OSA Treatment Outcomes Highlight Impact of Interdisciplinary Care
Can surgical treatment be as effective as continuous positive airway pressure (CPAP) in improving depression linked to obstructive sleep apnea (OSA)? In this expert Q&A, Mohamed A. Abdelwahab, MD, PhD, Medical University of South Carolina, Charleston, discusses his recent meta-analysis, “Depressive symptoms after surgical and medical management of OSA: a systematic review and meta-analysis,” comparing the mental health impacts of CPAP and surgical interventions, with key findings on depression, sleep quality, and treatment compliance.
Gain practical insights into how these findings can refine interdisciplinary treatment decisions and patient care.
Editors' note: This interview has been lightly edited for clarity.
Pulmonology Learning Network (PLN): Could you give us a brief overview of the study subject, design, and most significant findings?
Mohamed Abdelwahab, MD, PhD: Our study is a systematic review and meta-analysis examining how both CPAP and surgical interventions for OSA impact depressive symptoms. We reviewed 2018 abstracts and included 14 studies totaling 3,488 patients. We evaluated the following 3 outcomes: Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), and Beck Depression Inventory-II (BDI-II) scores pre- and post-treatment.
Both CPAP and surgical interventions led to significant reductions in AHI, daytime sleepiness, and depressive symptoms. Notably, we found no significant difference between the 2 treatments in terms of depression improvement, suggesting that surgical interventions are non-inferior to CPAP in addressing OSA-associated depressive symptoms.
PLN: How do the findings of your study compare with previous research on the relationship between OSA treatment and mental health outcomes? Were there any unexpected findings?
Dr Abdelwahab: Prior research largely focused on CPAP’s positive effect on mood symptoms, but there was limited consensus regarding the impact of surgical interventions. Our study stands out by comparing CPAP with surgical options using standardized depression measures (ie, Beck Depression Inventory-II [BDI-II]). We confirmed that both modalities yield significant improvements in depressive symptoms, with surgical interventions showing comparable outcomes to CPAP.
An unexpected but interesting finding was the higher percentage reduction in BDI-II scores in the surgical group, though this did not reach statistical significance. This raises interesting questions about the role of compliance and the long-term benefits of surgery, especially in CPAP-intolerant patients.
PLN: What are the potential biological and neurological mechanisms that explain the improvement in depressive symptoms following OSA treatment?
Dr Abdelwahab: Several mechanisms likely contribute to the improvement in depressive symptoms. OSA disrupts sleep architecture and induces intermittent hypoxia, leading to neurochemical imbalances, systemic inflammation, and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, all of which are linked to mood disorders.
Treatment with CPAP or surgery restores normal airflow, reduces hypoxic episodes, and improves sleep quality, which collectively help stabilize neurotransmitter function (eg, serotonin and dopamine) and decrease inflammatory markers. This neurophysiological change is believed to underlie the observed improvements in depressive symptoms.
PLN: Given that depression itself can contribute to fatigue and poor motivation, how can neurologists distinguish between residual symptoms of OSA versus persistent depression when evaluating patient outcomes post-treatment?
Dr Abdelwahab: Differentiating between residual OSA symptoms and persistent depression requires a multifaceted approach. Objective data, such as repeat polysomnography and CPAP adherence monitoring, are crucial to confirm OSA resolution. In parallel, validated depression scales like the BDI-II can help quantify mood symptoms. If sleep parameters normalize but depressive symptoms persist, it may suggest a primary mood disorder rather than residual OSA effects.
Neurologists play a key role by combining objective sleep data, such as polysomnography and CPAP adherence, with cognitive and mood assessments. Persistent depressive symptoms despite normalized sleep studies may suggest a primary mood disorder.
Neurologists can also evaluate neurocognitive function, often impacted in OSA, to see if deficits resolve post-treatment. Close coordination with psychiatrists and other sleep specialists, along with longitudinal follow-up, helps ensure both sleep-related and psychiatric symptoms are appropriately addressed. Additionally, persistent depressive symptoms despite CPAP use may require discussing compliance and consideration of surgical alternatives.
PLN: How might these findings influence the clinical decision-making process when neurologists collaborate with sleep specialists, psychiatrists, and ENT surgeons in managing OSA-related depressive symptoms?
Dr Abdelwahab: Our findings highlight the importance of a multidisciplinary, patient-centered approach. Given that both CPAP and surgical interventions provide comparable improvements in mood, treatment decisions should incorporate patient preferences, OSA severity, and adherence potential. For patients struggling with CPAP adherence, surgery presents a viable alternative with significant mental health benefits.
Neurologists, sleep specialists, ENT surgeons, and psychiatrists should work closely to screen for depression in OSA patients and tailor management plans to optimize both physiological and psychological outcomes.
Mohamed A. Abdelwahab, MD, PhD, is an otolaryngology-head and neck surgeon, who specializes in treatment of obstructive sleep apnea (OSA) and has an interest in surgical treatments for OSA and non-CPAP compliant patients. He completed his clinical training at Stanford University in California as a fellow and a clinical instructor. He graduated from the Stanford sleep surgery fellowship program after dual clinical training in maxillofacial surgery and otolaryngology. He also completed a scholarship at Stanford Facial Plastic and Reconstructive Surgery for 3 years through a joint supervision PhD program. As a surgeon scientist, he has focused his research on understanding patients’ perception and needs through multiple studies on patient outcome measures. He is a member of The American Academy of Otolaryngology-Head and Neck Surgery and International Sleep Surgery Society.
