Does Depression affect compliance with CPAP therapy in patients with Obstructive Sleep Apnea? Ramesh Metta, MBBS M Jeffery Mador, MD

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1 Does Depression affect compliance with CPAP therapy in patients with Obstructive Sleep Apnea? Ramesh Metta, MBBS M Jeffery Mador, MD

2 Background

3 Obstructive Sleep Apnea(OSA) Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that involves a decrease or complete halt in airflow despite an ongoing effort to breathe 1. Diagnosed by means of Polysomnography (PSG) AHI (Apnea Hypopnea Index) Types Mild: AHI of 5-15 Moderate: AHI of Severe: AHI >30 1. Americal Academy of Sleep Medicine; 2005

4 Anatomy in OSA

5 Treatments Continuous Positive Airway Pressure (CPAP) Oral appliances Surgery Behavioral changes Weight loss Positional Therapy

6 How CPAP works

7 CPAP machine & mask

8 CPAP Compliance Adherence = usage >4 hrs/night for >70% of days used 20-23% non-adherent 1 Effects of CPAP withdrawal 2 Recurrence of OSA Increased sleepiness Increase in morning BP & HR 1. Long-term Use of CPAP Therapy for Sleep Apnea/Hypopnea Syndrome; American Journal of Respiratory and Critical Care Medicine, Vol. 159, No. 4 (1999), pp Nigel McArdle, Graham Devereux, Hassan Heidarnejad, Heather M. Engleman, Thomas W. Mackay, Neil J. Douglas 2. Effects of continuous positive airway pressure therapy withdrawal in patients with obstructive sleep apnea: a randomized controlled trial. Kohler M, Stoewhas AC, Ayers L, Senn O, Bloch KE, Russi EW, Stradling JR. Am J Respir Crit Care Med. 2011;184(10):1192.

9 Compliance measures Smart Card

10 Depression & compliance Poor glycemic control & self-care in Type 2 Diabetic patients with depression 1 Meta-analysis 2 adherence with medical treatment in depression 3 times more likely to be noncompliant with medical treatment Cancer ESRD Rheumatoid Arthritis 1. Depression increases diabetes symptoms by complicating patients self-care adherence. McKellar JD, Humphreys K. Piette JD. Diabetes Educator. 30(3):485-92, 2004 May-Jun 2. Depression is a risk factor for noncompliance with medical treatment-meta-analysis of the effects of anxiety and depression on patient adherence. DiMatteo MR; Lepper HS; Croghan, TW. JAMA. 2000; 160(14):

11 CPAP compliance in PTSD Positive airway pressure adherence in veterans with posttraumatic stress disorder. Sleep 2010 Nov;33(11): Ali El-Sohl, L Ayyar, M Akinnusi, S Relia, Oo Akkinnusi

12 CPAP compliance in PTSD

13 Depression & CPAP? No association between HADS (Hospital Anxiety Depression Score) & machine use Initial problems (after 1 st night of use) predictive of future machine use Early predictors of CPAP use for the treatment of obstructive sleep apnea. Sleep Feb 1;27(1): Lewis KE, Seale L, Bartie IF, Watkins AJ, Ebden P.

14 Study Design

15 Aim To assess the compliance with therapy in a veteran population with Depression compared to matched controls without depression

16 Inclusion Criteria PSG demonstrating obstructive sleep apnea Diagnosis of depression on active medical therapy Follow-up visits from start of therapy Short term - 3 months and/or Long term - 1 year Smart card data at 3 months and/or 1 year visits

17 Exclusion Criteria Absence of baseline PSG History of PTSD, schizophrenia or anxiety Diagnosis of depression not on active medical therapy

18 Study Flow Diagram No. of patients screened (431) Excluded (163) PTSD 61 No PSG 31 Loss to F/u 51 No card data - 20 Cases (134) Controls (134)

19 Outcome Compliance Measures 4 variables measured at visits 1 & 2 Percent days with device usage No. of days when CPAP use recorded total no. of follow-up days Percent days with device usage > 4 hours No. of days >4 h use recorded total no. of follow-up days Average usage all days (in minutes) Total min. of CPAP usage total no. of follow-up days Average usage days used (in minutes) Total min. of CPAP usage total no. of days when CPAP use was recorded

20

21 Methods Sample: All VA patients on treatment for sleep apnea between Case-control retrospective analysis Matched for BMI, AHI & Age at diagnosis

22 Statistical Analysis Unpaired t-test used for continuous variables Fisher s test used for categorical variables p-value <0.02 significant

23 Demographics Characteristics Cases (134) Controls (134) p-value BMI (mean±sd) ± ± AHI (mean±sd) ± ± Age at diagnosis ± ± (mean±sd) ESS (mean±sd) ± ± Gender Male (%) Female (%) 123 (92%) 11 (8%) 128 (96%) 6 (4%) Race Caucasian (%) African-American (%) Others(%) 121 (90%) 11 (8%) 2 (2%) 116 (87%) 17 (12%) 1 (1%)

24 Co morbidities Co-morbidity Cases (134) Controls (134) p-value Smoking 31(23%) 33(24%) 0.88 CAD 40 (30%) 38 (28%) 0.89 CHF 2 (2%) 12 (9%) 0.01 HTN 103 (77%) 101 (76%) 0.88 DM 55 (41%) 64 (48%) 0.32 DYSLIPIDEMIA 109 (81%) 103 (77%) 0.45 CVA 9 (7%) 5 (4%) 0.41 GERD 33 (25%) 36 (27%) 0.78 RHINITIS 20 (15%) 28 (21%) 0.26 SINUSITIS 4 (3%) 5 (4%) 1.00

25 Results Short term (3 months) OUTCOMES Cases (106) Controls (110) Difference of Means p-value % Days device used (mean±sd) ± ± % Days device used > 4hrs (mean±sd) Avg. usage all days (min) (mean±sd) Avg usage days used (min) (mean±sd) ± ± ± ± ± ±

26 Results Long term (1 year) OUTCOMES Cases (92) Controls (88) Difference of Means p-value % Days device used (mean±sd) ± ± % Days device used > 4hrs (mean±sd) ± ± Avg. usage all days (min) (mean±sd) ± ± Avg usage days used (min) (mean±sd) ± ±

27 Conclusion Compliance with CPAP in depressed patients on active medical therapy is similar to that of matched controls without depression

28 Strengths & limitations Exclusion of patients not on active medical therapy Retrospective study Population studied predominantly male & Caucasian Diagnosis of depression based on EMR problem list

29 Acknowledgements Dr. M. Jeffery Mador Dr. Henri T. Woodman Dr. Awais Zaka

30

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