Sleep apnea and anxiety: how they're linked and what helps

Sleep apnea and anxiety often turn up together. Studies find anxiety symptoms in roughly a third of people with obstructive sleep apnea, and the two share enough symptoms that one can hide the other. Anxiety can also make CPAP, the main treatment, harder to get used to. The good news is that there are proven ways to make CPAP easier, and a sleep test can sort out what's going on at night.

Is sleep apnea linked to anxiety?

Sleep apnea and anxiety often go together. A 2020 systematic review and meta-analysis in Behavioral Sleep Medicine pulled together 73 studies of adults with obstructive sleep apnea. It found anxiety symptoms in about 32% of them and depressive symptoms in about 35%. The authors called the relationship probably bidirectional, meaning each condition may feed the other.

A large health records study points the same way. Researchers looked at more than 4 million people using the US Veterans Health Administration between 1998 and 2001 and found 118,105 with a sleep apnea diagnosis. Among them, 16.7% also had an anxiety diagnosis, 21.8% had depression and 11.9% had post-traumatic stress disorder. Each of these was significantly more common than in veterans without sleep apnea. The study was published in Sleep in 2005.

Neither study can show that sleep apnea causes anxiety. They show that the two often go together, which is reason enough for doctors and patients to look for both. We cover the related link with low mood in sleep apnea and depression.

Which symptoms do sleep apnea and anxiety share?

Sleep apnea and anxiety share several daytime symptoms, which is one reason sleep apnea can be missed in someone who already has an anxiety diagnosis. The table compares how the NHS describes sleep apnea with how the National Institute of Mental Health (NIMH) describes generalized anxiety disorder and panic attacks.

What sets sleep apnea apart are the night-time signs. The NHS lists breathing that stops and starts, gasping, snorting or choking noises, waking up a lot and loud snoring. You're usually asleep when they happen, so a partner is often the one who notices. The NHS suggests asking someone to stay with you while you sleep so they can check for symptoms.

Is it a panic attack or sleep apnea when you wake up gasping?

Waking up gasping can come from either sleep apnea or a panic attack, and you often can't tell which from the feeling alone. The NIMH lists a pounding or racing heart, sweating, chills, trembling, difficulty breathing, dizziness, chest pain and a fear of impending doom among panic attack symptoms. It says an attack can last from a few minutes to an hour or longer, and that panic attacks themselves aren't life-threatening.

Sleep apnea can bring on a similar jolt. The NHS lists gasping, snorting or choking noises and waking up a lot among its main symptoms. Some clues point toward sleep apnea, such as loud snoring, a partner noticing pauses in your breathing, and feeling very tired during the day. A sleep test is the only reliable way to know whether breathing pauses are behind your night-time episodes.

Chest pain, sudden severe breathlessness or fainting should never be put down to anxiety without a medical check. Our guide to waking up gasping covers other causes, from reflux to heart problems.

Does treating sleep apnea help anxiety?

Treating sleep apnea with CPAP doesn't seem to ease anxiety directly, though it does help other things. The best evidence comes from a secondary analysis of the SAVE trial, published in EClinicalMedicine in 2019. It included 2,410 people with moderate to severe sleep apnea and heart or blood vessel disease, followed for an average of 3.7 years.

CPAP lowered the odds of clinically relevant depression symptoms by about 20% compared with usual care. It made no difference to anxiety. The same paper reviewed randomized trials of CPAP and again found a benefit for depression symptoms but not for anxiety.

That doesn't mean treatment is pointless for someone with anxiety. Sleep apnea itself is worth treating, and anxiety has its own effective treatments. The NIMH says treatment for generalized anxiety disorder usually involves psychotherapy, medication or both, with cognitive behavioral therapy commonly used. Treating both conditions side by side is a sensible approach.

Why does CPAP make some people anxious?

CPAP makes some people anxious because the mask and the airflow can feel confining, a reaction often described as CPAP claustrophobia. A 2015 study in Heart & Lung measured claustrophobic tendencies in 97 adults with sleep apnea right after their first night on CPAP. Sixty-three percent had them, and women scored higher than men.

That reaction mattered. People with high claustrophobia scores were more likely to be non-adherent to CPAP after one week and to use it less after one month, even after the researchers took body weight and mask style into account. A 2020 teaching paper in MedEdPORTAL describes CPAP claustrophobia as discomfort with the mask, the air pressure or both, leading to anxiety, worry, avoidance and often insomnia.

If this sounds familiar, you're far from alone, and it doesn't mean CPAP can't work for you. Our guide to getting used to CPAP has more on the first weeks.

How can you get past CPAP anxiety?

You can get past CPAP anxiety by building up gradually and asking your care team to adjust the equipment. The NHLBI's advice includes:

• Wear your mask for part of the day, such as while watching TV, to get used to how it feels.
• Adjust the mask each night while lying down with the machine on, to make sure it fits.
• Tell your provider if you feel claustrophobic or are bothered by the noise. They can suggest a different type of mask or machine, or adjust the settings, such as having the pressure ramp up gradually while you fall asleep.
• Be patient, as it can take time to adjust.

Mask style is one of the things your provider can change. CPAP mask types explains the options, from full face masks to small nasal pillows.

For stronger fear, there's a structured approach called CPAP desensitization. The MedEdPORTAL paper describes it as a form of graded exposure therapy, in which you practice with the mask in small, manageable steps until it stops triggering anxiety. It notes that case studies and case series have reported large gains, including 2.6 more hours of use a night in one study, though large trials of desensitization itself haven't been done. Ask your sleep clinic whether a psychologist trained in behavioral sleep medicine can offer it.

Behavioral support in general has good evidence behind it. A 2020 Cochrane review found that in people new to CPAP, behavioral interventions increased use by about 1.3 hours a night compared with usual care, based on high-certainty evidence. Ask your sleep clinic whether this kind of support is available.

How do you get tested for sleep apnea if you have anxiety?

Getting tested for sleep apnea starts with telling your doctor about your night-time symptoms, alongside your anxiety. The NHS advises seeing a GP if your breathing stops and starts during sleep, you make gasping, snorting or choking noises, or you always feel very tired during the day. If someone else has seen the symptoms, it can help to bring them along.

The authors of the veterans study concluded that people with psychiatric conditions who also have symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea. In other words, an anxiety diagnosis shouldn't stop anyone from checking for sleep apnea too.

Testing is usually simple. The NHS says you may be given devices that check your breathing and heartbeat overnight, usually at home, though sometimes you'll stay at a clinic. The results give an apnea-hypopnea index (AHI): 5 to 14 is mild, 15 to 30 is moderate and over 30 is severe. If the idea of an overnight test makes you anxious, a home test may feel easier. Our guides to the home sleep apnea test and what happens at a sleep study explain what to expect.

When should you see a doctor?

See a doctor if you have signs of sleep apnea, such as loud snoring, breathing pauses someone has noticed, gasping or choking at night, or heavy daytime tiredness. The NHS says sleep apnea can be serious if it isn't diagnosed and treated. It's also worth seeing a doctor if anxiety is affecting your sleep, work or relationships, or if you're on CPAP and struggling to keep using it. If you're pregnant and have new snoring or breathing pauses, mention it to your clinician.

If you're in crisis or having thoughts of harming yourself, the NIMH says to call or text the 988 Suicide & Crisis Lifeline in the US. In a life-threatening situation, call 911.

This article is general information, not medical advice. Talk to your doctor about your own sleep and mental health.

Read next

• Sleep apnea and depression
• Getting used to CPAP
• Sleep apnea warning signs

* This content is for informational and educational purposes only and is not medical advice. It is not intended to diagnose, treat, cure or prevent any disease or health condition. Talk to a qualified healthcare provider about your health.