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How and Why is Sleep Apnea Misdiagnosed?

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Sleep apnea affects about 30 million people1 in the United States, though just 6 million of those people are formally diagnosed. This condition – in which the sleeper starts and stops breathing throughout the night – can be dangerous if left untreated. So, why is there such a gap in the number of people who have it, and the number of people who are diagnosed?

A big reason for this diagnosis gap is that sleep apnea shares many symptoms with depression. Another reason sleep apnea is misdiagnosed is that males and females exhibit symptoms differently, and oftentimes, our current tests fail to detect sleep apnea in females. In this article, we’ll get into the details about these common reasons for misdiagnosis, as well as how sleep apnea can affect your overall health.

Similarities Between Sleep Apnea and Depression Symptoms

Sleep apnea and depression share many similar symptoms. The overlapping symptoms of sleep apnea2 and depressive disorders3 can lead to both or either condition going untreated, or treated in a way that makes symptoms worse. This misdiagnosis may lead to life-threatening consequences.

Common Overlapping Symptoms Include:

  • Trouble concentrating2, 3
  • Fatigue2, 3
  • Sleep deprivation2, 3
  • Insomnia2, 3

Awareness of sleep apnea and depression and the various ways they may present may help you avoid misdiagnosis. Therefore, it is important to consult medical professionals, along with being educated on both of these conditions.

Get More Info: 5 Signs You May Have Sleep Apnea

The Concurrent Appearance of Sleep Apnea and Depression

A person can simultaneously deal with depressive symptoms and sleep apnea4. This overlap of conditions can create a challenge when it comes to diagnosing either one.

The problem with this overlap is that some treatments for depression might make sleep apnea worse. For example, some antidepressants can cause weight gain, and this weight gain can exacerbate symptoms of sleep apnea, like trouble breathing5

Conversely, one study6 points out that some obstructive sleep apnea patients who present depression symptoms see a major decrease in their depression symptoms when they use CPAP therapy.

The bottom line is, that determining whether the patient has depression, sleep apnea, or a combination of the two, is important in order to establish the appropriate treatment route. For this reason, consulting doctors with experience discerning between the two may help with a correct diagnosis.

Complex Sleep Apnea in Women and Misdiagnosis in the Female Population

To help physicians diagnose sleep apnea, the Apnoea-Hypopnea Index7 (AHI) was created. Unfortunately, this index is not as accurate when it comes to diagnosing sleep apnea in females because the bulk of scientific research on sleep apnea over the years has been conducted on males only8.

This gender-biased research means that numbers and figures are specific to male bodies, and not other genders. As a result, the AHI highly favors the male experience over the female experience, yet not all genders exhibit symptoms of sleep apnea in the same way.

For example, episodes of breathing pauses and upper airway resistance in females frequently fail to meet the AHI criteria9 for apneas, because those criteria were determined by male bodies.

Here’s what happens: The AHI measures the number of times a person’s breathing pauses or their airways collapse, along with the amount of time these pauses or collapses happen during one hour of sleep. For male bodies, this must occur for at least 10 seconds11 and be correlated with a decrease in blood oxygen levels. However, the AHI number is typically lower for females.9 

This difference leads to female symptoms not falling within the range of an official sleep apnea diagnosis, despite the life-threatening nature of the condition.

Symptoms in Females Often Appear Differently Than in Males

As covered, females typically don’t present sleep apnea symptoms as strongly as males do, which is a significant reason why sleep apnea regularly goes undiagnosed and untreated in females. Along with a lower AHI, women may exhibit shorter apneas and hypopneas12.

Further, some women have reported different outwardly presenting symptoms altogether. For example, an analysis of obstructive sleep apnea in women noted that women with OSA have complained of symptoms such as insomnia, restless legs, depression, nightmares, palpitations, and hallucinations.12 Males with sleep apnea, however, note more apneic episodes and snoring — issues that are more traditionally associated with complex sleep apnea.12

Women More Likely to be Misdiagnosed with Mental Health Issues

Another reason females may be misdiagnosed for sleep apnea is that they are more likely to be diagnosed with something in the realm of mental health instead. This misdiagnosis is not because females have more mental health issues than males; rather, it seems to be12 because females seek treatment for mental health concerns more than males do. This is largely due to socialization and cultural norms, in which females are taught earlier on to talk about their feelings, and males are taught to suppress emotions.

When females present with symptoms that are common among both depression and sleep apnea, like insomnia, depressive feelings, and feeling unrested, instead of speaking to a sleep expert, they are more likely to seek treatment from a psychiatric professional and receive a diagnosis: depression.

While depression can occur with sleep apnea, failure to identify sleep apnea can lead to females experiencing long-term complications from the condition. 

Other Reasons For a Misdiagnosis

Some studies theorize that females are less likely to report chronic or loud snoring in themselves, possibly not recognizing that it indicates a severe problem.11 Further, females’ breathing issues may be more subtle due to differences in anatomy between females and males, causing issues to go unidentified. For example, the airway length, tongue, soft palate, and total amount of tissue in the throat are smaller in females compared to males. Fat is also distributed in the body differently in females versus males, which plays a major role in obstructive sleep apnea.

Additionally, females usually attend clinical appointments independently, whereas males often bring their partner — leading to a more thorough assessment due to two people reporting symptoms rather than one.11

Even though sleep apnea misdiagnosis is more common in females than males, it can and does happen to people of any sex or gender. Requesting an overnight sleep study assessment in a sleep lab may be helpful in correctly identifying the problem.

If you are having trouble with snoring at night, check out our list of best mattresses for snoring.

Sleep Apnea, Cardiovascular Health, and Heart Disease

Not treating sleep apnea significantly increases the likelihood of cardiovascular disease13 and heart arrhythmias. Obstructive sleep apnea, in particular, is correlated with higher blood pressure, stroke, and coronary artery disease14.

One common underlying issue related to sleep apnea that we haven’t yet discussed in detail, but that is very important, is obesity. Obesity is frequently linked to both sleep apnea and heart disease.

Just like sleep apnea and depression are often interrelated, so are sleep apnea, obesity, and heart disease. Obesity on its own can be a cause of heart disease. In fact, according to the National Institute for Health and Care Research, obese people are two and a half times more likely to develop heart disease than healthy people of normal weight15.

Read more about the link between obesity and sleep.

However, obesity is also a common precursor to severe sleep apnea because an increase of fat deposits in the neck and throat16 area can wind up blocking the upper air passage during sleep.

This interrelation of sleep apnea and obesity both leading to heart disease can make for a “chicken or the egg” situation. Is the obesity causing the sleep apnea? Is the sleep apnea then causing the heart disease? Or is the obesity causing the heart disease directly?

Either way, in cases when obesity and sleep apnea are both present, weight loss is the recommended course of treatment, for both managing sleep apnea symptoms17 and reducing the risk of heart disease18.

How to Avoid a Sleep Apnea Misdiagnosis

Relying on someone else to diagnose a condition can feel hopeless when you’re not a trained professional. However, some simple education on your symptoms could help.

Request a Polysomnography

Physicians will occasionally recommend doing an overnight sleep study, otherwise known as polysomnography19, to help in correctly identifying sleep apnea. A polysomnography is when a person spends the night at a sleep center or a special unit at a hospital; this type of comprehensive examination typically involves being hooked up to various wires and machines to track your brain waves.

A polysomnography records blood oxygen levels, heart rate, brain waves, body movements, and breathing. In addition to assisting with a sleep apnea diagnosis, this sort of sleep test may also reveal whether or not you need to adjust your current treatment. At-home sleep studies are available; however, they are limited in identifying problems because they lack some of the comprehensive tools used in a designated lab.21

For example, at-home sleep studies can underestimate the severity of sleep apnea or even miss the diagnosis entirely. According to the University of Michigan20, at-home sleep studies are best for diagnosing people with moderate to severe sleep apnea, and they can give false negative results, especially for those who have fewer overt symptoms.

Your most reliable results will be obtained by doing an overnight sleep study in a laboratory.

Keep in Mind the Overlapping Symptoms of Depression and Sleep Apnea

Educating yourself and remaining aware of how closely related sleep apnea and depression symptoms are can be key to deciphering between the two. Common overlapping symptoms of both depression and sleep apnea include trouble concentrating, fatigue, sleep deprivation, and insomnia.2, 3

Staying aware of the closely linked symptoms may save you unnecessary treatment for the wrong condition.

Take Extra Steps If You’re a Female

As we’ve seen, there is a higher proportion of misdiagnosis for females with sleep apnea than for males.11 This misdiagnosis can be attributed to several reasons, including females more commonly seeking treatment for mental health, symptoms presenting differently, and certain sleep apnea tests being more designed for a male body.

Because of this high rate of misdiagnosis, if you’re a female-bodied person (regardless of how you gender identify), and you believe you have sleep apnea, be sure to advocate for yourself and get the appropriate tests. Your symptoms are more likely to be diagnosed as another condition, and undergoing a sleep study can help narrow down your issue.

Discuss Issues with Both a Sleep Specialist and Primary Care Provider

Consulting both a sleep specialist and your primary care provider may be a wise avenue in seeking treatment. Many primary care providers are well-versed in sleep apnea and other sleep disorders, but some are not.

Likewise, sleep specialists may be more highly skilled and attuned to the nuances of sleep apnea, but less familiar with depressive disorders. This way, consulting both types of specialists can help you determine where your symptoms originate, and what the best course of treatment is.

Be sure to find a qualified sleep specialist, experienced in complex, obstructive, and central sleep apnea. This knowledgeable professional may make the difference between a correct diagnosis or not, saving you time and suffering.

You may want to take a look at our recommended mattress for sleep apnea.

Seek a Second or Third Opinion

For individuals who have sought out treatment and have yet to find a successful remedy, it may be beneficial to seek a second or even third opinion from another healthcare provider specializing in sleep apnea or depression.

Final Word of Advice

Not only can sleep apnea lead to worse sleep, but it also increases your risk of long-term health complications. As such, it’s important to get formally diagnosed in order to access the optimal treatment. The difficulty with sleep apnea, however, is that sometimes it can present similarly to other health issues, which is why misdiagnosis can occur.

Understanding sleep apnea and its symptoms can give you the helpful knowledge you need so that you can consult a medical professional if needed. However, we also advise getting an extra opinion if you feel that you may be misdiagnosed.

Rachael Gilpin

Rachael Gilpin

Content Writer

About Author

Rachael is a content writer for Sleep Advisor who loves combining her enthusiasm for writing and wellness.

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References:

  1. Berg, Sara. “What doctors wish patients knew about sleep apnea”. American Medical Association. 2022.
  2. “Sleep apnea”. Mayo Clinic. Last modified April 6, 2023.
  3. “Depression (major depressive disorder)”. Mayo Clinic. Last modified October 14, 2022.
  4. Jehan, Shazia., et al. “Depression, Obstructive Sleep Apnea and Psychosocial Health”. National Library of Medicine. 2017.
  5. Wichniak, Adam., et al. “Effects of Antidepressants on Sleep”. National Library of Medicine. 2017.
  6. “CPAP therapy reduces symptoms of depression in adults with sleep apnea”. American Academy of Sleep Medicine. 2015.
  7. “Understanding the Results”. Division of Sleep Medicine: Harvard Medical School. Last modified April 16, 2021.
  8. Merone, Lea., et al. “Sex Inequalities in Medical Research: A Systematic Scoping Review of the Literature”. Women’s Health Reports. 2022.
  9. Bonsignore, Maria R., Saaresranta, Tarja., Riha, Renata L.“Sex differences in obstructive sleep apnoea”. European Respiratory Review. 2019.
  10. Sarver, Audra. “Apnea-Hypopnea Index (AHI)”. Sleepapnea.org. Last modified March 24, 2024.
  11. Wimms, Alison., et al. “Obstructive Sleep Apnea in Women: Specific Issues and Interventions”. BioMed Research International. 2016.
  12. Sagar-Ouriaghli, Ilyas., et al. “Improving Mental Health Service Utilization Among Men: A Systematic Review and Synthesis of Behavior Change Techniques Within Interventions Targeting Help-Seeking”. American Journal of Men’s Health. 2019.
  13. “Sleep Apnea and Heart Health”. American Heart Association. Last modified June 26, 2023.
  14. Tietjens, Jeremy R., Claman, David., et. al. “Obstructive Sleep Apnea in Cardiovascular Disease: A Review of the Literature and Proposed Multidisciplinary Clinical Management Strategy”. Journal of the American Heart Association. 2018.
  15. “Being overweight or obese is linked with heart disease even without other metabolic risk factors”. National Institute for Health and Care Research. 2017.
  16. Jehan, Shazia., et al. “Obstructive Sleep Apnea and Obesity: Implications for Public Health”. National Library of Medicine. 2017.
  17. “Weight Loss and Sleep Apnea”. American Thoracic Society. 2020.
  18. “Weight Management for a Healthy Heart”. UCSF Health. Webpage accessed July 3, 2024.
  19. “Polysomnography”. Medline Plus. Last modified January 1, 2022.
  20. Joy, Kevin. “When Is a Home Sleep Apnea Test Appropriate?”. University of Michigan Medicine. 2016.