen, of course you're not gonna think as clearly, but it, that's not necessarily the case that you're also depressed. So those are the overlapping symptoms. And the non-overlapping symptoms are things that
00:05:23 - of more cardinal features, the depression like agitation, loss of weight and appetite, depressed mood, feeling like everything is terrible and nothing is can can, can never get better, hopeless, helpless, guilt, suicidal thinking, changes in insight and awareness or the opposite actually a kind of feeling of disconnection from your feelings that you don't really feel anything is real. A sort of derealization
00:05:55 - of physical problems when actually is there. And they are very different qualitatively to the first set that I've just described. But they are all symptoms of depression. And the problem is, is that in all the previous trials that have looked at whether CPAP, treats depression, they've used a range of different measures with different numbers and different proportions of those overlapping and non-overlapping sym items or symptoms.

Link Between Sleep Apnea and Depression Symptoms

00:06:26 - was a meta-analysis of the prevalence of depression in sleep apnea. And we found a direct relationship between how many symptoms in a scale. So the proportion of symptoms in a scale that were overlapping a direct relationship between that and the prevalence of depression. Simply put, if you used a scale with very high numbers of overlapping symptoms, you reported a higher prevalence of depression in your sample than if you lose to scale with lower, numbers
00:06:56 - So that suggests to me that our understanding of what is the true nature of depression in sleep apnea is quite muddled. It is challenging. And we could have a whole existential argument about, well, a depression symptom is a depression symptom, it's still a bad thing. And I would agree, but I do think if we are trying to work out, well, who needs more help than OSA to treat their depression, we need to know the answer to this question. So this is a 12 week single arm study. So we didn't have a control group because we were only interested in individual differences.
00:07:29 - so everybody got CPAP, they had never had CPAP before. We had to exclude all the sorts of things that might've mi the water like psychosis and insomnia and central apnea, which is a different kind of sleep disorder. people who couldn't speak English well enough to follow the questionnaires, that kind of thing. and we basically, assessed them at baseline. They then went into 12 weeks of CPAP treatment and we assessed them at week three, week eight and week 13.
00:08:02 - and we used a questionnaire measure called the ham D and we used that because it allowed us to divide the symptoms into overlapping and non overlapping as I've described. And because there were different numbers of symptoms within the questionnaire that fit into those categories, we created two scores, but as, as a proportion of the number of items. So we produced percentage scores for those. We also just calculated the standard total score in raw points that you would expect to see.
00:08:37 - well obviously how depressed were they to begin with, and then what was the change in depression score over time and was it different between overlapping and non-overlapping symptoms? So we then did what's called growth curve modeling, which allows you to, describe the initial starting score at baseline and then a slope of change, a change function over time. And if I may, I could share a, an image with you when we're talking about the results that, that
00:09:06 - The first thing I think I want to say. And if you could just mentally combine those two lines that I'm showing you together, which are the overlapping and non-overlapping symptoms together, the first thing I wanted to say is everyone's depression improved. So on average they started at about 11 points and they went down about three, 3.2 points per visit, but it wasn't linear. So what you can see from those two separate slopes and imagine them smushed together, is that there was a, a faster change between baseline

Impact of CPAP on Depression Symptoms

00:09:36 - the 12 weeks of treatment. What I think you can also see, I think it's really obvious that the solid line here is the overlapping symptoms and the dotted line is the non-overlapping symptoms. So what you'll see, first of all, is that everyone started with higher percentage scores are overlapping symptoms than non-overlapping symptoms, which is not surprising given that they're overlapping with OSA. So you would expect that and that both overlapping
00:10:09 - and those changes were significant. What you'll also see is that the, the slope of change is much steeper, even though it still flattens off, it's much steeper overall for the overlapping symptoms. So they started at about 30% and they improved on average about 9% per visit. But again, it flattened off, off for the non-overlapping symptoms. They started at about, what was it, 12 percentage points
00:10:38 - Again, flattening off. So yes, both kinds of symptoms improved with treatment, but overlapping more than non-overlapping, you might say. Well, so what, what we wanted to know was, is this a function of how much people actually engage with their therapy? 'cause as I said, lots of people start CPAP, but don't continue it. Lots of people don't use it. The required number of hours a night. And the rough rule of thumb is if you use it fewer than four hours a night,
00:11:09 - I mean, you should really use it the whole night, but we kind of roughly say four hours or more is kind of better than less. So what we did was we looked to see whether there was a relationship between, how quickly people's depression improved within overlapping and non-overlapping symptoms and how much they used their CPAP. And there was, but only for the overlapping symptoms. So those people who use their CPAP device,
00:11:40 - or more percentages of a greater percentage of nights for more than four hours, four or more hours had a steeper slope of decline. So you could imagine that this average is made up of a whole load of different trajectories. Each person gets their own slope function. So someone who uses their CPA more would have a steeper slope than someone who uses their C who use their CPAP less. And that association was significant. And that is, I think, a very interesting finding, particularly as it contrasts with the fact
00:12:13 - how much people use their CPA treatment and the change, the rate of change in non-overlapping depression symptoms. The first conclusion, I guess I want to draw is, is the good news story is this confirms that CPAP improves depression for everyone. And I think we don't wanna lose sight of that in the excitement about the differences. So the proportion who started out depressed, in a sense of they met criteria for mild

CPAP's Impact on Depression Symptoms in OSA

00:12:44 - So that's a, that's a big change. Now you might say, well, that's just a placebo effect. There's no control group in this study because we weren't doing a randomized controlled trial. But placebo effects wouldn't explain the differences between non-overlapping and overlapping symptoms. They just wouldn't. So the second thing is to, you know, we conclude is that CPAP use does appear to improve overlapping symptoms more than non-overlapping, and in a way that is related to how much
00:13:15 - So, good news story, if you're trying to say to your patient, you really need to use CPAP 'cause it's gonna help your depression, and the more you use it, the more it will help your depression, right? Regardless of the type of depression symptom. But the relationship between CPAP use and depression was really only significant for overlapping symptoms. So if you were being really radical, you could conclude that CPAP doesn't treat depression, it only treats OSA
00:13:47 - that is a conclusion you could draw, right? because the symptoms that seem to be more persistent after CPAP treatment were the non-overlapping ones, the ones that as a psychologist I see as cardinal features of depression, the hopelessness, the helplessness, the guilt, the, the, you know, the negativity, the depressive mood, the kind of, it's all hopeless, helpless, worthless. I am a useless individual. Really, really strong symptoms.
00:14:19 - depression in OSA, maybe what it means is, is that those people who have a lot of those non-overlapping symptoms need something else apart from CPAP to treat their depression. There's no doubt they need the CPA, right? For other reasons that I'm interested in, which is cognition thinking and memory skills. We know that you is terrible for thinking and memory skills. We know it's terrible for hypertension. It's a risk factor for diabetes. So you've got to have the CPAP,
00:14:50 - That depression has a lot of those non-overlapping features, then I think it means that you need something else, perhaps, medication, perhaps something like a cognitive behavioral therapy or CBT. The other thing that I think is a potential, kind of next step from this would be, well, maybe we should be designing an OAA specific depression scale. Because that way we might be able to actually talk about
00:15:48 - of depression in obstructive sleep apnea and how best to treat depression in sleep apnea. That isn't of the overlapping kind. And I haven't seen anyone yet take up the, the challenge of that because some people would say, well it doesn't matter if you're treating depression symptoms, you're treating depression, who cares? And others like me kind of go, but maybe it does. And I actually dunno the answer.

Faculti AI can make mistakes

Research

Policy

Analysis