The Correlation Between Sleep-Disordered Breathing and Psychiatry

With increasing knowledge about sleep and its disorders and widespread use of diagnostic testing for sleep, more patients with sleep-disordered breathing (SDB) are being identified. Various comorbid medical, neurological, and psychiatric disorders are more prevalent in patients with clinically significant SDB. This article explores the relationship between SDB and psychiatric disorders and its implication for practicing psychiatrists. CASE VIGNETTE Alex is a 58-year-old married, certified public accountant who snores loudly and has frequent nocturnal awakenings, sometimes with gasping or choking. He generally goes to bed at midnight and wakes up at 6:30 am. On weekends, he usually sleeps 1 or 2 hours longer and sometimes takes a 1-hour nap. He gained 12 lb in the past year but is not obese (his BMI is 28.5). He reports increasing back pain, fatigue, irritability, and cognitive problems. He occasionally feels anxious and moody, especially when his aches and pains are exacerbated. Six months ago, nocturia developed, but prostate-specific antigen (PSA) test results were normal. At that time, he also began having morning dry mouth, morning headaches, sadness, tiredness, and generally depressed mood. Treatment with an SSRI was initiated; he also had a brief trial with methylphenidate. He was referred for polysomnography, which revealed severe obstructive sleep apnea with significant oxyhemoglobin desaturations occurring during REM sleep. There were also some central-type SDB events. The patient was treated with bilevel positive airway pressure, with good effect. This case illustrates a fairly common story. When a middle-aged man becomes less active, works at a sedentary job, gains weight, and begins to snore, chances are that he has or is developing SDB. Job demands and family responsibilities promote sleep schedule restriction, often prompting increased caffeine intake. Nonetheless, sleepiness, tiredness, and fatigue almost invariably follow. Obvious signs include fatigue, attention problems, less effective coping, and depressed mood. A patient may recognize cognitive dulling, as in this case. Less obvious symptoms include nocturia, morning headache, and difficult to control pain. Our