Depressive Symptoms Before and After Long-term CPAP Therapy in Patients With Sleep Apnea


      The outcome of depressive symptoms under CPAP therapy for OSA-hypopnea syndrome (OSAHS) has been poorly evaluated. In this multicenter, prospective cohort study, we evaluated the prevalence and correlates of persistent depressive symptoms after long-term CPAP therapy for OSAHS.


      This study included 300 patients with OSAHS and depressive symptoms (13-item, self-rated Pichot depression scale [QD2A] ≥ 7) at diagnosis. The primary dependent variable was persistent depressive symptoms after ≥ 1 year of CPAP therapy. Multivariate regression analyses were performed to determine variables independently associated with the persistence of depressive symptoms.


      After an average of 529 days (range, 365-1,569 days) of CPAP therapy, the mean (SD) QD2A score decreased from 9.2 (2.0) to 5.4 (4.0) (P < .0001), but 125 patients (41.7%) presented persistent depressive symptoms. The persistence of depressive symptoms was independently associated with persistent excessive daytime sleepiness (EDS) (OR, 2.72; 95% CI, 1.33-5.61), comorbid cardiovascular disease (OR, 1.76; 95% CI, 1.02-3.00), and female sex (OR, 1.53; 95% CI, 1.09-2.13). A positive linear trend was observed for the adjusted OR of persistent depressive symptoms with decreasing CPAP effect on the Epworth sleepiness scale (P < .0001).


      CPAP therapy does not resolve depressive symptoms in many patients with OSAHS. Persistent depressive symptoms are strongly associated with EDS. Active monitoring of depressive symptoms is needed in patients with OSAHS who are treated with CPAP. Interventional trials are required to evaluate the impact of antidepressants, cognitive behavioral therapy, or both on comorbid depression in patients with OSAHS.


      CVD (cardiovascular disease), EDS (excessive daytime sleepiness), ESS (Epworth Sleepiness Scale), IRSR (Institut de Recherche en Santé Respiratoire des Pays de la Loire), OSAHS (OSA-hypopnea syndrome), PSG (polysomnography), QD2A (13-item, self-rated Pichot depression scale), SDB (sleep-disordered breathing)
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • McDaid C
        • Griffin S
        • Weatherly H
        • et al.
        Continuous positive airway pressure devices for the treatment of obstructive sleep apnoea-hypopnoea syndrome: a systematic review and economic analysis.
        Health Technol Assess. 2009; 13 (143-274): 1-119
        • Bazzano LA
        • Khan Z
        • Reynolds K
        • He J
        Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea.
        Hypertension. 2007; 50: 417-423
        • Le Port A
        • Gueguen A
        • Kesse-Guyot E
        • et al.
        Association between dietary patterns and depressive symptoms over time: a 10-year follow-up study of the GAZEL cohort.
        PLoS ONE. 2012; 7: e51593
        • Lépine JP
        • Gasquet I
        • Kovess V
        • et al.
        Prevalence and comorbidity of psychiatric disorders in the French general population [in French].
        Encephale. 2005; 31: 182-194
        • Harris M
        • Glozier N
        • Ratnavadivel R
        • Grunstein RR
        Obstructive sleep apnea and depression.
        Sleep Med Rev. 2009; 13: 437-444
        • Bixler EO
        • Vgontzas AN
        • Lin HM
        • Calhoun SL
        • Vela-Bueno A
        • Kales A
        Excessive daytime sleepiness in a general population sample: the role of sleep apnea, age, obesity, diabetes, and depression.
        J Clin Endocrinol Metab. 2005; 90: 4510-4515
        • Pan A
        • Keum N
        • Okereke OI
        • et al.
        Bidirectional association between depression and metabolic syndrome: a systematic review and meta-analysis of epidemiological studies.
        Diabetes Care. 2012; 35: 1171-1180
        • Mulle JG
        • Vaccarino V
        Cardiovascular disease, psychosocial factors, and genetics: the case of depression.
        Prog Cardiovasc Dis. 2013; 55: 557-562
        • Pichot P
        • Boyer P
        • Pull CB
        • Rein W
        • Simon M
        • Thibault A
        A questionnaire for self-evaluation of depressive symptomatology, the QD2 Questionnaire: I. Construction, factorial structure and metrological properties [in French].
        Rev Psychol Appl. 1984; 34: 229-250
        • Pichot P
        • Boyer P
        • Pull CB
        • Rein W
        • Simon M
        • Thibault A
        A questionnaire for self-evaluation of depressive symptomatology, the QD2 Questionnaire: II. Abridged version, QD2A [in French].
        Rev Psychol Appl. 1984; 34: 323-340
        • de Bonis M
        • Lebeaux MO
        • de Boeck P
        • Simon M
        • Pichot P
        Measuring the severity of depression through a self-report inventory. A comparison of logistic, factorial and implicit models.
        J Affect Disord. 1991; 22: 55-64
        • Johns MW
        A new method for measuring daytime sleepiness: the Epworth sleepiness scale.
        Sleep. 1991; 14: 540-545
        • Barceló A
        • Piérola J
        • de la Peña M
        • et al.
        Free fatty acids and the metabolic syndrome in patients with obstructive sleep apnoea.
        Eur Respir J. 2011; 37: 1418-1423
      1. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force.
        Sleep. 1999; 22: 667-689
        • Schwartz DJ
        • Kohler WC
        • Karatinos G
        Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure.
        Chest. 2005; 128: 1304-1309
        • Kawahara S
        • Akashiba T
        • Akahoshi T
        • Horie T
        Nasal CPAP improves the quality of life and lessens the depressive symptoms in patients with obstructive sleep apnea syndrome.
        Intern Med. 2005; 44: 422-427
        • Diamanti C
        • Manali E
        • Ginieri-Coccossis M
        • et al.
        Depression, physical activity, energy consumption, and quality of life in OSA patients before and after CPAP treatment.
        Sleep Breath. 2013; 17: 1159-1168
        • Muñoz A
        • Mayoralas LR
        • Barbé F
        • Pericás J
        • Agusti AG
        Long-term effects of CPAP on daytime functioning in patients with sleep apnoea syndrome.
        Eur Respir J. 2000; 15: 676-681
        • Haensel A
        • Norman D
        • Natarajan L
        • Bardwell WA
        • Ancoli-Israel S
        • Dimsdale JE
        Effect of a 2 week CPAP treatment on mood states in patients with obstructive sleep apnea: a double-blind trial.
        Sleep Breath. 2007; 11: 239-244
        • Lee IS
        • Bardwell W
        • Ancoli-Israel S
        • Loredo JS
        • Dimsdale JE
        Effect of three weeks of continuous positive airway pressure treatment on mood in patients with obstructive sleep apnoea: a randomized placebo-controlled study.
        Sleep Med. 2012; 13: 161-166
        • Sforza E
        • de Saint Hilaire Z
        • Pelissolo A
        • Rochat T
        • Ibanez V
        Personality, anxiety and mood traits in patients with sleep-related breathing disorders: effect of reduced daytime alertness.
        Sleep Med. 2002; 3: 139-145
        • Gasa M
        • Tamisier R
        • Launois SH
        • et al.
        Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure.
        J Sleep Res. 2013; 22 (Scientific Council of the Sleep Registry of the French Federation of Pneumology-FFP): 389-397
        • Habukawa M
        • Uchimura N
        • Kakuma T
        • et al.
        Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: contribution of daytime sleepiness to residual depressive symptoms.
        Sleep Med. 2010; 11: 552-557
        • Kjelsberg FN
        • Ruud EA
        • Stavem K
        Predictors of symptoms of anxiety and depression in obstructive sleep apnea.
        Sleep Med. 2005; 6: 341-346
        • Hippisley-Cox J
        • Fielding K
        • Pringle M
        Depression as a risk factor for ischaemic heart disease in men: population based case-control study.
        BMJ. 1998; 316: 1714-1719
        • Kohler M
        • Ayers L
        • Pepperell JC
        • et al.
        Effects of continuous positive airway pressure on systemic inflammation in patients with moderate to severe obstructive sleep apnoea: a randomised controlled trial.
        Thorax. 2009; 64: 67-73
        • Vgontzas AN
        • Zoumakis E
        • Lin HM
        • Bixler EO
        • Trakada G
        • Chrousos GP
        Marked decrease in sleepiness in patients with sleep apnea by etanercept, a tumor necrosis factor-alpha antagonist.
        J Clin Endocrinol Metab. 2004; 89: 4409-4413
        • Libby P
        Inflammation in atherosclerosis.
        Arterioscler Thromb Vasc Biol. 2012; 32: 2045-2051
        • Irwin MR
        • Miller AH
        Depressive disorders and immunity: 20 years of progress and discovery.
        Brain Behav Immun. 2007; 21: 374-383
        • Fenik P
        • Veasey SC
        Pharmacological characterization of serotonergic receptor activity in the hypoglossal nucleus.
        Am J Respir Crit Care Med. 2003; 167: 563-569
        • Aloia MS
        • Arnedt JT
        • Smith L
        • Skrekas J
        • Stanchina M
        • Millman RP
        Examining the construct of depression in obstructive sleep apnea syndrome.
        Sleep Med. 2005; 6: 115-121
        • Pillar G
        • Lavie P
        Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index.
        Chest. 1998; 114: 697-703
        • Silverman SL
        From randomized controlled trials to observational studies.
        Am J Med. 2009; 122: 114-120
        • Wiernik E
        • Pannier B
        • Czernichow S
        • et al.
        Occupational status moderates the association between current perceived stress and high blood pressure: evidence from the IPC cohort study.
        Hypertension. 2013; 61: 571-577
        • Lemogne C
        • Thomas F
        • Consoli SM
        • Pannier B
        • Jégo B
        • Danchin N
        Heart rate and completed suicide: evidence from the IPC cohort study.
        Psychosom Med. 2011; 73: 731-736
        • Gagnadoux F
        • Le Vaillant M
        • Paris A
        • et al.
        Adherence to positive airway pressure in non-sleepy patients with obstructive sleep apnoea.
        Eur Respir J. 2013; 42 (IRSR Sleep Cohort Group): 863-866
        • Priou P
        • Le Vaillant M
        • Meslier N
        • et al.
        Independent association between obstructive sleep apnea severity and glycated hemoglobin in adults without diabetes.
        Diabetes Care. 2012; 35 (IRSR Sleep Cohort Group): 1902-1906
        • Nguyên XL
        • Rakotonanahary D
        • Chaskalovic J
        • Fleury B
        Insomnia related to sleep apnoea: effect of long-term auto-adjusting positive airway pressure treatment.
        Eur Respir J. 2013; 41: 593-600
        • Depression in adults with a chronic physical health problem: treatment and management. NICE clinical guideline 91. National Institute for Health and Clinical Excellence website
        (Accessed January 28, 2013)
        • Coventry PA
        • Bower P
        • Keyworth C
        • et al.
        The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis.
        PLoS ONE. 2013; 8: e60532
        • Kline CE
        • Ewing GB
        • Burch JB
        • et al.
        Exercise training improves selected aspects of daytime functioning in adults with obstructive sleep apnea.
        J Clin Sleep Med. 2012; 8: 357-365