Association Between Anxiety and Obstructive Sleep Apnea
Yes, there is a well-established bidirectional association between anxiety and OSA, with approximately 32% of OSA patients experiencing anxiety symptoms, and anxiety patients having nearly double the risk of developing OSA. 1, 2
Prevalence and Strength of Association
The relationship between anxiety and OSA is clinically significant and bidirectional:
Pooled prevalence data demonstrates that 32% (95% CI, 22-42%) of OSA patients experience anxious symptoms, making anxiety one of the most common psychiatric comorbidities in this population 1
Patients with anxiety disorders have an 86% increased risk of OSA comorbidity (adjusted OR = 1.864; 95% CI = 1.337-2.405) compared to those without anxiety 2
The VA/DoD guidelines specifically recognize that military personnel and veterans with sleep disorders frequently present with comorbid PTSD and symptoms of anxiety, which complicates both diagnosis and management 3
High-Risk Subgroups Requiring Heightened Vigilance
Certain populations demonstrate particularly strong associations that warrant aggressive screening:
Male patients with anxiety have more than double the risk of OSA (adjusted OR = 2.104; 95% CI = 1.436-2.589) 2
Patients aged 18-44 years with anxiety show elevated risk (adjusted OR = 1.942; 95% CI = 1.390-2.503) 2
Patients aged 45-64 years with anxiety demonstrate even higher risk (adjusted OR = 2.179; 95% CI = 1.564-2.811) 2
Hypertensive patients with anxiety face substantially increased OSA risk (adjusted OR = 2.092; 95% CI = 1.497-2.706) 2
Critical Clinical Nuances: Severity Paradox
A counterintuitive finding reveals that anxiety symptoms correlate inversely with OSA severity as measured by AHI, which has important diagnostic implications 4:
Patients with severe OSA (AHI ≥30) are significantly less likely to have depression and anxiety symptoms compared to those with mild OSA, even after adjusting for age, sex, comorbidities, psychiatric history, and daytime sleepiness 4
However, subjective OSA symptoms—particularly nocturnal awakenings and morning waking symptoms—are positively correlated with anxiety, independent of AHI severity 4
This suggests that relying solely on AHI to predict psychiatric comorbidity will miss many anxious patients with OSA 4
Persistence of Anxiety as a Severity Marker
The persistence of anxiety over time shows a linear relationship with OSA severity 5:
Each one-unit increase in AHI increases the likelihood of persistent anxiety by 18% (OR 1.18; 95% CI 1.03-1.34) after adjusting for age, sex, and body fat percentage 5
Lifestyle modifications focusing solely on diet and exercise may be insufficient to treat OSA in patients with persistent anxiety, suggesting the need for integrated psychiatric treatment 5
Treatment Implications for PAP Adherence
The VA/DoD guidelines emphasize that anxiety is a recognized barrier to PAP therapy adherence 3:
Patients with OSA and concurrent anxiety should be offered adherence interventions upon PAP initiation (weak recommendation) 3
Educational, behavioral, and supportive interventions are strongly recommended to improve PAP adherence in high-risk patients with anxiety (strong recommendation) 3
Screening Recommendations
Based on the evidence, clinicians should:
Screen all OSA patients for anxiety using validated tools such as the Generalized Anxiety Disorder-7 (GAD-7) scale, with scores ≥8 indicating clinically significant anxiety 4, 6
Screen anxiety patients—particularly males, those aged 18-64 years, and those with hypertension—for OSA using the STOP questionnaire, with scores ≥2 indicating high risk 3, 2
Pay particular attention to subjective sleep complaints (nocturnal awakenings, morning symptoms) rather than relying solely on AHI, as these correlate more strongly with anxiety 4
Common Pitfall to Avoid
Do not assume that patients with mild OSA (low AHI) are less likely to have anxiety—the opposite is true. The severity paradox means that patients with less severe respiratory events may actually have higher rates of anxiety symptoms, possibly because they remain more aware of their sleep disturbances 4. Focus on the patient's subjective experience and functional impairment rather than AHI alone when assessing psychiatric comorbidity.