Original Research

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

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Initial self-reported depression and insomnia prior to the diagnosis and treatment of obstructive sleep apnea with continuous positive airway pressure therapy did not reliably predict short- and long-term adherence in a sample of active-duty military and veteran patients.



Continuous positive airway pressure therapy (CPAP) is the first-line treatment for obstructive sleep apnea (OSA) recommended by the American College of Physicians and the American Academy of Sleep Medicine.1,2 CPAP reduces the apnea hypopnea index (AHI), improves oxyhemoglobin desaturation, and reduces cortical arousals associated with apneic/hypopneic events.3 Despite being an effective treatment for OSA, a significant limitation of CPAP is treatment adherence. Factors associated with CPAP adherence include disease and patient characteristics, perceived self-efficacy, treatment titration procedure, device technology factors, adverse effects, and psychosocial factors.4

Recent studies suggest that insomnia and depression may be associated with OSA. According to a review by Luyster and colleagues, insomnia is present in 39% to 58% of patients with OSA.5 Since OSA may disturb sleep by the number of nightly awakenings, OSA may cause or worsen insomnia. Furthermore, insomnia may exacerbate sleep apnea thus impeding the effectiveness of sleep apnea treatment.

In some studies, the presence of insomnia symptoms prior to initiating CPAP treatment has been found to be associated with reduced CPAP adherence. For example, in 2010, Wickwire and colleagues found that there was a negative association with the average nightly minutes of CPAP use for those patients with OSA that reported symptoms of sleep maintenance insomnia.6 This was not found for those patients with OSA who reported symptoms of sleep onset insomnia or reported no insomnia at all. In another study by Pieh and colleagues, self-reported insomnia symptoms were predictive of CPAP adherence (defined as < 4 hours use/night) at a 6-month follow-up.7 However, results from a separate study indicated that insomnia was not associated with 6-month CPAP adherence.8

Depressive symptoms are commonly reported by patients with OSA, and higher rates of depressive symptomatology in patients with OSA have been observed in a number of prevalence studies when compared with the general population.9,10 Between 15% and 56% of patients with OSA are diagnosed with a depressive disorder compared with 6.6% of the general population.11 OSA may be causally related with depression or coexist as a separate disorder. Apnea severity has been shown to exacerbate depressive symptoms, and treatment with CPAP can improve depressive symptoms.12,13 Unfortunately, depression has been found to reduce CPAP adherence. For example, Law and colleagues found that depression was independently associated with poorer adherence during home-based auto-PAP titration.14 Furthermore, in a study by Gurlanick and colleagues, depressive symptoms were independently associated with reduced CPAP adherence in surgical patients with OSA.15

To the best of our knowledge, the combined impact of both insomnia and depression on CPAP adherence has not been investigated. In military populations this may be especially important as CPAP adherence has been reported to be worse in military patients with posttraumatic stress disorder (PTSD) and other psychiatric disorders, and there are increasing rates of insomnia and OSA in the military.16,17 We hypothesize that active-duty and retired military patients with self-reported insomnia and depression will have reduced short and long-term CPAP adherence.


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