Yeni Symposium / Eylül 2015 / Cilt: 53, Sayı: 3
YENİ SYMPOSIUM
57
ABSTRACTTreatment resistance is an important issue in patients with de-pressive disorder and nearly a third of patients may not reach remission despite multiple drug trials. Obstructive sleep apnea syndrome (OSAS) is a common sleep disorder in which daytime sleepiness, sleep disturbance, fatigue, decreased quality of life, memory problems, irritability are frequently observed. Polysom-nography is required to confirm the diagnosis of OSAS We aim to present a case with treatment resistant depressive symptoms. In his detailed assessment we observed that his complaints were related to OSAS and he was successfully treated with bi-level pos-itive airway pressure (BPAP). Particular attention shoul be paid to OSAS symptoms in patients with treatment resistant depression.
Key words: Treatment resistant depression, sleep apnea,
treat-ment
ÖZET
Tedaviye dirençli depresyon ve uyku apne sendromu: Bir vaka sunumu
Tedaviye direnç, depresif bozukluk hastalarında önemli bir konudur ve bu olguların yaklaşık üçte biri çoklu ilaç tedavilerine rağmen remisyona ulaşamazlar. Tıkayıcı uyku apnesi sendromu günboyu uykululuk, uyku rahatsızlığı, ağrı, azalmış yaşam kalitesi, hafıza problemleri ve irritabilitenin sıklıkla gözlendiği yaygın bir uyku bozukluğudur. Tıkayıcı uyku apnesi sendromu tanısı poli-somnografi sonucu ile doğrulanır. Bu yazıda tedaviye dirençli de-presif semptomları olan bir olguyu sunmayı amaçlıyoruz. Olguyu detaylı incelediğimizde tıkayıcı uyku apne sendromu ile ilişkili belirtiler gösterdiğini gözlemledik ve olgu BPAP (bi-level positive airway pressure) tedavisi ile başarılı bir şekilde tedavi edildi. Te-daviye dirençli depresyon olgularında tıkayıcı uyku apnesi sen-dromunun akılda tutulmasının önemli olduğunu vurgulamak istiyoruz.
Anahtar sözcükler: Tedaviye dirençli depresyon, uyku apne,
te-davi
Treatment Resistant Depression and Sleep Apnea: A Case
Report
Esra Aydın Sünbül1, Hayal Ergin Toktaş2, Hüseyin Güleç1, Füsun Mayda Domaç2, Ömer Yanartaş3 1Specialist, Erenkoy Mental Health and Training Hospital, Psychiatry Department, Istanbul 2Specialist, Erenkoy Mental Health and Training Hospital, Neurology Department, Istanbul
3Specialist, Marmara University, Pendik Hospital, Psychiatry Department, Istanbul
Corresponding Author: Ömer Yanartaş, Marmara University, Pendik Hospital, Psychiatry Department, Istanbul E-mail: omeryanartas@yahoo.com - Phone: 0216 421 22 22 - Fax: 0216 414 47 31
Date of receipt: 22 July 2015 - Date of acceptance: 11 October 2015
Yeni Symposium / Eylül 2015 / Cilt: 53, Sayı: 3
YENİ SYMPOSIUM
58
INTRODUCTION
Major depression is a common psychiatric condition which affects many people all over the world 1.
Al-though it is quite commonly observed, nearly a third of patients may not reach remission with multiple drug trials 2. However the underlying causes of this
inade-quate treatment response have not been clarified yet. Obstructive sleep apnea syndrome (OSAS) is a com-mon sleep disorder defined by frequent episodes of obstructed breathing during sleep, which is character-ized by sleep-related decreases (hypopneas) or pauses (apneas) in respiration. An episodic interruption of ven-tilation for 10 seconds or more is defined as obstruc-tive apnea. Day time sleepiness, sleep disturbance, fa-tigue, irritability, memory problems, decreased quality of life are among the common psychiatric symptoms of OSAS.
The diagnosis of OSAS is confirmed when a polysomnog-raphy recording determines an Apnea-hypopnea-index (AHI) of >5 per hour of sleep 3. AHI scores is correlated
to severity of OSAS, such as; 5-15 mild, 15-30 moderate and >30 severe OSAS. Positive airway pressure (PAP) is the approved choice of treatment for OSAS.
Here, we present a case that has been followed by our outpatient clinic for three years due to treatment re-sistant depressive symptoms. He was referred to sleep medicine unit because of falling asleep during daytime and pseudoseizures.
CASE
The patient was a 50 year old man. He reported that he had depressive symptoms such as; anhedonia, lack of sexual drive and depressive mood, felt asleep during the day and muscle contraction during night time for nearly three years. He was diagnosed with as depres-sive disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). His Beck De-pression Inventory (BDI) score was 24. He was treated with various antidepressant drugs such as selective se-rotonin reuptake inhibitors, sese-rotonin and noradrena-lin reuptake inhibitors for sufficient dose and time. But his depressive symptoms did not decrease substan-tially. Feeling of contraction symptom was evaluated by the electroencephalography (EEG) whether it was due to epilepsy or not and cranial MRI was performed. There were not any pathological findings in EEG and MRI.
Finally, he was referred to sleep disorders outpatient clinic for falling asleep and contractions. He
com-plained about snoring and using of toilet nearly 5 times per night. His Epworth Sleep Scale (ESS) was 24. In the first night a standard PSG montage was used including video electroencephalography (EEG; F3, F4, Fz,C3, C4, Cz, P3, P4, Pz, O1, and O2), electromyography (EMG; electrodes on chin), electrocardiography (ECG; elec-trode on heart) and electro-oculography (EOG; one electrode on the supraorbital ridge of the right eye and another on the infraorbital ridge of the left eye) record-ings. Leg EMG (electrodes on tibialis) and breathing de-vices were used to detect breathing disorders and limb movements. The PSG result was consistent with severe OSAS (total AHI index: 32,5, supine AHI:193, non supine AHI index:24, AHI REM index:5,4, AHI NREM index:36,8) and bruxism. One week later he was admitted for PAP titration. CPAP titration was applied first. Because of central apneas, BPAP ST mode was applied at 14/10 cm H2O. Since his initial depressive symptoms such as anhedonia and feeling of worthlessness were partly improved with duloxetine he continued this agent and klonazepam was prescribed for bruxism. After a month of treatment with BPAP, patient’s complaints about de-pressive symptoms, feeling asleep and snoring were disappeared and BDI score decreased from 24 to 15.
DISCUSSION
Patients with OSAS have a high rate of psychiatric co-morbidity, anxiety disorders and depression are es-pecially common 4. In this case snoring and day time
sleepiness due to OSAS may be associated with treat-ment resistant depression. The relationship between affective disturbances and sleep apnea may be bidirec-tional.5 Hypoxemia and sleep fragmentation may
pro-voke depressive symptoms6 and also depressive mood
may trigger sleep apnea.7 Some researchers believe
that the psychological impairment can be reversed af-ter appropriate treatment,8 while some of them have
found that these impairments might persist after treat-ment.9 Yue evaluated the relation between OSAS and
psychological symptoms and found that scores of SCL-90 subitems such as; General severity index (GSI), so-matization, obsession-compulsion, depression, anxiety and hostility, were higher in OSAS patients than healthy controls.10
The severity of psychological symptoms in OSAS pa-tients was inversely correlated with total sleep time, percentage of stage 1 NREM sleep and latency of NREM sleep. Reynolds et al. stated that, in contrast to the sleep EEG of depressed patients which characteristical-ly shows a shorter latency of REM sleep, sleep apnea patients with depression displayed an increase in REM
Yeni Symposium / Eylül 2015 / Cilt: 53, Sayı: 3
YENİ SYMPOSIUM
59
latency. In our patient, sleep efficiency was sleep laten-cy, and REM latency measured at first night PSG were within normal limits.
In this case report, we aim to present a case with treat-ment resistant depression and comorbid OSAS and its treatment with BPAP. According to our observation clinicians should investigate sleep disorders particu-larly in patients with treatment resistant depression. Excessive daytime sleepiness, loud snoring, observed episodes of breathing cessation during sleep, abrupt awakenings accompanied by shortness of breath, awa-kening with a dry mouth or sore throat, awaawa-kening with chest pain, morning headache, difficulty concentrating during the day are alerting symptoms of obstructive sleep apnea.11
REFERENCES:
1) Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results for the National Comorbidity Survey Replication (NCS-R). JAMA 2003; 18: 3095-3105.
2) Rush AJ. Star-D: lessons learned and future implications. De-press Anxiety 2011; 28: 521-524.
3) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical
research. The Report of the American Academy of Sleep Medicine Task Force. Sleep 1999; 22: 667-689.
4) Saunamäki T, Jehkonen M. Depression and anxiety in obstruc-tive sleep apnea syndrome: a review. Acta Neurol Scand 2007; 116: 277-288.
5) Velasco-Rey MC, Sánchez-Muñoz M, Gutiérrez-López MI, Trujil-lo-Borrego A, Sánchez-Bonome L. Psychotic depression induced by Obstructive Sleep Apnea Syndrome (OSAS): a case report-ed. Actas Esp Psiquiatr 2012; 40: 43-45.
6) Pochat MD, Ferber C, Lemoine P. Depressive symptomatology and sleep apnea syndrome. Encephale 1993; 19: 601-607. 7) Baran AS, Richert AC. Obstructive sleep apnea and depression. CNS Spectrum 2003; 8: 120-134.
8) Henke KG, Grady JJ, Kuna ST. Effect of nasal continuous pos-itive airway pressure on neuropsychological function in sleep apnea-hypopnea syndrome. A randomized, placebo- controlled trial. Am J Respir Crit Care Med 2001; 163: 911-917.
9) Munoz 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.
10) Yue W. A case-control study on psychological symptoms in sleep apnea-hypopnea syndrome. Can J Psychiatry 2003; 48: 318-323.
11) Reynolds CF, Kupfer DJ, McEachran AB, Taska LS, Sewitch DE, Coble PA. Depressive psychopathology in male sleep apneics. J Clin Psychiatry 1984; 45: 287- 290.
