Do you snore loudly at night? Are you overweight or obese? Do you get 8 hours of sleep at night but feel sluggish the next day? Do you walk around feeling like your brain is “foggy” much of the time? You may have sleep apnea and you may be surprised of the negative effect of sleep apnea on depression and mood. On top sleep apnea do you have any history of depression or bipolar disorder? The effect of sleep apnea on depression and mood can be drastic and this blog posts reviews what sleep apnea is, what causes it, effects it has on psychiatric symptoms, drugs that can worsen it and treatments to fix it.
Obstructive sleep apnea (referred to as OSA) is a sleep disorder where the muscles and tissues both inside your airway and surrounding your airway collapse around your airway, usually at night time when laying down, to produce periods of inability to get oxygen to your lungs and ultimately depriving your brain of oxygen. Not getting oxygen to the brain clearly cause worsening of depression and mood. Several causes of OSA include obesity, anatomy of neck and airways tissue (large tonsils, significant overbite, short neck and large palate or tongue.) When someone lays down, gravity forces the tissues around the airway to put force on the airway and when you sleep, muscles normally responsible for holding the airway open, relax and ultimately collapse, thus shutting off oxygen’s pathway to your lungs.
So what happens if you do not get oxygen to your lungs? That means your brain is often deprived of oxygen throughout the night. An example of what can happen is illustrated by looking at a situation now with a patient I am taking care of. This patient is obese, has anatomy around her neck conducive to OSA and also has severe bipolar disorder. Despite being relatively stable on mood stabilizing medications which has prevented her from being in a hospital for over a decade, she has almost constant hypomanic (mildly manic) symptoms on a daily basis. She is always tired during the day and ends up napping which makes her sleep at night even more disruptive given the drive to sleep is worse if you nap.
She is also on medications that worsen sleep apnea-some medications that are not advised are benzodiazepines given they are potent muscle relaxants and cause the surrounding airway muscle to collapse even more easily. Examples include valium, ativan and klonopin.
Alcohol is also terrible for sleep apnea as it has potent muscle relaxant effects and for the same reason as benzodiazepines can worsen airway collapse.
Without adequate oxygen to your brain, the ability of psychiatric medications, exercise and healthy living to improve depression or bipolar disorder is decreased and thus many patients present as “treatment resistant” when in reality they are resistant only due to a co-morbid sleep apnea disorder that has gone unrecognized.
Losing weight is the single best option someone can do on their own to combat sleep apnea but it is often not enough on its own. First line therapy is Positive airway pressure therapy (CPAP or Bi-pap) where a mask is placed over your mouth, nose or both to “force” oxygen down the airway at a high enough pressure to keep the airway open despite the collapse of surrounding tissues. The problem with wearing this contraption is compliance as people find it sometimes loud or uncomfortable. There are also second line (less effective) treatments that are more comfortable such as proper dental devices that can be created by a dentist specializing in sleep dentistry. Last, there is a surgical option which not many trained sleep doctors recommended given the risks of the surgery.
So in conclusion, if you struggle with almost any psychiatric disorder, especially depression or bipolar disorder, and you find despite treatment you still do not feel well, then always consider an underlying medical disorder that may be contributing to the treatment resistance. In this example the effect of sleep apnea on depression and mood should be considered. They can perform a sleep study where you sleep overnight in a sleep lab, get monitored and diagnosed with the severity of sleep apnea and this dictates appropriate treatment.
If you take benzodiazepines such as A (lorazepam), Valium or Klonopin; or if you drink alcohol, be aware these significantly worsen the condition and therefore worsen the depression and bipolar disorder in most cases. Talk with your doctor on potentially tapering off of these detrimental substances in a controlled taper under their supervision.
You may find this will make you feel better than you ever have before and it is something often not mentioned by treating psychiatrists.
Michael Yasinski M.D