Effect of Treatment of Obstructive Sleep Apnea on Depressive Symptoms: Systematic Review and Meta-Analysis
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BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms. METHODS AND FINDINGS: We performed a systematic review and meta-analysis of randomized controlled trials that examined the effect of CPAP or MADs on depressive symptoms in patients with OSA. We searched Medline, EMBASE, the Cochrane Central Registry of Controlled Trials, and PsycINFO from the inception of the databases until August 15, 2014, for relevant articles. In a random effects meta-analysis of 19 identified trials, CPAP treatment resulted in an improvement in depressive symptoms compared to control, but with significant heterogeneity between trials (Q statistic, p<0.001; I(2) = 71.3%, 95% CI: 54%, 82%). CPAP treatment resulted in significantly greater improvement in depressive symptoms in the two trials with a higher burden of depression at baseline (meta-regression, p<0.001). The pooled standardized mean difference (SMD) in depressive symptoms with CPAP treatment in these two trial populations with baseline depression was 2.004 (95% CI: 1.387, 2.621), compared to 0.197 (95% CI: 0.059, 0.334) for 15 trials of populations without depression at baseline. Pooled estimates of the treatment effect of CPAP were greater in parallel arm trials than in crossover trials (meta-regression, p = 0.076). Random effects meta-analysis of five trials of MADs showed a significant improvement in depressive symptoms with MADs versus controls: SMD = 0.214 (95% CI: 0.026, 0.401) without significant heterogeneity (I(2) = 0%, 95% CI: 0%, 79%). Studies were limited by the use of depressive symptom scales that have not been validated specifically in people with OSA. CONCLUSIONS: CPAP and MADs may be useful components of treatment of depressive symptoms in individuals with OSA and depression. The efficacy of CPAP and MADs compared to standard therapies for depression is unknown. Please see later in the article for the Editors' Summary.
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A meta-analysis of 22 RCTs reported that therapy of OSA resulted in a dose-dependent improvement in depressive symptomatology using recognised depression scales.
“A meta‐analysis of 22 RCTs reported that therapy of OSA resulted in a dose‐dependent improvement in depressive symptomatology using recognised depression scales (Povitz et al., 2014).”
From Obstructive sleep apnea: transition from pathophysiology to an integrative disease model (2022) · cites this paper as Povitz et al., 2014
The Discussion reports a meta-analysis of 22 RCTs and modest improvements in depressive symptoms with OSA treatment; the Methods specify validated depression questionnaires. The claimed dose-dependent improvement is not supported. In Results, Table 4 shows no significant difference by CPAP adherence (p=0.213), and the higher-adherence group had a smaller estimated effect. (LLM, conf=0.90)
Experimental — accuracy not yet measuredSleep therapies have even larger effects on depression in those with mental illness compared to subclinical depressive symptoms.
“Of note, whereas many trials have shown the alleviation of subclinical depressive symptoms following sleep interventions, the available evidence suggests that even larger effects of sleep therapies on depression are observed in those with mental illness 79-81,94 .”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [80]
The Results (Efficacy of CPAP for Depression) report a significantly larger CPAP effect in populations whose average baseline scores exceeded a depression-scale cutoff than in populations below it. The Discussion says the trials measured symptoms with questionnaires rather than diagnostic interviews, so this does not establish a larger effect in people diagnosed with mental illness or for sleep therapies generally. (LLM, conf=0.86)
Experimental — accuracy not yet measuredContinuous positive airway pressure produces large, significant reductions in depressive symptoms in people with depression and comorbid obstructive sleep apnoea (SMD=2.00, 95% CI 1.39-2.62).
“Large, significant reductions in depressive symptoms were also found from continuous positive airway pressure in people with depression and comorbid obstructive sleep apnoea (NIH=6, SMD=2.00, 95% CI: 1.39-2.62, I²=12%) 80”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [80]
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- Authors
- Povitz, M., Bolo, C. E., Heitman, S. J., Tsai, W. H., Wang, J., & James, M. T.
- Affiliations
- Western University (CA)
- University of Calgary (CA)
- Corresponding author
- James, Matthew T.
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-11-25
- Volume
- 11
- Issue
- 11
- Pages
- e1001762
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC4244041
- OpenAlex
- W2096306751
- Cited by
- 147
- References
- 67
- Citations by year
- 2026: 8 · 2025: 7 · 2024: 14 · 2023: 10 · 2022: 14 · 2021: 15 · 2020: 13 · 2019: 10 · 2018: 17 · 2017: 12 · 2016: 15 · 2015: 10 · 2014: 1 · 2013: 1
- FWCI
- 1.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
- Keywords
- obstructive sleep apnea, depressive symptoms, depression, continuous positive airway pressure, mandibular advancement device, sleep apnea treatment, quality of life, quality of life interventions, sleep-disordered breathing, sleep apnea comorbidity
- MeSH terms
- Depression, Humans, Quality of Life, Mandibular Advancement, Sleep Apnea, Obstructive, Continuous Positive Airway Pressure
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