I recently had a major depressive episode out of nowhere without any obvious catalyst. It crippled me. I quit taking graduate courses and could barely go to work. Given the opportunity, I would just sleep. I am doing all of the right things to address the issue ie; therapy and an ssri. Throughout this process, which began about 4 months ago I also had a medical w/u as I had severe fatigue and vague aches and pains. My work up was negative for any organic medical problem. I had previously been diagnosed with mixed central and obstructive sleep apnea, but due to non-compliance with the mask did not meet the insurance companies qualification to have the ASV machine covered by insurance. I couldnāt afford it out of pocket at that time which was several years ago. I am unsure if I still have sleep apnea as I lost approximately 40 pounds since the initial study and my wife no longer reports the gasping and snoring that she once did. My symptoms have slightly improved, as far as the depression , but I am nowhere near baseline. I am back to training albeit inconsistently and a far cry from previous levels of strength. When I had the consultation with the sleep specialist last month he was of the opinion that though sleep disturbances such as apnea may worsen depression it is not causal. I have read studies that state the contrary and assert that untreated apnea may directly cause, not only contribute to depression. My hope is that I can just get the apnea treated, improve my quality fof life, energy, mood, concentration, etc and stop taking meds and was curious what your opinion was on the correlation between sleep apnea (central or obstructive) and depression
Thanks so much for all of the information you all provide here.
Iām sorry to hear itās been a rough go around for you. I know thereās not much weight in the statement, āYouāre not aloneā but when I look at a number of patients I see regularly (both in Sleep and Family Practice) who have concerns similar to yours, itās actually a large portion, if not a majority.
It sounds as though as what you experienced may certainly be unipolar major depression, at least by DSM5 criteria. That being said, Iām glad your health care team went forward with a medical evaluation to make sure things checked out okay.
Okay, so letās get down to the specifics that I might be able to help with. The sleep related parts:
One caveat that may sound like a broken record in this setting is that although youāve given us a lot of information, thereās still A LOT that is missing that would be helpful to know. Iām glad you touched base with a sleep physician, as face to face or via virtual/telemedicine encounters with an actual sleep provider are really the only way to go about reviewing your history, your diagnoses and relevant work ups/data. So what we exchange in this forum is going to be limited, but hopefully it will still help. For everyoneās future reference: things like, age, BMI, Epworth, sleep study results, medications, and cormobidities are most helpful to me when Iām seeing a patient (at minimum).
Your comments about your sleep apnea are very much relevant, but hereās whatās missing: how severe was your sleep apnea (i.e. what was your apnea-hypopnea index/hour, and what was the actual breakdown of your obstructive (apneas and hyponeas) relative to your central apnea index? If in fact you met the criteria for central sleep apnea, depending on your age (presumably youngish) and comorbidities (presumably minimal), as well whether your sleep study was conducted at altitude, I might not worry much about there being a strong central component. At this time, we just don;'t have a lot of great evidence demonstrating what the implications of central sleep apnea are on otherwise healthy individuals, unlike the data we have on moderate/severe OSA and the longterm associations/potential implications of going untreated. On the other hand, if you have anything else going on i.e. heart issues or neurologic issues, and you donāt live at altitude, it might be reasonable to consider an evaluation of causes for central apnea. While idiopathic central sleep apnea is a thing, there are some well known associations with central sleep apnea worth assessing for that Iāll list here briefly: altitude (think along the lines of lower partial pressure of oxygen, leading you to breath faster/more and therefore blowing off CO2, which makes your brain pause in breathing to hold onto CO2), medications that depress your respirations (most commonly narcotics), heart disease (usually heart failure), neurologic causes (neuroanatomical abnormalties are most common), being a male who has severe, untreated OSA. DONāT READ TOO MUCH INTO THIS. Your sleep doctor would have likely considered these causes, but for the sake of education these are some of the most common causes of central sleep apnea (i.e. your brain decides to breath less often when youāre asleep).
Your concerns about sleep apnea having a causal effect towards depression are reasonable, as studies are out there that state such. However, when you look at the OVERALL evidence, itās suggestive that the relationship between sleep disturbances (all of the different kinds) and mood disorders (like depression) are actually much more complex, and likely resemble a bi-directional relationship. In other words, like I tell most patients, sleep issues and depression are a two-way street, if one suffers from depression, the person may likely have subjective sleep complaints (and vice versa). There are plenty of studies demonstrating that people with depression are much more likely to complain of insomnia as their hallmark sign of depression (and sometimes excessive sleepiness aka hypersomnia), and there are plenty of studies that demonstrate that people who have insomnia, or in your case, untreated sleep disordered breathing, are more likely to experience daily fatigue and depressive symptoms accordingly. I know Austin and Jordan refrain from the āit makes senseā approach, but if youāre not sleeping well and are chronically sleep deprived because you have untreated moderate/severe or even central sleep apnea, then it would likely benefit you to get that in check, sleep more and likely improve your mood.
So which should you concentrate on most? Hard to say, but what I advise most patients to avoid putting either condition on the back burner. Persons with sleep apnea have a 1.8-fold increased risk of developing major depresion, and those with depression, a 1.6 fold increased risk of OSA. Other studies have shown that treating OSA results in sustained symptomatic improvement in depressive symptoms, and the degree of improvement of OSA with PAP therapy also correlated to the improvement of depressive symptoms.
SO what do? Iād recommend considering a repeat sleep evaluation (although if you had moderate/severe obstructive sleep apnea, your chances are still relatively high that you have a degree of it despite the weight loss) and give PAP therapy another trial. I would recommend this in particular if your obstructive or central apnea was significant. People struggle with getting used to PAP all the time, I get that and unfortunately insurance companies donāt. Again, itās specific to every patient, but I recommend nightly use of the mask during the last 30-60 minutes of your night, while you;'re awake relaxing/winding down before going to bed. This desensitization protocol will help you get used to falling asleep with it (think about the first time you put a seatbelt onā¦ it was weird, but now you barely notice it). I would keep fighting the depression fight with both therapy and pharmacologic treatment as the consensus among studies is that the net effect of both is better than that of monotherapy. If your mood symptoms begin to improve as you treat your sleep disordered breathing, great! Maybe then in conjunction with your behavioral health team you can consider weaning off medications (some can cause insomnia and have other negative impacts on sleep). But if you find that you need to stick with the treatment, then do it. Your sleep may benefit in the long run from it.
Austin, thanks so much for tagging Dr
Gordon on this. Dr. Gordon, I donāt know how to thank you enough for taking the time to give such a thoughtful response to a stranger. Inspiring and immensely appreciated. Thank you. To give a little more context ,I had the initial sleep study in 2016 at sea level in Florida. I currently reside at an elevation of approximately 7000 feet and have been here for almost 2 years. I was notified the day after the study by the pulmonologistās office that I had some significant sinus bradycardia that correlated with the apnea episodes. They referred me to an electrophysiologist who was reassured since all of my EKG intervals were normal, just sinus bradycardia. I dont remember how low it was. Maybe 30s if i remember correctly. I wore a holter monitor for 24 hours and didnāt have any bradycardia during that period of time. The electrophysiologist explained that the bradycardia was a protective mechanism to reduce myocardial oxygen demand during the apnea episodes preventing ischemia. There was talk of a pacemaker briefly, but he ultimately decided that given I am otherwise healthy that asv would be the way to go. I also had an echocardiogram which showed some mild right ventricular hypertrophy. I was about 222lbs at that time and Iām in the low 180s now. Waist 34 inches neck 15. He did comment that I have very large tonsils. As for the ahi I do not remember. As far as sleep, I do fall asleep very easily. When speaking with the sleep specialist last month I was explaining to him that I have sincerely never felt fully rested in my entire life. I wake up feeling exhausted every single day regardless of how many hours I sleep. Iām left wondering if Iām chronically depressed and thatās why Iām exhausted or what exactly is going on. Maybe ive conditioned myself to believe that im always tired. I dont know. For a little more context Iām 35 years old, married, children, working professional. I carry out a normal life albeit in a foggy, irritable state. Thanks again.
Yup, the fact that you donāt feel rested after sleeping may be suggestive of untreated sleep disordered breathing but I also hear that complaint from people who have dysfunctional sleep due to insomniaā classic, exaggerated example: person tells you that they sleep for 6 hours on a regular basis. During the weekdays due to time constraints they spend about 8 hours in bed nightly, but on the weekends try to catch up and spend closer to 12 hours in bed. Despite that, they still seem to get about 6 hours of sleep on the weekend, and they feel even less restored when they wake on the weekends ā but it doesnāt matter much because they lay around the house, and catch up with a few cat naps here or there. Sunday nights are the most difficult to fall asleep.
Person is spending 8-12 hours in bed, relative to the time that they spend asleep. Thatās a sleep efficiency of (time asleep/time in bed) 50-75% at best. In general, itās been suggested that a sleep efficiency somewhere in the range of 85-95% will produce better, perceived sleep quality. Makes sense, right? If you spent 6 hours asleep, and the other 6 hours awake, youād feel terrible.
Person naps on the weekends, resulting in lower sleep homeostatic sleep drive, and thus has an even harder time going to bed when you add in the stressors associated with returning to the work week.
Your docs point about ASV is a good one. Itās reasonable in a young male with otherwise no problems to look at ASV for treating both OSA and CSA, depending on the severity. This is why I think knowing your original AHI for determining severity would be helpful. That being said, if you live at 7000 ft., which is approximately about the same altitude that I am practicing at, I wouldnāt be surprised to see that your numbers had worsened slightly due to the reduced partial pressure of oxygen (I have patients who are on CPAP who have higher residual abnormal breathing events due to altitude induced CSA, but go to Alabama for a week and have beautiful numbers presumably because theyāre at sea level). CSA gets worse with altitude due to the lower partial pressure of oxygen, causing you to breath at a higher respiratory rate, and blow off CO2, thus making you prone to have more central apneas (because your brain senses youāre blowing off too much CO2).
the TL;DR is I would recommend figuring out what your original study showed, and if it was moderate or severe, strongly consider either talking with your sleep doc about getting an ASV titration done, or just getting started on some form of treatment, whether it be ASV (which studies support for OSA/CSA) or PAP (some people adjust and the CSA improves on its own).
I could talk about this stuff for days, so donāt mind the lengthā¦
I donāt mind the length at all. I really appreciate hearing anything you have to say on the matter. I have a sleep study in 3 weeks. Ill report back in as I have new information. Thanks again for the advice. It helps more than you know. Last question for now, do you think that treatment with asv could reverse the r ventricular hypertrophy that was previously noted on the echo?
Itās hard to say that it would reverse things to ānormalā as opposed to āmildly hypertrophiedā. Some quick reading suggests that due to measurement variability in echocardiography, there is a low sensitivity and specificity for identifying true RV hypertrophy.
I recognize the concern though, itās your heart we are talking about and something considered out of the norm and therefore possibly worrisome. The test isnāt perfect for identifying this anatomical change, and given your health and presumed absence of exercise fatigue/shortness of breath, I think youāre okay to press on. Iām no cardiologist though, but the one you spoke with was on the money when he talked about transient bradycardia in the setting of sleep related apneas.
Instead I would think about how treatment might improve your mood, your sleep quality, and your energy levels.
sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotence, and headaches. Observed episodes of stopped breathing or abnormal breathing patterns during sleep. A good way to solve this problem, Modalert 200 is used to treat excessive sleepiness caused by narcolepsy, Sometimes it is used off-label as a cognitive enhancer. Modafinilās exact mechanism is unclear, though it affects many neurotransmitter systems in the brain.