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Comorbid Insomnia and Depression among Patients with Sleep Apnea: a cross-sectional clinical study and a longitudinal database study
Other Title
Comorbid Insomnia and Depression among Patients with Sleep Apnea: a cross-sectional clinical study and a longitudinal database study
Type
thesis
Date Issued
2025-06-27
Author(s)
Tran Van Hoc
Advisor
李信謙
Subjects
系所名稱：國際醫學研究博士學位學程
Publisher
國際醫學研究博士學位學程
Description
學位別：博士
口試委員：楊建銘; 李佩玲; 劉文德; 葉篤學; 李信謙
關鍵字：OSA、COMISA、insomnia、depression、sleep architecture、major adverse cardiovascular event
口試委員：楊建銘; 李佩玲; 劉文德; 葉篤學; 李信謙
關鍵字：OSA、COMISA、insomnia、depression、sleep architecture、major adverse cardiovascular event
Abstract
Title of Dissertation: Comorbid Insomnia and Depression among Patients with Sleep Apnea: a cross-sectional clinical study and a longitudinal database study
Institution: International PhD Program in Medicine, College of Medicine
Author: Tran Van Hoc
Dissertation Advisor: Associate Professor Hsin-Chien Lee, MD, MPH
INTRODUCTION Obstructive sleep apnea (OSA) and insomnia frequently coexist, complicating diagnosis and treatment. The overlap of these conditions, known as COMISA, has been associated with distinct clinical features, yet data on Asian populations remain limited. Patients with COMISA exhibited more severe symptoms of depression, anxiety, and stress compared to those with insomnia or sleep apnea alone. Additionally, depression is increasingly recognized as a key comorbidity in OSA, contributing to an elevated risk of major adverse cardiovascular events (MACE). This study aims to (1) characterize the clinical and polysomnographic differences between OSA and COMISA in an Asian cohort and (2) assess the prognostic impact of depression on cardiovascular outcomes in OSA patients.
METHODS This doctoral thesis includes 1) a prospective cross-sectional analysis, and 2) a longitudinal cohort investigation. The cross-sectional study enrolled patients from a sleep center between June 2022 and November 2022 who underwent polysomnography (PSG) and completed self-reported questionnaires and mood assessments. OSA was diagnosed based on an Apnea-Hypopnea Index (AHI) ≥ 5 events/hour, while COMISA was identified in patients reporting persistent sleep dissatisfaction. The longitudinal study utilized a nationwide health insurance database (2010-2016) to examine OSA patients with and without depression. Kaplan-Meier curves and Cox proportional hazards regression analyses were used to evaluate the cumulative incidence and risk of MACE over a three-year follow-up period.
RESULTS Study 1 indicated that, among 170 patients with OSA (AHI ≥ 5), 40% met COMISA criteria. While no significant differences in PSG parameters were observed between OSA and COMISA patients, COMISA was associated with poorer self-reported sleep quality and higher levels of anxiety and depression. On the other hand, findings from study 2 indicated that 11.3% of adult patients with OSA also had comorbid depression. Over a three-year follow-up period, those with comorbid depression demonstrated a higher cumulative incidence of MACE (21.5% vs. 13.5%, p<0.0001), including increased risks of stroke (HR=1.79, 95%CI: 1.25-2.58) and cardiovascular mortality (HR=1.28, 95%CI: 1.14-1.44). However, no significant associations were found for myocardial infarction or heart failure until after 36 months.
CONCLUSIONS These findings underscore the critical need to recognize and address psychiatric comorbidities—especially depression—as key modifiers of symptom perception, disease trajectory, and cardiovascular risk in patients with OSA. By moving beyond a purely respiratory framework, this work contributes to a more nuanced and multidimensional approach to phenotyping and managing sleep-disordered breathing. The integration of mental health assessment into routine sleep medicine practice may offer significant potential for improving long-term outcomes and tailoring individualized treatment strategies.
Institution: International PhD Program in Medicine, College of Medicine
Author: Tran Van Hoc
Dissertation Advisor: Associate Professor Hsin-Chien Lee, MD, MPH
INTRODUCTION Obstructive sleep apnea (OSA) and insomnia frequently coexist, complicating diagnosis and treatment. The overlap of these conditions, known as COMISA, has been associated with distinct clinical features, yet data on Asian populations remain limited. Patients with COMISA exhibited more severe symptoms of depression, anxiety, and stress compared to those with insomnia or sleep apnea alone. Additionally, depression is increasingly recognized as a key comorbidity in OSA, contributing to an elevated risk of major adverse cardiovascular events (MACE). This study aims to (1) characterize the clinical and polysomnographic differences between OSA and COMISA in an Asian cohort and (2) assess the prognostic impact of depression on cardiovascular outcomes in OSA patients.
METHODS This doctoral thesis includes 1) a prospective cross-sectional analysis, and 2) a longitudinal cohort investigation. The cross-sectional study enrolled patients from a sleep center between June 2022 and November 2022 who underwent polysomnography (PSG) and completed self-reported questionnaires and mood assessments. OSA was diagnosed based on an Apnea-Hypopnea Index (AHI) ≥ 5 events/hour, while COMISA was identified in patients reporting persistent sleep dissatisfaction. The longitudinal study utilized a nationwide health insurance database (2010-2016) to examine OSA patients with and without depression. Kaplan-Meier curves and Cox proportional hazards regression analyses were used to evaluate the cumulative incidence and risk of MACE over a three-year follow-up period.
RESULTS Study 1 indicated that, among 170 patients with OSA (AHI ≥ 5), 40% met COMISA criteria. While no significant differences in PSG parameters were observed between OSA and COMISA patients, COMISA was associated with poorer self-reported sleep quality and higher levels of anxiety and depression. On the other hand, findings from study 2 indicated that 11.3% of adult patients with OSA also had comorbid depression. Over a three-year follow-up period, those with comorbid depression demonstrated a higher cumulative incidence of MACE (21.5% vs. 13.5%, p<0.0001), including increased risks of stroke (HR=1.79, 95%CI: 1.25-2.58) and cardiovascular mortality (HR=1.28, 95%CI: 1.14-1.44). However, no significant associations were found for myocardial infarction or heart failure until after 36 months.
CONCLUSIONS These findings underscore the critical need to recognize and address psychiatric comorbidities—especially depression—as key modifiers of symptom perception, disease trajectory, and cardiovascular risk in patients with OSA. By moving beyond a purely respiratory framework, this work contributes to a more nuanced and multidimensional approach to phenotyping and managing sleep-disordered breathing. The integration of mental health assessment into routine sleep medicine practice may offer significant potential for improving long-term outcomes and tailoring individualized treatment strategies.