The high prevalence of obstructive sleep apnea among patients with bipolar disorders

doi:10.1016/j.jad.2013.05.047

Journal of Affective Disorders

Volume 151, Issue 1, October 2013, Pages 54-58

https://doi.org/10.1016/j.jad.2013.05.047 Get rights and content

Abstract

Introduction: Sleep plays an important role in maintaining stability in bipolar disorders, and sleep disturbances can trigger mood episodes. Obstructive sleep apnea (OSA) is a common sleep disorder, yet the co-occurrence with bipolar disorder has not been methodically studied. Methods: This is a chart review of 482 consecutively seen patients with a bipolar disorder who underwent routine screening for OSA using a self-report sleep apnea questionnaire. Positive screens were referred for a sleep study. Results: A positive screen was found in 214 (44.4%) patients. Sleep studies were obtained on 114 patients, and 101, were diagnosed with OSA: point prevalence 21%. Discussion: The 21% prevalence fails to consider the false negative rate of the questionnaire, or the exclusion of patients who screened positive but failed to get a sleep study. Taking these into consideration it is estimated that the true prevalence of OSA in this study may be as high as 47.5%. The co-occurrence of OSA and bipolar disorders is markedly higher than previously thought. Of note, OSA may play a role in refractory bipolar, disorders, and carries significant mortality and morbidity that overlap, with the mortality and morbidity found with bipolar disorders. Limitations: This was a retrospective study based on a self-report questionnaire. Polysomnographic confirmation was performed in only a subgroup of subjects. Conclusions: The data suggest that unrecognized OSA may play a major role in the mortality and morbidity of bipolar disorders. All patients diagnosed with a bipolar disorder should be screened with an OSA questionnaire.

Introduction

Obstructive sleep apnea (OSA) is a common sleep disorder characterized by airflow cessation associated with night time arousals, fragmented sleep, and oxygen desaturation. Symptoms of OSA may include daytime sleepiness, insomnia, morning headaches, fatigue, irritability, memory problems, snoring, depression and cognitive problems. OSA is associated with a multitude of health problems, a diminished quality of life and if left untreated can shorten life by 20 years (Chung, 2011). Sleep disturbances occur frequently in the context of both mania and depression, and represent diagnostic criteria items in the DSM-IV. At the same time, exogenous causes of sleep disturbance, such as jet lag and shift work, can destabilize a euthymic patient with a bipolar disorder (Wehr et al., 1987). Full syndromal sleep disorders, such as OSA, have been associated with psychiatric complications, particularly depression and anxiety, but a link to bipolar disorders has not been well established (Schroder and O'Hara, 2005, Ohayon, 2003). Bipolar disorders and OSA are both associated with a high risk of mortality from accidents, high cardiovascular morbidity and mortality, and neural structural changes (Marshall et al., 2008, Young et al., 1993, Ohayon, 2003, Sharafkhaneh et al., 2005, Angst et al., 2002, Van Winkel et al., 2008, Konarski et al., 2008).

Prior research indicates low prevalence rates of OSA among patients with a bipolar disorder. In a general population study, OSA was found to affect 2% of women and 4% of men in the United States (Young et al., 1993). Similarly, a review of the Veterans Health Administration database of four million veterans found the prevalence of sleep apnea in patients with bipolar disorders to be 3.3% (Joo et al., 2010). The rate of comorbid bipolar disorders in patients with sleep apnea in this same database was 4.65% (Schroder and O'Hara, 2005) Beyond the Veterans Health Administration data there has been no systematic study of the prevalence of OSA in bipolar disorders.

Plante and Winkelman in their 2008 American Journal of Psychiatry article, Sleep Disturbances in Bipolar Disorder: Therapeutic Implications, discussed the critical nature of sleep for bipolar disorders and raised the possibility that obstructive sleep apnea may destabilize bipolar disorders (Plante and Winkelman, 2008). They called for the routine screening for sleep apnea in all patients with bipolar disorders.

Because of the bi-directional interaction between sleep disturbance and mood instability, an elevated rate of OSA among bipolar patients would be clinically important. A high prevalence of OSA could impact the health of patients with one of the bipolar disorders. The objective of this study was to identify the prevalence of OSA in a mood disorders specialty clinic where every new patient was systematically screened for sleep disorders using a standardized assessment instrument. The health consequences of unrecognized OSA and the possible link between OSA and bipolar disorders morbidity and mortality are discussed below.

Section snippets

Methods

The medical charts of 482 consecutive patients with bipolar I, II, or NOS treated at The Depression & Bipolar Clinic of Colorado between October 1, 2005 and December 31, 2008 were examined. The following information was extracted from the chart: diagnosis, gender, age at the time of the evaluation (Table 1), height, weight, sleep apnea screen score, and the results of polysomnography, if performed (Table 2). BMI was calculated using the patient's height and weight. The Depression & Bipolar

Results

A total of 482 consecutive charts were included in the review. All had completed the screening questionnaire. Demographics are described in Table 3. A positive OSA screen was documented in 44.4% (n=214) of the charts. Only 53.3% of patients with a positive screen went on to receive a sleep study (n=114). Of those who received a sleep study (n=114) 88.6% were diagnosed with OSA. OSA was diagnosed in 21% (n=101) of patients suffering from a bipolar disorder. There were no significant differences

Discussion

To the best of our knowledge this is the first study of a bipolar population that involves systematic screening for sleep apnea in patients with bipolar disorders. The point prevalence of OSA in this study was at minimum 21%. This is markedly higher than the previous rate of 3.3% from the Veterans Health Administration database that only checked for the diagnosis but did not involve any systematic screening.

At least three factors suggest that OSA may play a critical role in refractory bipolar

Limitations

There are a number of potential weaknesses of this study. It is retrospective in nature and the data is from a single clinician's practice. These limitations are mitigated by the use of a structured, self-report screening instrument, and to an even greater degree by use of sleep studies performed by an independent sleep specialist as the primary outcome variable. Factors related to psychiatric illness, such as employment, social support, insurance status and severity of bipolar symptomatology,

Conclusions

OSA is a hitherto underappreciated co-occurring illness with bipolar disorders that potentially contributes substantially to the morbidity and mortality of patients with bipolar disorders. The point prevalence of this study indicates that a range of one-fifth to almost one-half of patients with bipolar disorders may suffer from obstructive sleep apnea, 6 to 14 times more prevalent than previous studies of bipolar disorders have indicated (3). Clinic populations that have a higher BMI would

Role of funding source

This study was self funded.

Conflict of interest

Daniel Z. Lieberman, MD, Lanny Douglas APRN, Ginger Brasuell APRN and Lawrence Denmark Ed.D report no financial relationships with commercial interests. Tammas Kelly MD served on a Drug advisory panel for Teva Pharmaceutical industries LTD on one occasion.

Acknowledgment

The authors would like to thank Steve Dubovsky and Jim Phelps for their help and encouragement.

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Research reportThe high prevalence of obstructive sleep apnea among patients with bipolar disorders

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Limitations

Conclusions

Role of funding source

Conflict of interest

Acknowledgment

Journal of Affective Disorders

Endocrinology and Metabolism Clinics of North America

Journal of Affective Disorders

Accident Analysis & Prevention

Psychiatry Research: Neuroimaging

Changes in intra-abdominal visceral fat and serum leptin levels in patients with obstructive sleep apnea syndrome following nasal continuous positive airway pressure therapy

Circulation

STOP questionnaire: a tool to screen patients for obstructive sleep apnea

Anesthesiology

Investigation of serum high-sensitive C-reactive protein levels across all mood states in bipolar disorder

European Archives of Psychiatry and Clinical Neuroscience

Sleep 4: sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome

Thorax

Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults

Journal of Clinical Sleep Medicine

Metabolic syndrome in bipolar disorder: findings from the Bipolar Disorder Center for Pennsylvanians

Bipolar Disorders

Obesity as a correlate of outcome in patients with bipolar I disorder

The American Journal of Psychiatry

Elevated prevalence of obesity, metabolic syndrome, and cardiovascular risk factors in bipolar disorder

Annals of Clinical Psychiatry

Undiagnosed sleep apnea in patients with essential hypertension

Annals of Internal Medicine

Identifying and treating cognitive impairment in bipolar disorder

Bipolar Disorders

Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure

Circulation

Cognitive functioning and acute sedative effects of risperidone and quetiapine in patients with stable bipolar I disorder: a randomized, double-blind, crossover study

Journal of Clinical Psychiatry

Reduced brain gray matter concentration in patients with obstructive sleep apnea syndrome

Sleep

Sleep apnea syndrome and its complications

Acta Medica Austriaca

Research report
The high prevalence of obstructive sleep apnea among patients with bipolar disorders