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Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 516-520

Evaluation of quality of life, anxiety, and depression in the spouses of patients with obstructive sleep apnea syndrome

1 Department of Chest Diseases, Adnan Menderes University Faculty of Medicine, Aydin, Turkey
2 Department of Chest Diseases, Trakya University School of Medicine, Edirne, Turkey

Date of Acceptance28-Dec-2018
Date of Web Publication11-Apr-2019

Correspondence Address:
Dr. O Yazici
Department of Chest Disease, Adnan Menderes University Faculty of Medicine, Aydin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_500_18

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Background: Impaired quality of life can be seen in the spouses of the obstructive sleep apnea syndrome (OSAS) patients. The main aim of the study is to assess the quality of life, anxiety, and depression in the spouses of the OSAS patients. Materials and Methods: A total of 100 OSAS patients and their spouses were included in the study. The demographic features of patients and the findings related to their disease and relevant clinical conditions were recorded. The quality of life of the spouses was evaluated by Short Form-36, their depression levels by Beck's depression inventory (BDI), anxiety levels by Beck's anxiety inventory, and the hospital anxiety and depression scale (HADS). Results: About 33% and 26% of patients' spouses showed depression by BDI and HADS, respectively; 14% of them showed anxiety by hospital anxiety scale. Among the subparameters of quality of life in spouses of patients who receive PAP (positive airway pressure) treatment, scores of physical condition, physical role restrictions, and role restrictions due to emotional problems were significantly higher than the ones in spouses of nontreated patients (P < 0.05). Depression scores of spouses of patients who use PAP were significantly lower than the ones who do not use the device (P < 0.05). A significant difference was not found between the two groups by means of anxiety scores (P > 0.05). Conclusion: The use of continuous PAP improves not only the quality of life for OSAS patients but also for their spouses and reduces the spouses' depression risk.

Keywords: Anxiety, depression, life quality, obstructive sleep apnea syndrome, spouses

How to cite this article:
Yazici O, Hatipoglu O N. Evaluation of quality of life, anxiety, and depression in the spouses of patients with obstructive sleep apnea syndrome. Niger J Clin Pract 2019;22:516-20

How to cite this URL:
Yazici O, Hatipoglu O N. Evaluation of quality of life, anxiety, and depression in the spouses of patients with obstructive sleep apnea syndrome. Niger J Clin Pract [serial online] 2019 [cited 2021 May 17];22:516-20. Available from:

   Introduction Top

Today, the most encountered respiration disorder during sleep is obstructive sleep apnea syndrome (OSAS). Any patients with OSAS lose their life quality due to the excessive daytime sleepiness, depression, and decreases in cognitive functions and performance.[1],[2] This is because apnea and hypopnea lead to hypoxia and sleep fragmentation and, thus, cause daytime symptoms: excessive daytime sleepiness, cognitive impairment, decreased energy, and morning headaches, which impair daytime functioning and may cause some changes in the emotional state of the patients.[3]

Although the OSAS affects the quality of life, this condition on patients' spouses has not drawn attention yet. Snoring and sleep apnea that patients experience during the night may also negatively affect the life quality of their spouses as well.[4] Only a few studies have examined the quality of life of the bed partners of the patients with OSAS.[5],[6] Previous studies revealed that spouses of OSAS patients demonstrated an improvement in sleep efficiency after the patients started nasal continuous positive airway pressure (CPAP) therapy, which was confirmed by increased scores of health-related quality-of-life inventory. While bed partners showed benefits in their health status with regard to OSAS patients' CPAP therapy, data on their emotional condition improves after the patients treatment. Spouses find this situation strange in the beginning, but with time, they accept their spouses who restlessly sleep in a bed due to either snoring or apnea. Serious problems among couples can be observed due to various reasons such as snoring, excessive sleepiness, impotence in men, and decreasing libido in women. The most frequently used solution for the accumulated problems is separating rooms of spouses, but in the developed societies, divorce can also be often observed.[7]

The nature of spouse interaction during OSAS may vary and is likely to have important implications for patients continued to the treatment. The purpose of this study is to assess the effects of the OSAS over the spouse in terms of quality of life, anxiety, and depression.

   Materials and Methods Top

This prospective clinical study was approved by the Ethical Committee of Trakya University Medical School with the Ethic Number 2010/44. All the patients gave their informed consent prior to their inclusion into the study. In the study, we reviewed polyclinic records of 178 patients provided with PAP (positive airway pressure) reports who applied to Trakya University Chest Diseases Outpatient Clinic and who were diagnosed with OSAS between August 2017 and 2018. We reached the participants' details and their spouses from the mailing address information where are recorded in the digital hospital policlinic records. After providing the preliminary information about the study participation by the phone conversation, 100 patients who are available for arrival and had spouses without chronic disease were asked to come to the hospital with their spouses. Exclusion criteria of the study were being under the age of 18 years, being pregnant and breastfeeding women, and having spouses of patients with any chronic disease.

Short Form-36

We carried out Short Form-36 (SF-36) in order to evaluate general life quality of the spouses of the patients with OSAS.[8] SF-36 consists of two main topics such as physical health and mental health. Physical health area covers physical function (10 questions), physical role restrictions (10 questions), body pain (2 questions), and perception of general health (5 questions). Mental health area instead covers social function (10 questions), emotional role restriction (3 questions), mental health (5 questions), and liveliness (4 questions). The spouse participants were asked to answer the questions by considering the last 4 weeks except for the ones about general changes in the health condition. Each scale was graded between 0 and 100.

Beck's depression inventory

Beck's depression inventory (BDI) is a test that aims quantitative evaluation of the intensity of depression and has a total of 21 questions.[9] We carried out BDI to the spouses of patients and gave 0–3 points per question. The baseline grade demonstrating the presence of depression was accepted as 10. Results were evaluated as 10–18 points mild, 19–29 points moderate, and 30–63 points meaning severe depression.

Beck's anxiety inventory

Beck's anxiety inventory (BAI) is used to measure the severity of anxiety in a person. It is a self-assessment inventory.[10] It has 21 items in total. Four points Likert scale is used. The scale was given to the spouses of patients and 0–3 points were graded per item. Varying points between 0 and 63 were obtained in total. Results were evaluated as no findings of anxiety for 0–10 points, mild anxiety for 11–17 points, moderate anxiety for 18–29 points, and severe anxiety for 30–63 points.

Hospital anxiety and depression scale

Hospital anxiety and depression scale (HADS) is a self-assessment scale to determine the anxiety and depression risks in the patient and to measure their level with changes in severity.[11] The scale has 14 questions. Seven of them (odd numbers) grade anxiety, and the rest seven of them (even numbers) grade depression. The anxiety and depression points that patients take by HADS are separated into two groups as below the baseline and above the baseline. Answers are evaluated by four-point Likert scale. The questionnaire has been conducted in the spouses of patients and 0–3 points were given per item. Varying points between 0 and 21 were obtained in total. The baseline point for the scale was accepted as 10 for anxiety subscale and 7 for depression subscale. People who receive higher points than the baseline are evaluated as the group at risk. Accordingly, we evaluated whether the patients belong to the group above or below the baseline by means of anxiety and depression and recorded the results as normal for 0–7; normal at the border for 8–10 and abnormal for 11–21.

Statistical analysis

Following the data review, all data were collected, tabulated, and then analyzed using MINITAB statistical computer software to obtain the results of our study. Qualitative data were presented as numbers and percentage. They are all expressed as means and standard deviation (mean ± SD). Evaluating the data of the study, Spearman's Rho is used to analyze the nonparametric correlations. Mann–Whitney U test is chosen for nonparametric comparisons. Kruskal–Wallis test is used for nonparametric multiple comparisons of the groups. For all statistical tests, a P value of <0.05 was considered significant.

   Results Top

100 OSAS patients and their spouses were assessed within the scope of this study. About 28% of patients with OSAS were women and 72% of them were men. The mean age of spouses of patients was found as 53.75 ± 10.54. Demographic data of spouses of patients can be found in [Table 1]. About 79% of patients with OSAS had snoring, excessive daytime sleepiness, and accompanying sleep apnea during night sleep. The mean symptom duration of patients was 101.04 ± 87.91 months. When the severity of disease was evaluated according to the apnea–hypopnea index (AHI), the mean AHI value of patients was found as 50.08 ± 26.57.
Table 1: Demographic features of the spouses of OSASs

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While 32% of the patients were using the PAP device, 68% were not using it. The reasons of patients who refuse to use the device included no available spare time to buy the device in case of new diagnosis (41.2%), the idea that they cannot handle the use of the device (30.9%), financial incapability (22.1%), and problems with social security institution or the companies selling the device (5.8%). The mean daily duration for using the device was found as 6.12 ± 1.79 h/day. The descriptive data of patients regarding their disease can be found in [Table 2]. All of the spouses who contributed to our study were sleeping in the same room; they did not separate their rooms.
Table 2: Descriptive data for the disease of the OSAS patients

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We evaluated depression state of spouses of patients by BDI and found that 67% of them had no depression, while 21% had mild, 11% of them had moderate, and 1% of them had severe depression. Assessment by HADS revealed 26% of depression in the spouses. Assessing the spouses by BAS, 55% had no anxiety; yet, 25% had mild, 16% had moderate, and 4% had severe anxiety. Assessing them by hospital anxiety scale, 14% of the spouses had anxiety. The life quality, anxiety, and depression scores of spouses of patients can be found in [Table 3]. No significant relationship between the disease severity of patients with OSAS and the points that they took from scales of quality of life, depression, and anxiety is found.
Table 3: Scores of quality of life, depression, and anxiety in the spouses of the OSASs

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When the relationship of patients with OSAS about either receiving PAP treatment or not and the scales of quality of life, depression, and anxiety were examined, it was found that the spouses of former group had significantly higher points of physical function, physical role restrictions, general health, emotional problems, and physical scores in SF-36; however, their Beck's depression and hospital depression points were significantly lower. The quality of life, depression, and anxiety scores of spouses of patients who receive or do not receive PAP treatment can be found in [Table 4].
Table 4: The relationship between conditions of patients in terms of PAP treatment

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   Discussion Top

As well known, the OSAS has some negative effects and life-quality-lowering outcomes over the patients with OSAS. All these events can increase the OSAS-related psychological conditions not only in the patients but also in the spouses of the OSAS patients. In the present study, we aimed to investigate the psychological conditions such as anxiety and depression in addition to life quality. We believe that treating the OSAS may improve not only the quality of life for OSAS patients but also for their spouses.

Recent studies have reviewed the association of OSAS with the psychological conditions such as depression and anxiety; however, the relationship with the spouses of the OSAS patients is an unclear area.[12] We commonly know that in the untreated OSAS, rates of depression and anxiety are elevated compared with general populations, although in some studies, it seems still controversial to confirm this association between OSAS and anxiety or depression.[13] In our study, as a big difference, we analyzed the OSAS patients' spouses in terms of anxiety or depression. We found that 67% of them had no depression, while 21% had mild, 11% of them had moderate, and 1% of them had severe depression. Assessing the spouses' anxiety, 55% had no anxiety; yet, 25% had mild, 16% had moderate, and 4% had severe anxiety. Assessing them for hospital anxiety, 14% of the spouses had anxiety.

The novel reports suggested that a CPAP treatment might lessen the symptoms of the OSAS.[1],[3],[14] Hence, the psychological effects of the OSAS over the spouses can decrease by the time.[15] In the literature, Doherty et al. evaluated the effect of CPAP treatment on sleep and daytime symptoms of the patients and their spouses.[16] They found the mean hospital anxiety as 48.4 ± 22.2. In the study by Parish et al. evaluating the life quality of spouses of OSAS patients who underwent CPAP treatment, hospital anxiety values were similarly 48.4 ± 33.[6] In our study, we did not find a relationship between hospital anxiety values and the quality of life, anxiety, and depression state of their spouses. We think that the reason for this result is a level as high as requires a PAP device. Though all patients were provided with a PAP report and recommended to use the PAP treatment, 32% of them were using the device, whereas 68% were not. Doherty et al. mentioned in their study that 17% of 54 OSAS patients were sleeping at different rooms with their spouses.[16] The reason lying behind the spouses' nonseparating behavior could be based on the idea that separating bedrooms is a wrong behavior. In the present study process, we assured that all the 100 couples were sleeping in the same room. The couples reminded that they did not separate their room despite the discomfort.

The OSAS results in not only the anxiety but also the depression many times.[12] Doherty et al. reported that 18% reported depressive symptoms before the CPAP treatment initiation.[16] Conversely, a study of 122 partners of patients with untreated OSA found the quality of life on the SF-36 to be similar to age- and sex-adjusted normative values.[17] Another researcher found that the annual frequency of major depression was 0.8–5.8% in 10 countries; on the other hand, the lifetime frequency was 1.5–19%. The severe depression rate of patients in our study seems to be consistent with the recent studies.[15],[17] Similar to the literature, 26% of the spouses of the OSAS patients in our study had depression. In addition, 21% of the spouses had mild, 11% had moderate, and 1% had severe depression, while 67% had no depression. Comparing the anxiety and depression scores of the spouses of patients who use and do not use PAP, we observed that the depression scores of the former group are significantly lower according to the depression indexes we used in this study.

As a result, when we evaluated the life qualities of spouses of patients who use and do not use PAP, we found that the former group had significantly better parameters by means of physical function, physical role restrictions, general health, role restrictions due to emotional problems, and physical scores. Spouses thought it was their responsibility to help the patients by sharing the bedroom despite disturbed sleep to ensure the patient was breathing and making sure the patient received help and treatment for his or her symptoms, which lead to feeling like more of a parent than a spouse does. The decrease in complaints of patients and the recovery in physical functions remind us the recovery of this parameter because it has a positive effect on both the morale of patients and their spouses. Maybe it seems like a big health problem for the patients. However, the spouse needs a special physiological health care as same as the OSAS patients do during this treatment period.

Although we reached interesting outcomes, the current study has some limitations. First, the size of the studied population would be wider than we encountered. Second, cultural variables or family conflicts may affect the results. Additionally, there were no equal numbers of genders, as the gender of subjects may have a significant impact on mood, since women are more vulnerable to mood alterations. Another important note for the limitations of mood scales is that they can only show depressive and anxious symptoms. In our cases, the patients mentioned that no available spare time was present to buy the device in case of a new diagnosis. They think that they cannot handle the use of the device (30.9%), financial incapability (22.1%) and problems with social security institution or with the companies selling the device (5.8%). Considering these facts, further investigation for the spouse of the OSAS has been still a necessity in these conditions.

   Conclusion Top

The quality of life and depression states in spouses of patients with OSAS using PAP treatment were better than that of the ones who did not use it. Though it was not the main purpose of our study, one of the most appealing results of this study is the fact that majority of patients who had OSAS diagnosis and provided with a PAP use report did not buy the device. After the report is arranged for the diagnosis of OSAS to the patients, they should be informed that in case they use the device, their sleep and therefore life quality will improve; and then, the life quality of surrounding people and especially their spouses will also improve. Unless solutions for the problems of supplying the device, which is the gold standard, and getting the device have been produced, all the efforts for diagnosis of the disease is wasted and the patients who were diagnosed remain untreated.


The authors thank Prof. Dr. Necdet Süt for the assessment of statistical data and Prof. Dr. Okan Çalıyurt for assessment of psychiatric topics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Modica DM, Marchese D, Lorusso F, Speciale R, Saraniti C, Gallina S. Functional nasal surgery and use of CPAP in OSAS patients: Our experience. Indian J Otolaryngol Head Neck Surg 2018;70:559-65.  Back to cited text no. 1
Baratta F, Pastori D, Fabiani M, Fabiani V, Ceci F, Lillo R, et al. Severity of OSAS, CPAP and cardiovascular events: A follow-up study. Eur J Clin Invest 2018;48:e12908.  Back to cited text no. 2
Myllyla M, Kurki S, Anttalainen U, Saaresranta T, Laitinen T. High adherence to CPAP treatment does not prevent the continuation of weight gain among severely obese OSAS patients. J Clin Sleep Med 2016;12:519-28.  Back to cited text no. 3
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Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 11
Daabis R, Gharraf H. Predictors of anxiety and depression in patients with obstructive sleep apnea. Egypt J Chest Dis Tuberc 2012;61:171-7.  Back to cited text no. 12
Paiva T, Attarian H. Obstructive sleep apnea and other sleep-related syndromes. Handb Clin Neurol 2014;119:251-71.  Back to cited text no. 13
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  [Table 1], [Table 2], [Table 3], [Table 4]

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