Psychosomatics 49:447-449, September-October 2008
doi: 10.1176/appi.psy.49.5.447
© 2008 Academy of Psychosomatic Medicine
Onset of Mania After CPAP in a Man With Obstructive Sleep Apnea
D. Bergé, M.D.,
P. Salgado, M.D.,
A. Rodríguez, M.D., and
A. Bulbena, M.D., Ph.D.
Received November 23, 2006; revised April 17, 2007; accepted April 24, 2007. From Centre Forum Hospital del Mar, Institut d’Atenció Psiquiàtrica Salut Mental i Toxicomanies (IAPS). Send correspondence and reprint requests to Dr. Daniel Bergé, Centre Forum Hospital del Mar, C/ Llull 410, Barcelona, Spain 08019. e-mail: 94482{at}imas.imim.es
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: This short report presents the case of a man with chronic anergy and mild depressive symptoms probably due to obstructive sleep apnea (OAS). METHOD: The patient was treated with continuous positive airway pressure (CPAP). RESULT: He developed a first manic episode at an atypical age simultaneously with the beginning of treatment. DISCUSSION: Several possible connections between affective syndromes, OAS, and CPAP treatment are proposed and discussed relating to current literature.
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INTRODUCTION
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A connection between sleep disturbances and psychiatric disorders has been reported in previous investigations. Conventionally, obstructive sleep apnea syndrome (OAS) has been associated with depressive disorders. Depending on the author, this association has been explained by theories of chronic hypoxemia causing depressive-like symptoms1 or depressive symptoms secondary to a medical disease, in the present case.2,3 A previous study, involving a large cohort of 300,000 patients, revealed, not only a major rate of depressive disorder, but also major rates of anxiety disorders, posttraumatic stress disorder, psychosis, and bipolar disorders in patients suffering from OAS, as compared with non-OAS patients.2 An improvement in affective and cognitive status in clinically depressed OAS patients after starting continuous positive airways pressure (CPAP) treatment has been demonstrated in a wide range of studies.4–6 Recently, there has been a report in the literature of a shift to a hypomanic episode in a depressed OAS patient upon starting CPAP treatment.7
We report here a case of a manic episode in a 64-year-old man with OAS after starting CPAP treatment. "Mr. D" had no personal or family history of psychiatric illness.
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Case Report
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Five years earlier, Mr. D had been diagnosed with diabetes mellitus Type 2, and, since that time, had been treated with Metformin 850 mg every 8 hours. He was married, and was the father of three children, all of them independent and without psychiatric history. The family described the patient as usually tired, sleepy during the day, without much energy for the last 10 years, and longing to retire next year. Four months before his admission, his primary-care physician had ordered a polysomnography test, suspecting OAS. The polysomnography revealed a high number of apnea episodes (defined as an impairment in the naso-oral flow higher than 50%) and hypoapneas (defined as an impairment in the naso-oral flow associated with undersaturations higher than 3% of oxyhemoglobin), with moderate undersaturation. A total number of 355 respiratory events were registered, mostly apneas (Apnea-Hypopnea Index: 47, Hypopnea Index: 9), with an average duration of 25 seconds per event; 7% of his sleeping time showed O2 saturations under 90%. An average saturation of 94% and minimum saturation of 73% were recorded. CPAP treatment and dietary measures were prescribed. CPAP treatment was started 2 months before the beginning of the psychiatric symptoms, with 9 hours of 20-cm continuous pressure.
One month after starting the CPAP treatment, the patient switched to a steadily manic state, with motor hyperactivity, euphoria, excessive socialization, verbal aggressiveness, and verbosity. Several complementary tests were conducted to rule out underlying medical causes. Cranial computerized axial tomography ruled out structural cerebral anomalies; measurement of thyroid hormone levels showed no changes; and no anomalies in blood count, liver, or kidney function were found. One month after the onset of symptoms, and once the results of the complementary tests ascertained no medical cause, the patient was admitted to the acute-care hospitalization service of our center.
When Mr. D was admitted to our hospital, he showed verbosity, motor hyperactivity, and megalomaniacal thoughts. He reported a loss of weight during the weeks before the admission. He was assessed at admission with the Mania Rating Scale (MRS),8 scoring 33. Risperidone, titrated to 9 mg per day, and valproate, titrated to 1,200 mg per day, were prescribed as essential treatment, resulting in valproate plasma levels of 50.23 mcg/ml. Fifteen days after mood stabilization (MRS score: 8) was reached, Mr. D was discharged. During the 2-week admission period, he lost 1 kg without any dietary restriction. His history and present episode were assessed with the Structured Clinical Interview for DSM–IV Disorders (SCID–I),9 carried out by an experienced psychiatrist and resulting in a diagnosis of Bipolar Disorder, Recent Episode: Severe Mania Without Psychotic Symptoms. No other psychiatric diagnosis in Axis I was obtained from the above-mentioned interview.
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Discussion
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In summary, this report presents the case of a man with chronic mild depressive symptoms, probably due to OAS, who switched to a first manic episode at an atypical age, simultaneously with the beginning of a CPAP treatment.
The complementary tests carried out, including brain-imaging and hormone levels, ruled out possible underlying organic cause. No severe cognitive deficits were found, either before or during the admission period. Taking into account the results of the above-mentioned complementary tests, Mr. D’s loss of weight in the previous weeks and during the admission period was attributed to his motor hyperactivity.
Metformin, although it has been reported to possibly reduce free-testosterone plasma levels,10 which seem to be higher in bipolar patients,11 had been prescribed to the patient 5 years before the episode, without any change in mood. No other medication was prescribed or discontinued before the manic episode. All these data suggest a late-onset bipolar disorder, co-occurring when the CPAP treatment started.
This is not an isolated case of mania associated with CPAP treatment; Hilleret et al.7 reported a case of a 50-year-old man with depressive symptoms and OAS who switched to a hypomanic state after starting CPAP. Other authors have also found a co-occurrence of bipolar disorder and sleep apnea.12,13 In general, an increasing rate of bipolar disorder has been reported in OAS patients.2
All these reports suggest an association between mood disorders and sleep apnea syndrome. According to current literature, four different mechanisms may be involved in this relationship: 1) Patients suffering from OAS may show depressive-type symptoms, with hypersomnia secondary to hypoxemia and a lighter sleep, with reductions in Stages 3, 4, and REM sleep.14,15 These depressive-like symptoms would improve after the normalization of the sleep pattern, which may not happen immediately after the CPAP treatment starts;6,16 2) Depressive symptoms in OAS patients could be considered as secondary, as they can be secondary to any other medical condition causing a functional limitation and, subsequently, lower mood;2,9 3) Other studies suggest a certain brain structural association between regulation of mood (not only depression) and sleep abnormalities—more sleep arousals and unstable circadian activity patterns are strongly associated with bipolar disorder.17,18 Moreover, sleep disturbances have been reported as early signs of both mania and depression in bipolar patients.19 Alterations in the non-REM and REM periods (usually a shortened REM-period latency) are widely found in affective disorders, persisting even after clinical improvement.20,21 In some patients suffering from OAS, impairment affecting cognition22 and mood may persist even after CPAP treatment.16 These persistent deficits could be the clinical correlate of a subtle structural brain damage that functional neuroimaging studies seem to show in prefrontal cortex and cingulate areas.23,24 Injuries in the right-side and mid-line brain structures such as the cingulate may be associated with secondary mania.25
To sum up, this case shows a patient suffering from OAS recently treated by CPAP, who displayed a first manic episode. Several hypotheses have been found in the literature, suggesting a possible association between mood and sleep disorders. Future research will be needed in order to find out more about the physiological basis underlying this possible association.
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REFERENCES
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- Pochat MD, Ferber C, Lemoine P: (Depressive symptomatology and sleep apnea syndrome.) Encephale 1993; 19:601–607[Medline]
- Sharafkhaneh A, Giray N, Richardson P, et al: Association of psychiatric disorders and sleep apnea in a large cohort. Sleep 2005; 28:1405–1411[Medline]
- Amercian Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision. Washington, DC, 2000
- Borak J, Cieslicki J, Koziej M, et al: Effects of CPAP treatment on psychological status in patients with severe obstructive sleep apnoea. J Sleep Res 1996; 5:123–127[CrossRef][Medline]
- Means MK, Lichstein KL, Edinger JD, et al: Changes in depressive symptoms after continuous positive airway pressure treatment for obstructive sleep apnea. Sleep Breathing 2003; 7:31–42[CrossRef][Medline]
- Millman RP, Fogel BS, McNamara ME, et al: Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry 1989; 50:348–351[Medline]
- Hilleret H, Jeunet E, Osiek C, et al: Mania resulting from continuous positive airways pressure in a depressed man with sleep apnea syndrome. Neuropsychobiology 2001; 43:221–224[CrossRef][Medline]
- Young RC, Biggs JT, Ziegler VE, et al: Rating Scale for Mania: reliability, validity, and sensitivity. Br J Psychiatry 1978; 133:429–435[Abstract/Free Full Text]
- First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-CV). Washington, DC, American Psychiatric Press, Inc., 1996
- Awartani KA, Cheung AP: Metformin and polycystic ovary syndrome: a literature review. J Obstet Gynaecol Can 2002; 24:393–401[Medline]
- Ozcan D, Banoglu R: Eur Arch Psychiatry Clin Neurosci 2003; 253:193–196[CrossRef]
- Fleming JAE, Fleetham JA, Taylor DR, et al: A case report of obstructive sleep apnea in a patient with bipolar affective disorder. Can J Psychiatry (Revue Canadienne de Psychiatrie) 1985; 30:437–439
- Strakowski SM, Hudson JI, Keck PE, et al: Four cases of obstructive sleep apnea associated with treatment-resistant mania. J Clin Psychiatry 1991; 52:156–158[Medline]
- Malhotra A, White DP: Obstructive sleep apnoea. Lancet 2002; July 20; 360(9328):237-245
- Parrino L, Thomas RJ, Smerieri A, et al: Reorganization of sleep patterns in severe OSAS under prolonged CPAP treatment. Clin Neurophysiol 2005; 116:2228–2239[CrossRef][Medline]
- El-Ad B, Lavie P: Effect of sleep apnea on cognition and mood. Int Rev Psychiatry 2005; 17:277–282[CrossRef][Medline]
- Ohayon MM, Priest RG, Zulley J, et al: The place of confusional arousals in sleep and mental disorders: findings in a general population sample of 13,057 subjects. J Nerv Ment Dis 2000; 188:340–348[CrossRef][Medline]
- Jones SH, Hare DJ, Evershed K: Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder. Bipolar Disord 2005; 7:176–186[CrossRef][Medline]
- Bauer M, Grof P, Rasgon N, et al: Temporal relation between sleep and mood in patients with bipolar disorder. Bipolar Disord 2006; 8:160–167[CrossRef][Medline]
- Reynolds CF III, Coble PA, Spiker DG, et al: Prevalence of sleep apnea and nocturnal myoclonus in major affective disorders: clinical and polysomnographic findings. J Nerv Ment Dis 1982; 170:565–567[Medline]
- Tsuno N, Besset A, Ritchie K: Sleep and depression. J Clin Psychiatry 2005; 66:1254–1269[Medline]
- Bedard MA, Montplaisir J, Malo J, et al: Persistent neuropsychological deficits and vigilance impairment in sleep apnea syndrome after treatment with continuous positive airways pressure (CPAP). J Clin Exp Neuropsychol 1993; 15:330–341[Medline]
- Harper RM, Macey PM, Henderson LA, et al: fMRI responses to cold pressor challenges in control and obstructive sleep apnea subjects. J Appl Physiol 2003; 94:1583–1595[Abstract/Free Full Text]
- Beebe DW, Gozal D: Obstructive sleep apnea and the prefrontal cortex: toward a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits. J Sleep Res 2002; 11:1–16[Medline]
- Strakowski SM, Mcelroy SL, Keck PW, et al: The co-occurrence of mania with medical and other psychiatric disorders. Int J Psychiatry Med 1994; 24:305–328[Medline]
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ABSTRACT
INTRODUCTION
