Association between sleep-related breathing disorder and depression in young adults and aged population-A survey

Srinisha M1, Karthik Ganesh Mohanraj*2, Hemavathy Muralidoss3 1Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600 077, Tamilnadu, India 2Department of Anatomy, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600077, Tamilnadu, India 3Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University Chennai – 600077, Tamilnadu, India


INTRODUCTION
Sleep is de ined as a naturally occurring state of the body within inhibited sensory activity, reduced metabolic rate and decreased interaction with the surrounding (Jochebed and Priya, 2015). Sleep is an important aspect for a successful academic and economically prosperous career. Sleep disorders can be described as the disruption of the quality or quantity of sleep due to certain disturbances and habits (Aravinth et al., 2018).
Sleep related breathing disorders refers to abnormal respiration during sleep. Sleep related breathing disorders result in improper sleep during night which results in depression. There was much research done on the effects of depression in accidents (Chung and Park, 2011). Improper sleep during night and driving to work in morning may lead to various accidents. Orthopnea and paroxysmal nocturnal dyspnea are some and most important sleep related breathing problems.
Orthopnea refers to shortness of breath while lying down. PND awakens the person from sleep due to reverse shortness of breath and is quite frightening. OSA refers to recurrent episodes of partial or complete closure of the upper airway resulting in disturbed breathing while sleeping. This clearly shows OSA results in decreased quality of life. The presence of risk factors such as age, gender and obesity increases the incidence of OSA (Viswanath et al., 2015).
Untreated obstructive sleep apnea leads to various complications. The complications include stroke, coronary artery disease and atrial ibrillation. Many researchers have done research about association between sleep related breathing problems and depression. According to the study, out of 182 patients, 47 suffered from depression with a mean age signi icantly more than that of the other population and out of 47 depressed patients, 44 had abnormal PSG (a type of sleep study) (Shoib et al., 2017).
Obstructive sleep apnea (OSA) is characterized by repeated airway collapse during sleep (Bowsiya and Kumar, 2020). Nocturnal attended polysomnography is the standard diagnostic modality in determining if a patient has OSA (Padma et al., 2007). The severity of the OSA can also be assessed using apnea-hypopnea index and respiratory distress index (Sunitha and Aravindkumar, 2009). A proper diet and physical activity is very essential for the prevention of many chronic diseases (Uma et al., 2018). Exercise has been proven to improve sleep and helps to overcome depression.
Depression is a serious, chronic disease that can be managed with the chronic care model in primary care settings (Munuswamy et al., 2018). Dental students showed considerable stress symptoms and also showed higher levels of depression (Soh et al., 2017). Most of the physicians would encourage staying physically active to ight disease and doing a physical activity which acts as a stress reliever (Shahroom et al., 2019). Yoga elevates brain neurotransmitter levels like gamma-aminobutyric acid that may help to treat depression and anxiety (Varshini et al., 2018).
OSA is associated with an increased likelihood of hypertension, cardiovascular disease, and dimin-ished quality of life. Hence, it becomes a prime concern for health-care personnel to diagnose it at earliest. Alcohol, sedatives and tranquilizers may also promote sleep apnea by relaxing throat muscles (Gokul, 2016). Sleep deprivation leads to slower brain waves, shortened attention span, higher anxiety, impaired memory, and a bad mood (Ranasinghe et al., 2018). Too little sleep can lead to an increase in body weight by changing levels of the hormones that control satiety and hunger, resulting in overeating, overweight, and obesity (Labh et al., 2018). Previously our team has conducted numerous original studies (Keerthana and Thenmozhi, 2016;Choudhari and Thenmozhi, 2016;Sriram et al., 2015;Thejeswar and Thenmozhi, 2015) and lab animal studies (Seppan et al., 2018) over the past 5 years (Nandhini et al., 2018;Krishna and Babu, 2016;Subashri and Thenmozhi, 2016;Samuel and Thenmozhi, 2015;Hafeez and Thenmozhi, 2016). Now we are focussing on epidemiological surveys. The idea for this survey stemmed from the current interest in our community (Johnson et al., 2020;Sekar et al., 2019;Pratha and Thenmozhi, 2016;Menon and Thenmozhi, 2016;Kannan and Thenmozhi, 2016).
The aim of the study is to create awareness about depression caused by improper sleep due to breathing disorder. It also aims in creating awareness about the necessity of treatment of obstructive sleep apnea.

Study setting
This is an online survey based study, conducted among the Chennai population.
A Questionnaire was prepared and distributed among people through an online link from the survey planet. This study was approved by the International Review Board.

Sampling
The sample size was 100 people. Sampling method used was simple random sampling. In order to minimise bias randomisation ( i.e all variables were included) was done. Internal validity was the pre tested questionnaire. External validity was homogenisation, replication of experiment and cross veri ication with existing studies.

Data collection
The questionnaire contained 20 questions. Independent variables were demographics such as age, gender. Dependent variables were sleep related breathing problems and depression. The collected results were entered in Microsoft excel.

Data analysis
Data analysis was done using SPSS software. Statistics used for analysis was Descriptive statistics. The Statistical test used for comparison between age and other variables was chi-square test, P<0.05 statistically signi icant. Graphs were drawn according to the results obtained.

RESULTS AND DISCUSSION
From this online based survey, it was found that 97% people were aware of OSA and 99% of people were aware that untreated OSA could lead to many complications. Individuals with obstructive sleep-disordered breathing (OSDB) commonly report symptoms of depression (Deldin et al., 2006). It is very necessary to study about sleep related breathing problems and depression. About 59% male and 48% females participated in the survey (Figure 1). Age groups participated in the 66% of the people experience breathing dif iculties and 8% do not experience any breathing dificulties ( Figure 3). According to a study, 22.7% of men, 15.4% of women had breathing dif iculties at least one night per week (Wheaton et al., 2005). About 99% of people are aware that sleep deprivation leads to depression (Figure 4). Similar evi- dence is seen in a study, where the prevalence of depression is higher among those diagnosed of sleep apnea (Wheaton et al., 2005).
74% people have taken antidepressants and 26% people have not taken antidepressants ( Figure 5). Similar evidence is seen in a study Hansen (Gartlehner et al., 2011). 98% are aware that poor sleep leads to accidents and an increased mortality rate (Figure 6). In a similar study, Figure 21: Bar graph depicts the comparison of age and awareness of obstructive sleep apnea increased risk of traf ic accidents were higher due to poor quality of sleep (Philip et al., 2014). 58% of people have sleep problems and 39% of people rarely have sleep problems (Figure 7). According to a study by Robert Adams, inadequate sleep is more common in Australian adults affecting about 33-45% of adults . About 95% people are aware that depressed individuals are affected by breathing related sleep disorders (Figure 8).
About 97% of people are aware of OSA (Figure 9). According to a study by a national OSAKA survey, anaesthetists show de icits in knowledge about OSA (Corso et al., 2017). 87% of people are aware that obesity, being older, being male are risk factors of OSA ( Figure 10). About 57% felt sad or frustrated rarely which are the signs of depression ( Figure 11). 94% of people are aware that sleeping pills result in depression ( Figure 12). According to a study, incidence of depression is 2% among participants taking hypnotics (Kripke, 2016).
98% of people are aware that alcoholism makes depression and sleep apnea worse ( Figure 13). According to a study, prevalence of depression before detoxi ication from alcoholism was 63.8% (Kuria et al., 2012). About 93% people are aware that symptoms of OSA are attention problems, loud snoring and excessive tiredness ( Figure 14).
99% of people agree that untreated OSA leads to many complications ( Figure 15). According to a study, comparison between treated OSA and untreated OSA was done and they found that untreated OSA leads to cardiopulmonary complications (Abdelsattar et al., 2015). 96% of people agree to the fact that exercise treats sleep apnea and depression ( Figure 16). A similar evidence is seen in a study done by Franz SI, according to whom moderate intensity exercise leads to happier mood and is bene icial for overcoming depression (Craft and Perna, 2004).
69% of people agree that old aged people are more prone to depression and OSA ( Figure 17). Similar evidence is seen in a study by Duckworth et al. (2005). About 99% of people are aware that untreated OSA leads to brain damage ( Figure 18).
The limitation of this study was limited sample size. Other research in similar topics were done in larger sample sizes, for example 788 men aged 40 to 88 years were assessed for sleep apnea and depression .
In Figure 19, blue colour depicts the participants who agree that exercise as a way to manage sleep apnea and depression and green colour depicts the participants who disagree that exercise as a way to manage sleep apnea and depression. X-axis denotes age and Y-axis denotes the frequency distribution for the response of the question 'Do you know exercise helps in sleep apnea as well as depression'. 59.0% participants aged 25-45 years accept exercise as a way to manage sleep apnea and depression. Using Chi-Square analysis, p=0.118, statistically not signi icant (p<0.05 considered statistically signi icant). In Figure 20, blue colour depicts the participants who have taken antidepressants and green colour depicts the participants who have not taken antidepressants. X-axis denotes age and Y-axis denotes the frequency distribution for the response of the question 'Have you ever taken antidepressants'. 51.0% participants aged 25-45 years have taken antidepressants. Using Chi-Square analysis, p=0.039, statistically signi icant (p<0.05 considered statistically signi icant). In Figure 21, blue colour depicts the participants who were aware of obstructive sleep apnea and green colour depicts the participants who were not aware of obstructive sleep apnea. X-axis denotes age and Y-axis denotes the frequency distribution for the response of the question 'Are you aware of obstructive sleep apnea'. 60.0% participants aged 25-45 years have taken antidepressants. Using Chi-Square analysis, p=0.178, statistically not signi icant (p<0.05 considered statistically signi icant).

CONCLUSION
This survey aims in creating awareness among people about sleep related breathing disorder and depression in young adults and aged population. The future scope of this study is to help in diagnosis of sleep related breathing problems and depression.