How and Why is Sleep Apnea Misdiagnosed?

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Roughly one in five Americans suffer from sleep apnea, which is when you stop breathing momentarily in your sleep. The issue can not only cause life-threatening results but impairs sleep quality, leading to individuals waking up feeling groggy, tired, and reliant on CPAP machines to breathe.

Despite the commonality of the ailment, many individuals with sleep apnea are frequently misdiagnosed; a significant factor is that male and female symptoms regularly present differently, leading to many individuals not receiving the treatment they need. Women appear to experience a wide discrepancy regarding accurate diagnoses.

In many cases, sleep apnea can appear similar to other issues, one of the most common being depression. Trouble concentrating, fatigue, hopelessness, insomnia, and headaches are symptoms of both sleep apnea and depression. So naturally, discerning between the two can present a challenge due to overlapping indicators.

Further education around the issue and treating the underlying root cause can help, leaving patients in a much better place mentally and physically and not reliant on a CPAP machine.

Illustration of a Woman Stuggling to Fall Asleep Alone

Similarities Between Sleep Apnea and Depression Symptoms

Symptoms of both depression and sleep apnea often present the same, which commonly leads to misdiagnosis. Both conditions can occur concurrently, and sleep apnea is regularly diagnosed incorrectly as a result of these overlapping symptoms.

Sleep apnea is rarely assessed in people with depression because sleep issues are often a symptom of depression, leading to the condition going untreated. Some studies indicate a mutual relationship between sleep apnea and depression[2]. In some cases, sleep apnea was believed to be responsible for the failure of antidepressant treatment.

The overlapping symptoms can lead to both or either condition going untreated, potentially with life-threatening consequences.

Common Overlapping Symptoms Include:

Animated Image of a Woman Struggling To Fall Asleep
  • Headaches
  • Excessive daytime sleepiness after a full night of sleep
  • Concentration issues
  • Fatigue
  • Sleep deprivation
  • Insomnia
  • Negative thoughts or feelings of hopelessness

Americans are notorious for exhausting themselves, neglecting health conditions, and not taking time off to rest, so we often write off feelings of tiredness as typical side effects of being overworked and moody. However, these symptoms can indicate sleep apnea, depression, or both.

Awareness of both these issues and the various ways they may present may help you avoid misdiagnosis. While we regularly defer to highly-trained general practitioners, some doctors aren't familiar with mental health issues like depression or anxiety. Conversely, some psychiatrists specializing in mental health aren't trained in physical problems like sleep apnea.

Get More Info: 5 Signs You May Have Sleep Apnea

The Concurrent Appearance of Sleep Apnea and Depression

Obstructive, central, or complex sleep apnea and depression not only appear the same in many cases, but they commonly exist together as well, creating a challenge when diagnosing either condition. Studies indicate a higher prevalence of mental health issues, specifically depression, within obstructive sleep apnea patients.

Managing Sleep and Depresison Illustration

Long-term studies show an increased risk of depression development among individuals with sleep apnea; conversely, the studies show an association between the severity of sleep apnea and depression. Thus, it seems highly probable the two conditions are closely linked. Due to the overlapping nature of the issues, diagnosis can be complicated.

Keeping the association between both in mind and consulting doctors with experience discerning between the two may help with a correct diagnosis. While a significant connection between the conditions may present obstacles, treating both disorders at once could be an effective avenue for treatment.

Complex Sleep Apnea in Women and Misdiagnosis in the Female Population

To help physicians diagnose sleep apnea, the Apnoea-Hypopnea Index (AHI) was created. However, much scientific and medical research has historically been conducted by and on men. As a result, the AHI highly favors the male experience over the female experiences, but women don't always exhibit the same signs as men.

Specific medical criteria are used to help diagnose sleep apnea, but because most research has been done on males, the AHI numbers used to help discern whether or not a person suffers from the condition often don't encompass female experiences. For example, episodes of breathing pauses and upper airway resistance in women frequently fail to meet the criteria for apneas, leading to many female symptoms being disregarded.

Symptoms in Females Often Appear Differently Than in Males

Women typically don't present symptoms as strongly as men do, which is a significant reason why sleep apnea regularly goes undiagnosed and untreated in females. An AHI (apnoea-hypopnea index) represents the number of times a person's breathing pauses due to airway collapse per hour of sleep. According to research, women seem to have less severe complex sleep apnea symptoms with a shorter apnea-hypopnea index.[3]

The AHI measures the number of times a person's breath pauses or their airway collapses and how long it happens per hour of sleep. The AHI index guidelines state that apneas must occur for at least 10 seconds and be correlated with a decrease in blood oxygen level— however, the 10-second guideline was created in response to research conducted primarily on men.

Male and female bodies are different, so women typically experience pauses in breath or airway collapses at a lesser frequency than males and for shorter periods. 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.[4]

Illustration of Restless Leg Syndrome

Further, women commonly report symptoms unique to men's experiences. For example, females tend to present more daytime symptoms than men like restless legs, insomnia, nightmares, palpitations, depression, or hallucinations. Males, however, note more apneic episodes and snoring— issues that are more frequently associated with complex sleep apnea.[5]

Due to the lack of research in females, this leads to frequent misdiagnosis.

Women More Likely to be Misdiagnosed with Mental Health Issues

One theory why women are disproportionately misdiagnosed is that women may seek mental health treatment more than men due to societal norms, making it so symptoms may be more commonly attributed to depression in females by psychiatrists.

Further, while men with obstructive sleep apnea typically complain of snoring and apneic episodes, women with obstructive sleep apnea more often report other issues. For example, females usually report symptoms of insomnia, restless legs, anxiety, and depressive feelings— which are all commonly associated with depression and also indicative of obstructive sleep apnea.

As a result, many women are misdiagnosed with depression. While this can occur comorbidly to sleep apnea, failure to identify sleep apnea can lead to women suffering long-term from the condition, potentially, and ironically, even developing depression due to no treatment.

Other Reasons For A Misdiagnosis

A Doctor Standing Next to a Woman on an Exam Table Illustration

Some studies theorize that women are less likely to report chronic or loud snoring in themselves, possibly not recognizing that it indicates a severe problem. Further, women's breathing issues may be more subtle due to body differences, causing issues to go unidentified. Additionally, according to a study, researchers noticed that men seem to seek treatment due to their partner's observations, and attend doctor appointments with their partner, whereas women typically go to appointments independently.[6]

One research study went so far as to theorize that women possibly consider their snoring to be “unladylike” and thus don't report it to their doctor. Additionally, women usually attend clinical appointments independently, but men often bring their partner— leading to a more thorough assessment due to two people reporting symptoms rather than one.

Despite these issues predominantly affecting women, subtle symptoms still exist in men too. Requesting an overnight assessment in a sleep lab may be helpful in correctly identifying the problem.

Sleep Apnea, Cardiovascular Health, and Heart Disease

Not treating sleep apnea significantly increases the likelihood of cardiovascular disease and heart arrhythmias; in fact, it's estimated that people with sleep apnea are up to four times as likely to develop heart issues than healthy individuals. Further, the risk of heart failure is increased by 140% and coronary heart disease by 30% due to sleep apnea struggles.[7]

Obesity is frequently linked to the development of sleep apnea and heart disease. However, sleep apnea on its own can increase the risk for coronary disease, as well as obesity. As a result of these closely linked medical conditions, treating sleep apnea can often go ignored due to confusion of the overlapping symptoms.

Illustration of Tom and His Heart Having High Blood Pressure

Poor cardiovascular health is regularly attributed to obesity, which also plays a factor in sleep apnea. In addition, obesity is a common precursor to severe sleep apnea, being that the increase of fat deposits in the neck and throat area can wind up blocking the upper air passage during sleep.

According to studies, even just a 10% body weight increase could significantly up the risk of obstructive sleep apnea. Research suggests roughly 60 to 90% of individuals with obstructive or central sleep apnea are obese. Still, only about 30% of people with obesity are also diagnosed with sleep apnea— indicating a lack of correct sleep apnea diagnosis and sleep medicine.[8]

How to Avoid a Sleep Apnea Misdiagnosis

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

Request a Polysomnography

Physicians will occasionally recommend doing an overnight sleep study, otherwise known as polysomnography, to help in correctly identifying sleep apnea. Polysomnography is when a person will spend 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.

Polysomnography records the blood oxygen level, heart rate, brain waves, body movements, and breathing. In addition to assisting with a sleep apnea diagnosis, they may also help adjust treatment when necessary. Some home polysomnography tests are available; however, they are limited in identifying problems because they lack the comprehensive tools used in a designated lab.[9]

Illustration of A Doctor Doing Research on Patient Who Suffers from Insomnia

While at-home polysomnography tests can be helpful, home sleep studies can underestimate the severity of sleep apnea or even be incorrect entirely. A positive diagnosis of sleep apnea typically isn’t an issue, so it makes sense to treat the problem. However, negative results through at-home tests aren’t always accurate, in which case it’s wise to request a comprehensive sleep study in a laboratory.[10]

Keep In Mind The Overlapping Symptoms of Depression and Sleep Apnea

Education yourself and remaining aware of how closely overlapped the symptoms of sleep apnea are with indicators of depression may be key in deciphering between the two conditions. Sleep apnea could cause headaches, tiredness, restless legs, insomnia, fatigue, and negative feelings— possibly as a result of lack of quality rest— which may appear to indicate depression as well.

Culturally it may be more acceptable for women to embrace medication for depression, rather than sleep apnea, given the increased treatment for the mental issue in recent years. However, staying aware of the closely linked symptoms may save you unnecessary treatment for the wrong condition.

Discuss Issues with Both a Sleep Specialist and Psychiatrist

Consulting both a sleep specialist and a psychiatrist may be a wise avenue in seeking treatment. Many psychiatrists are well-versed in sleep apnea and other sleep disorders, but some are not. Sleep specialists may be more highly skilled and attuned to the nuances of sleep apnea and the various ways in which it can present in different people.

Psychiatrists may also be helpful if you're struggling with something that appears like sleep apnea. A doctor trained in mental health issues could recognize traits that other doctors may not. In addition, finding qualified professionals experienced in complex, obstructive, and central sleep apnea may be the difference between a correct diagnosis, saving you time and suffering.

Illustration of A Tired Man at the Doctors Office

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. Unfortunately, physicians and nurses don't always enquire about sleep symptoms, but this could be at your own cost, so finding an alternative professional who is well-versed in sleep apnea or depression could be worth your efforts.

Sources and References:

Content Writer

Rachael is a content writer for Sleep Advisor who loves combining her enthusiasm for writing and wellness. She’s had a passion for writing since she was a kid when she wrote awful poetry. She’s honed her craft quite a bit since then and considers herself a lucky duck to get paid to do what she loves.

Embracing the remote work life, she occasionally takes her work on the road and lives out her travel writer pipe dream.

In her free time, she attempts to meditate regularly, rides her bike to Trader Joe’s, and enjoys trying every type of food that she can get her hands on.

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