Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease
Abstract
:1. Introduction
2. Experimental Section
2.1. Study Population
2.2. Clinical Assessment and Spirometry Measurements
2.3. Questionnaires
2.4. Sleep Study
2.5. Data Analysis
2.6. Statistical Analysis
3. Results
3.1. Demographic Data
3.2. Respiratory and Metabolic Indices
3.3. Questionnaires
3.4. Sleep Data
3.5. Comorbidities
3.6. Medications
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Acknowledgments
Conflicts of Interest
References
- Pack, A.I. Advances in sleep-disordered breathing. Am. J. Respir. Crit. Care Med. 2006, 173, 7–15. [Google Scholar] [CrossRef] [PubMed]
- Kallianos, A.; Trakada, G.; Papaioannou, T.; Nikolopouloss, I.; Mitrakou, A.; Manios, E.; Kostopoulos, K.; Kostopoulos, C.; Zakopoulos, N. Glucose and arterial blood pressure variability in obstructive sleep apnea syndrome. Eur. Rev. Med. Pharmacol. Sci. 2013, 17, 1932–1937. [Google Scholar] [PubMed]
- Trakada, G.; Chrousos, G.; Pejovic, S.; Vgontzas, A. Sleep apnea and its association with the stress system, inflammation, insulin resistance and visceral obesity. Sleep Med. Clin. 2007, 2, 251–261. [Google Scholar] [CrossRef] [PubMed]
- American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual, 3rd ed.; American Academy of Sleep Medicine: Westchester, NY, USA, 2014. [Google Scholar]
- Heinzer, R.; Vat, S.; Marques-Vidal, P.; Marti-Soler, H.; Andries, D.; Tobback, N.; Mooser, V.; Preisig, M.; Malhotra, A.; Waeber, G.; et al. Prevalence of sleep-disordered breathing in the general population: The hypnolaus study. Lancet Respir. Med. 2015, 3, 310–318. [Google Scholar] [CrossRef]
- Senaratna, C.V.; Perret, J.L.; Lodge, C.J.; Lowe, A.J.; Campbell, B.E.; Matheson, M.C.; Hamilton, G.S.; Dharmage, S.C. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med. Rev. 2017, 34, 70–81. [Google Scholar] [CrossRef] [PubMed]
- Gupta, M.A.; Simpson, F.C. Obstructive sleep apnea and psychiatric disorders: A systematic review. J. Clin. Sleep Med. 2015, 11, 165–175. [Google Scholar] [CrossRef] [PubMed]
- Grunstein, R.; Wilcox, I.; Yang, T.S.; Gould, Y.; Hedner, J. Snoring and sleep apnoea in men: Association with central obesity and hypertension. Int. J. Obes. Relat. Metab. Disord. 1993, 17, 533–540. [Google Scholar]
- Allison, D.B.; Newcomer, J.W.; Dunn, A.L.; Blumenthal, J.A.; Fabricatore, A.N.; Daumit, G.L.; Cope, M.B.; Riley, W.T.; Vreeland, B.; Hibbeln, J.R.; et al. Obesity among those with mental disorders: A national institute of mental health meeting report. Am. J. Prev. Med. 2009, 36, 341–350. [Google Scholar] [CrossRef]
- Chrousos, G.P. The role of stress and the hypothalamic-pituitary-adrenal axis in the pathogenesis of the metabolic syndrome: Neuro-endocrine and target tissue-related causes. Int. J. Obes. Relat. Metab. Disord. 2000, 24, S50–55. [Google Scholar] [CrossRef]
- Vancampfort, D.; Probst, M.; Stubbs, B.; Soundy, A.; De Herdt, A.; De Hert, M. Metabolic syndrome and lung function in schizophrenia: A pilot study. Psychiatry Res. 2014, 220, 58–62. [Google Scholar] [CrossRef] [Green Version]
- Himelhoch, S.; Lehman, A.; Kreyenbuhl, J.; Daumit, G.; Brown, C.; Dixon, L. Prevalence of chronic obstructive pulmonary disease among those with serious mental illness. Am. J. Psychiatry 2004, 161, 2317–2319. [Google Scholar] [CrossRef] [PubMed]
- Partti, K.; Vasankari, T.; Kanervisto, M.; Perala, J.; Saarni, S.I.; Jousilahti, P.; Lonnqvist, J.; Suvisaari, J. Lung function and respiratory diseases in people with psychosis: Population-based study. Br. J. Psychiatry 2015, 207, 37–45. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Stubbs, B.; Vancampfort, D.; Veronese, N.; Solmi, M.; Gaughran, F.; Manu, P.; Rosenbaum, S.; De Hert, M.; Fornaro, M. The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: A systematic review and meta-analysis. J. Affect. Disord. 2016, 197, 259–267. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Available online: http://www.who.int/iris/handle/10665/37958 (accessed on 1 March 2019).
- Miller, M.R.; Hankinson, J.; Brusasco, V.; Burgos, F.; Casaburi, R.; Coates, A.; Crapo, R.; Enright, P.; van der Grinten, C.P.; Gustafsson, P.; et al. Standardisation of spirometry. Eur. Respir. J. 2005, 26, 319–338. [Google Scholar] [CrossRef] [Green Version]
- Chung, F.; Yegneswaran, B.; Liao, P.; Chung, S.A.; Vairavanathan, S.; Islam, S.; Khajehdehi, A.; Shapiro, C.M. Stop questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology 2008, 108, 812–821. [Google Scholar] [CrossRef] [PubMed]
- Johns, M.W. A new method for measuring daytime sleepiness: The epworth sleepiness scale. Sleep 1991, 14, 540–545. [Google Scholar] [CrossRef] [PubMed]
- Valko, P.O.; Bassetti, C.L.; Bloch, K.E.; Held, U.; Baumann, C.R. Validation of the fatigue severity scale in a swiss cohort. Sleep 2008, 31, 1601–1607. [Google Scholar] [CrossRef] [PubMed]
- Zigmond, A.S.; Snaith, R.P. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 1983, 67, 361–370. [Google Scholar] [CrossRef] [PubMed]
- Berry, R.B.; Budhiraja, R.; Gottlieb, D.J.; Gozal, D.; Iber, C.; Kapur, V.K.; Marcus, C.L.; Mehra, R.; Parthasarathy, S.; Quan, S.F.; et al. Rules for scoring respiratory events in sleep: Update of the 2007 aasm manual for the scoring of sleep and associated events. Deliberations of the sleep apnea definitions task force of the American academy of sleep medicine. J. Clin. Sleep Med. 2012, 8, 597–619. [Google Scholar]
- WHO Collaborating Centre for Drug Statistics Methodology. Guidelines for ATC Classification and DDD Assignment; WHO Collaborating Centre for Drug Statistics Methodology: Oslo, Norway, 2017. [Google Scholar]
- Lakens, D. Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and anovas. Front. Psychol. 2013, 4, 863. [Google Scholar] [CrossRef]
- Tufik, S.; Santos-Silva, R.; Taddei, J.A.; Bittencourt, L.R. Obstructive sleep apnea syndrome in the sao paulo epidemiologic sleep study. Sleep Med. 2010, 11, 441–446. [Google Scholar] [CrossRef] [PubMed]
- Young, T.; Evans, L.; Finn, L.; Palta, M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997, 20, 705–706. [Google Scholar] [CrossRef] [PubMed]
- Trakada, G.; Steiropoulos, P.; Bouros, D. Continuous positive airways pressure treatment in a patient with sleep apnea-hypopnea syndrome and coexisting bipolar disorder. Psychopharmacol. Bull. 2008, 41, 89–92. [Google Scholar] [PubMed]
- Trakada, G.; Velentza, L.; Konsta, A.; Pataka, A.; Zarogoulidis, P.; Dikeos, D. Complications of anesthesia during electroconvulsive therapy due to undiagnosed obstructive sleep apnea: A case-study. Respir. Med. Case Rep. 2017, 20, 145–149. [Google Scholar] [CrossRef] [PubMed]
- Alam, A.; Chengappa, K.N.; Ghinassi, F. Screening for obstructive sleep apnea among individuals with severe mental illness at a primary care clinic. Gen. Hosp. Psychiatry 2012, 34, 660–664. [Google Scholar] [CrossRef] [PubMed]
- Krieger, J. Breathing during sleep in normal subjects. Clin. Chest Med. 1985, 6, 577–594. [Google Scholar]
- Guilleminault, C.; Hagen, C.C.; Huynh, N.T. Comparison of hypopnea definitions in lean patients with known obstructive sleep apnea hypopnea syndrome (OSAHS). Sleep Breath 2009, 13, 341–347. [Google Scholar] [CrossRef]
- Gupta, M.A.; Simpson, F.C.; Lyons, D.C. The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: A systematic review and meta-analysis. Sleep Med. Rev. 2016, 28, 55–68. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Lopresti, A.L.; Drummond, P.D. Obesity and psychiatric disorders: Commonalities in dysregulated biological pathways and their implications for treatment. Prog. Neuro-Psychopharmacol. Biol. Psychiatry 2013, 45, 92–99. [Google Scholar] [CrossRef] [Green Version]
- Ness-Abramof, R.; Apovian, C.M. Waist circumference measurement in clinical practice. Nutr. Clin. Pract. 2008, 23, 397–404. [Google Scholar] [CrossRef]
- Luppino, F.S.; de Wit, L.M.; Bouvy, P.F.; Stijnen, T.; Cuijpers, P.; Penninx, B.W.; Zitman, F.G. Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Arch. Gen. Psychiatry 2010, 67, 220–229. [Google Scholar] [CrossRef] [PubMed]
- Bak, M.; Fransen, A.; Janssen, J.; van Os, J.; Drukker, M. Almost all antipsychotics result in weight gain: A meta-analysis. PloS ONE 2014, 9, e94112. [Google Scholar] [CrossRef] [PubMed]
- Rishi, M.A.; Shetty, M.; Wolff, A.; Amoateng-Adjepong, Y.; Manthous, C.A. Atypical antipsychotic medications are independently associated with severe obstructive sleep apnea. Clin. Neuropharmacol. 2010, 33, 109–113. [Google Scholar] [CrossRef]
- Norton, J.R.; Ward, D.S.; Karan, S.; Voter, W.A.; Palmer, L.; Varlese, A.; Rackovsky, O.; Bailey, P. Differences between midazolam and propofol sedation on upper airway collapsibility using dynamic negative airway pressure. Anesthesiology 2006, 104, 1155–1164. [Google Scholar] [CrossRef] [PubMed]
- Agnew, H.W., Jr.; Webb, W.B.; Williams, R.L. The first night effect: An EEG study of sleep. Psychophysiology 1966, 2, 263–266. [Google Scholar] [CrossRef]
- Hombali, A.; Seow, E.; Yuan, Q.; Chang, S.H.S.; Satghare, P.; Kumar, S.; Verma, S.K.; Mok, Y.M.; Chong, S.A.; Subramaniam, M. Prevalence and correlates of sleep disorder symptoms in psychiatric disorders. Psychiatry Res. 2018. [Google Scholar] [CrossRef] [PubMed]
Total Population (n = 110) | Major Depressive Disorder (MDD) (n = 66) | Bipolar Disorder (BD) (n = 34) | Schizophrenia and Psychotic Disorder (n = 10) | |
---|---|---|---|---|
Sex (men/women) | 54/56 | 29/37 | 15/19 | 10/0 † |
Age (years) | 55.1 ± 10.6 | 57.2 ± 10.4 | 52.6 ± 10.6 | 51.0 ± 9.8 |
BMI (kg/m2) | 32.6 ± 6.6 | 32.1 ± 7.1 | 34.0 ± 6.1 | 31.3 ± 4.3 |
Neck circumference (cm) | 40.9 ± 5.2 | 40.2 ± 5.3 | 41.1 ± 4.3 | 44.8 ± 5.9 * |
Waist circumference (cm) | 113.0 ± 14.3 | 109.9 ± 15.4 | 117.0 ± 11.3 | 120.7 ± 9.1 * |
Hip circumference (cm) | 112.3 ± 12.0 | 110.8 ± 12.2 | 114.9 ± 12.5 | 113.8 ± 5.8 |
Systolic Arterial Blood Pressure (mmHg) | 122.6 ± 16.2 | 122.2 ± 15.2 | 123.5 ± 18.7 | 122.5 ± 15.6 |
Diastolic Arterial Blood Pressure (mmHg) | 79.4 ± 10.3 | 78.6 ± 10.3 | 79.4 ± 11.1 | 84.4 ± 7.3 |
FVC (L) | 3.21 ± 1.01 | 3.20 ± 1.05 | 3.20 ± 0.99 | 3.36 ± 0.91 |
FVC (%) | 91.4 ± 16.8 | 94.1 ± 17.1 | 90.0 ± 14.5 | 77.0 ± 15.7 * |
FEV1 (L) | 2.72 ± 1.09 | 2.64 ± 0.95 | 2.86 ± 1.39 | 2.80 ± 0.76 |
FEV1 (%) | 91.9 ± 17.4 | 94.3 ± 18.5 | 90.7 ± 13.4 | 79.6 ± 17.8 |
FEV1/FVC | 82.8 ± 6.2 | 82.1 ± 6.6 | 84.0 ± 5.7 | 83.5 ± 5.1 |
PEF (L/min) | 6.40 ± 2.31 | 6.48 ± 2.24 | 6.24 ± 2.38 | 6.36 ± 2.83 |
PEF (%) | 88.2 ± 23.5 | 91.5 ± 21.7 | 85.4 ± 23.0 | 74.5 ± 32.9 |
SaO2 (%) | 96.1 ± 1.8 | 96.3 ± 1.7 | 95.8 ± 2.0 | 96.2 ± 2.3 |
Total Population (n = 110) | Major Depressive Disorder (MDD) (n = 66) | Bipolar Disorder (BD) (n = 34) | Schizophrenia and Psychotic Disorder (n = 10) | |
---|---|---|---|---|
ESS | 7.9 ± 5.0 | 8.5 ± 5.0 | 6.8 ± 4.9 | 8.2 ± 5.2 |
FSS | 5.7 ± 1.9 | 5.2 ± 2.2 | 6.4 ± 0.8 | 7.0 ± 0.0 |
HADS A | 10.3 ± 5.6 | 9.2 ± 5.0 | 12.2 ± 5.8 | 10.1 ± 6.9 |
HADS D | 10.4 ± 5.6 | 9.0 ± 5.0 | 12.6 ± 5.8 * | 10.5 ± 5.9 |
Total Population (n = 110) | Major Depressive Disorder (MDD) (n = 66) | Bipolar Disorder (BD) (n = 34) | Schizophrenia and Psychotic Disorder (n = 10) | P Value | η2 (Effect Size) | |
---|---|---|---|---|---|---|
TRT (min) | 348.2 ± 99.6 | 352.3 ± 99.3 | 355.7 ± 88.0 | 291.5 ± 132.3 | 0.202 | 0.030 |
TST (min) | 273.5 ± 98.3 | 275.9 ± 103.4 | 280.9 ± 89.6 | 228.8 ± 87.5 | 0.355 | 0.020 |
SE (%) | 79.0 ± 17.0 | 77.7 ± 19.1 | 80.8 ± 13.0 | 81.2 ± 12.7 | 0.641 | 0.008 |
Sleep onset (min) | 32.3 ± 37.5 | 30.8 ± 30.5 | 34.4 ± 36.7 | 34.6 ± 75.6 | 0.888 | 0.002 |
WASO (min) | 50.0 ± 65.5 | 48.6 ± 70.5 | 58.6 ± 63.2 | 19.8 ± 27.4 | 0.751 | 0.020 |
N1 (min) | 23.8 ± 33.1 | 24.2 ± 34.5 | 19.9 ± 27.5 | 34.7 ± 42.4 | 0.487 | 0.014 |
N1 (%) | 10.5 ± 15.6 | 10.0 ± 13.1 | 7.9 ± 10.7 | 22.8 ± 34.8 | 0.037 | 0.061 |
N2 (min) | 183.7 ± 90.5 | 180.7 ± 93.3 | 195.4 ± 77.6 | 161.8 ± 116.3 | 0.567 | 0.011 |
N2 (%) | 67.0 ± 22.9 | 66.0 ± 22.8 | 69.8 ± 19.1 | 64.2 ± 35.8 | 0.688 | 0.007 |
N3 (min) | 39.5 ± 43.7 | 38.9 ± 43.3 | 44.0 ± 44.1 | 27.2 ± 48.2 | 0.587 | 0.010 |
N3 (%) | 14.0 ± 15.4 | 13.9 ± 15.6 | 14.9 ± 14.1 | 11.0 ± 19.1 | 0.795 | 0.004 |
REM (min) | 24.1 ± 31.6 | 28.4 ± 36.4 | 20.7 ± 21.1 | 5.1 ± 13.2 | 0.087 | 0.046 |
REM (%) | 8.9 ± 12.3 | 10.5 ± 14.3 | 7.4 ± 7.9 | 2.1 ± 5.4 | 0.112 | 0.041 |
Apneas (n) | 151.7 ± 134.1 | 142.3 ± 122.6 | 147.0 ± 143.4 | 237.9 ± 164.1 | 0.130 | 0.038 |
Obstructive (n) | 49.6 ± 85.3 | 41.9 ± 63.2 | 44.9 ± 82.3 | 118.6 ± 172.4 | 0.038 | 0.064 |
Central (n) | 19.4 ± 44.8 | 21.4 ± 49.0 | 14.2 ± 32.4 | 24.4 ± 55.9 | 0.721 | 0.007 |
Mixed (n) | 6.9 ± 17.3 | 8.5 ± 20.8 | 3.4 ± 8.0 | 9.0 ± 15.9 | 0.390 | 0.019 |
Hypopneas (n) | 83.1 ± 77.7 | 79.2 ± 73.6 | 89.9 ± 90.7 | 85.9 ± 58.5 | 0.815 | 0.004 |
Mean Duration (s) | 19.6 ± 4.8 | 19.8 ± 4.5 | 18.7 ± 4.3 | 22.2 ± 7.8 | 0.161 | 0.035 |
Max Duration (s) | 49.8 ± 26.0 | 48.8 ± 22.9 | 46.8 ± 23.0 | 67.9 ± 47.1 | 0.085 | 0.047 |
AHI | 35.3 ± 27.3 | 33.3 ± 24.8 | 30.9 ± 25.9 | 66.1 ± 33.6 * | 0.001 | 0.119 |
AHI (nREM) | 34.0 ± 28.4 | 31.9 ± 26. 1 | 28.9 ± 26.0 | 66.5 ± 33.4 * | 0.001 | 0.131 |
AHI (REM) | 18.3 ± 25.7 | 19.2 ± 27.1 | 20.0 ± 25.3 | 6.7 ± 13.2 | 0.364 | 0.021 |
minSaO2 (%) | 82.9 ± 7.7 | 84.2 ± 6.1 | 82.2 ± 8.2 | 75.3 ± 12.4 | 0.006 | 0.096 |
meanSaO2 (%) | 92.1 ± 2.8 | 92.5 ± 2.6 | 92.2 ± 2.3 | 88.4 ± 4.2 * | <0.001 | 0.142 |
SaO2 < 90% (min) | 23.8 ± 44.5 | 20.9 ± 41.5 | 20.5 ± 33.2 | 61.2 ± 85.0 | 0.046 | 0.058 |
SaO2 < 90% (%) | 16.7 ± 26.3 | 13.8 ± 23.9 | 15.4 ± 25.8 | 45.2 ± 33.1 | 0.005 | 0.098 |
Variable | Medication Group | p Value | η2 (Effect Size) | ||||||
---|---|---|---|---|---|---|---|---|---|
N03 (n = 2) | N05 (n = 6) | N06 (n = 29) | N03, N05 (n = 5) | N03, N06 (n = 7) | N05, N06 (n = 21) | N03, N05, N06 (n = 15) | |||
BMI (kg/m2) | 28.6 ± 2.9 | 29.8 ± 6.0 | 30.2 ± 7.1 | 32.3 ± 5.8 | 32.8 ± 3.5 | 34.4 ± 5.5 | 35.7 ± 6.3 | 0.078 | 0.132 |
Neck circumference (cm) | 42.0 ± 8.5 | 43.3 ± 7.3 | 38.5 ± 4.3 | 40.2 ± 4.8 | 42.9 ± 5.9 | 42.0 ± 4.0 | 41.1 ± 5.2 | 0.128 | 0.120 |
Waist circumference (cm) | 109.5 ± 3.5 | 113.3 ± 12.3 | 106.1 ± 16.0 | 115.2 ± 16.8 | 117.1 ± 13.2 | 117.0 ± 11.6 | 119.8 ± 10.6 | 0.046 | 0.151 |
Hip circumference (cm) | 103.5 ± 7.8 | 110.8 ± 8.2 | 108.8 ± 11.4 | 112.8 ± 4.8 | 116.4 ± 9.3 | 116.4 ± 14.2 | 118.9 ± 11.6 | 0.091 | 0.131 |
FEV1 (%) | 113.2 ± 26.2 | 82..4 ± 19.3 | 97.0 ± 12.7 | 86.2 ± 15.2 | 97.3 ± 15.6 | 90.4 ± 18.2 | 87.2 ± 16.1 | 0.091 | 0.129 |
FVC (%) | 110.6 ± 5.7 | 81.1 ± 16.6 | 97.8 ± 14.3 | 83.1 ± 14.7 | 96.9 ± 15.7 | 89.1 ± 18.4 | 85.0 ± 14.9 | 0.027 | 0.165 |
AHI | 31.8 ± 0.0 | 55.8 ± 32.0 | 31.3 ± 21.6 | 53.1 ± 50.9 | 50.1 ± 32.2 | 24.0 ± 18.9 | 32.1 ± 26.5 | 0.058 | 0.146 |
meanSaO2 (%) | 95.0 ± 0.0 | 88.7 ± 4.4 | 92.6 ± 2.5 | 92.9 ± 2.4 | 92.6 ± 1.9 | 92.3 ± 3.0 | 91.3 ± 3.2 | 0.077 | 0.138 |
minSaO2 (%) | 93.0 ± 0.0 | 76.0 ± 13.3 | 85.5 ± 5.7 | 83.2 ± 8.3 | 81.7 ± 7.3 | 83.3 ± 6.7 | 80.9 ± 10.7 | 0.131 | 0.120 |
time with SaO2 < 90% (min) | 0.0 ± 0.0 | 58.3 ± 44.5 | 8.6 ± 14.6 | 14.6 ± 15.7 | 14.2 ± 12.8 | 18.3 ± 31.4 | 25.2 ± 32.8 | 0.006 | 0.211 |
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Knechtle, B.; Economou, N.-T.; Nikolaidis, P.T.; Velentza, L.; Kallianos, A.; Steiropoulos, P.; Koutsompolis, D.; Rosemann, T.; Trakada, G. Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease. J. Clin. Med. 2019, 8, 534. https://doi.org/10.3390/jcm8040534
Knechtle B, Economou N-T, Nikolaidis PT, Velentza L, Kallianos A, Steiropoulos P, Koutsompolis D, Rosemann T, Trakada G. Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease. Journal of Clinical Medicine. 2019; 8(4):534. https://doi.org/10.3390/jcm8040534
Chicago/Turabian StyleKnechtle, Beat, Nicholas-Tiberio Economou, Pantelis T. Nikolaidis, Lemonia Velentza, Anastasios Kallianos, Paschalis Steiropoulos, Dimitrios Koutsompolis, Thomas Rosemann, and Georgia Trakada. 2019. "Clinical Characteristics of Obstructive Sleep Apnea in Psychiatric Disease" Journal of Clinical Medicine 8, no. 4: 534. https://doi.org/10.3390/jcm8040534