There is evidence that individuals with higher depression are more likely to fail to use their CPAP (see e.g. ACK D. EDINGER, SANDRA CARWILE, PATRICIA MILLER, CINDY MAYTI, and VICTOR HOPE (1994) PSYCHOLOGICAL STATUS, SYNDROMATIC MEASURES, AND COMPLIANCE WITH NASAL CPAP THERAPY FOR SLEEP APNEA. Perceptual and Motor Skills: Volume 78, Issue , pp. 1116-1118.

doi: 10.2466/pms.1994.78.3c.1116 and citing studies).

The problem is that this is a cycle. More severe OSA is associated with more severe depression as depression also appears to be a consequence of OSA, which in turn leads to a reduction in the likelihood of engaging with treatment.

This problem is not unique to OSA, however. Depression also predicts poorer uptake or usage of treatments in many other chronic health disorders (see DiMatteo, M. R., et al. (2000). Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101-2107).

Dear Imran Khawaja - an interesting question and relatively poorly studied despite the frequency of depression amongst patients needing CPAP;)

1. Lewis KE, Seale L, Bartle IE, Watkins AJ, Ebden P. Early predictors of CPAP use for the treatment of obstructive sleep apnea. Sleep. 2004 Feb 1; 27(1):134–8. 28. 2. Stepnowsky C, Bardwell WA, Moore PJ, Ancoli-Israel S, Dimsdale JE. Psychologic correlates of compliance with continuous positive airway pressure. Sleep. 2002; 25:758–62.

3. . Wells RD, Freedland KE, Carney RM, Duntley SP, Stepanski EJ. Adherence, reports of benefits, and depression among patients treated with continuous positive airway pressure. Psychosomatic Medicine. 2007; 69:449–54.

4. . Brostom A, Stromberg A, Martensson J, Ulander M, Harder L, Svanborg E. Association of Type D personality to perceived side effects and adherence in CPAP-treated patients with OSAS. J Sleep Research. 2007; 16:439–47.

There is a recent systematic review on the subject of CPAP adherence from the University of Pennsyvania ( attached) which covers the matters Romola has discussed above.

5. Sawyer et al (2011)Sleep Med Rev. 15(6): 343–356.

What should be remembered that although the adherence may be lower in depressed patients, the absolute adherence is still worthwhile (53%) and the effect of CPAP in these patients with depression and OSA is beneficial both for the OSA and their depression, as evidenced by a recent (albeit small ) study from Afyon in Turkey (

6. Fidan et al (2007) Compliance to CPAP treatment and effects of treatment on anxiety and depression in patients with obstructive sleep apnea syndrome

Tuberk Toraks.;55(3):271-7

Hope this helps.

" Few studies have examined depression and mood as influential on CPAP adherence, yet psychological disposition may be an important consideration among adults with CPAP-treated OSA. Although depression and/or low mood at diagnosis/treatment initiation has not been identified as influential on CPAP use, preliminary studies have identified patients’ perceptions of symptoms, including change in symptoms with CPAP treatment, and patients’ perceptions of experiences of side effects, differ among adults with and without depression (and Type D (distressed) personality which may in turn influence CPAP adherence. Improved depressive symptoms on CPAP treatment predicted daytime symptom improvement with CPAP use (r = −0.54, p = 0.0001) while more severe baseline depressive symptoms was not associated with daytime symptom improvement (r = 0.19; p = 0.17). Similarly, Brostrom and colleagues identified adults with OSA and Type D personality (n=72), a combination personality type of negative affectivity and social inhibition, perceived higher frequency and severity of CPAP side effects (p < 0.05–0.001) and demonstrated lower objectively measured CPAP adherence (p< 0.001) than adult OSA participants without Type D personality (n=175). Future research is needed to further describe the influence of mood, depression, and personality type on CPAP adherence and explore such relationships in terms of moderators/mediators that may guide the development of adherence interventions among adult OSA patients with concomitant low mood and/or psychological disorders."

Thank you dr. Khawaja for bringing up this question!

Regarding PAP treatment adherence, previous research clearly shows that both biological, psychological and social factors are contributing. In addition to the recommended llterature from dr Datta and dr Bucks I highly recommend this recently published article:

Sleep Med Rev. 2014 Apr;18(2):123-139. doi: 10.1016/j.smrv.2013.03.002. Epub 2013 May 29.

Integrating psychology and medicine in CPAP adherence - New concepts?

Crawford MR1, Espie CA2, Bartlett DJ3, Grunstein RR3.

Finally: I must oppose the claim from dr. Bucks that more severe OSA is associated with more severe depression. Very few studies of the relation between OSA and depression have been conducted in a general population setting. Although Peppard et al has shown a linear relation in the Wisconsin material, other community-based studies, including my own research indicates that OSA is only a minor, biological contributor to depression compared to other factors. These factors are probably mainly of psychological and social nature.

Accordingly, I really think the study by Crawford et al points out the right direction for optimizing PAP treatment adherence.

It is likely that some causes of depression could be linked to sustained periods of stress experienced by OSA sufferers. Studies have shown elevated levels of serotonin-induced cortisol release caused by OSA are reduced by CPAP therapy Hudgel, D.W et al. (1997). Serotin-induced cortisol release in CPAP-treated obstructive sleep apnea patients. Chest, Mar 1997;111,3.

A more recent publication by Schmoller et al. reinforces the benefits of CPAP in reducing cortisol levels. Schmoller, A. et al. (2007). Continuous positive airway pressure decreases evening cortisol concentrations in patients with severe obstructive sleep apnea. Metabolism Clinical and Experimental, 58, p848-853.

I agree that this is a (very complex) cycle and that there are many factors influencing depression.

Also the "Attitudes Towards CPAP Treatment Inventory (ACTI)" and the "Side Effects of CPAP Inventory (SECI)" are promising tools in order to better understand the patient. However, what we really need to do is to understand how such tools can be used to identify risk populations and then to develop tailored interventions for such sub groups.

Therapy adherence and compliance is a specific depression problem, but not a specific OSAS problem.

Conversely, depression or depressive moods can be reduced by CPAP use in OSAS patients (own results).