INTRODUCTION
Sleep-related breathing disorders (SRBDs), such as obstructive sleep apnea and upper airway resistance syndrome, are characterized by repetitive upper airway obstructions during sleep. These diseases’ main symptoms are loud snoring, disrupted nocturnal sleep, and excessive daytime sleepiness. The course is usually progressive, and profound functional impairment and/or life-threatening complications can occur.
1 According to recent, extensive population-based surveys on SRBDs, SRBD prevalence is relatively high, especially among obese middle-aged and older adults,
2,
3 and SRBDs constitute a major public health problem.
4,
5
A diagnosis of SRBD is stressful because of the disorder’s progressive course and associated significant physical and psychological distress. Many studies have documented that patients with SRBD experience mood changes, psychological dysfunction,
6,
7 and an impaired quality of life.
8
Coping has been defined as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.”
9 Researchers view coping as a response to perceived stress and considered it to be particularly important for mediating life stresses and the onset of a psychiatric illness, especially depression.
9 It has two widely-recognized major functions: regulating emotions or distress (emotion-focused coping) and managing the problem causing the distress (problem-focused coping). In most stressful encounters, individuals use both forms of coping apportioning the amount of each form according to how the individual appraises the encounter.
10 The type of coping strategies one uses influences one’s feelings. Researchers have thought that the use of cognitive coping strategies reduce the depression levels individuals experience, while the use of avoidance (emotion-focused) coping strategies correlate with higher levels of depression and anxiety.
10–
13 Although little consensus exists regarding which coping strategies are effective for dealing with stress,
14 in practice, studies have often implied that active coping behaviors, such as problem-solving and seeking social support, are “adaptive,” whereas suppression coping such as avoidance and distancing, are “maladaptive.”
During the past few decades, reports in the medical and psychological literature have increasingly focused on strategies for coping with chronic illness. However, researchers know little about the strategies patients with SRBD employ to cope with their illnesses or the extent to which these coping strategies affect patients’ psychological distress, such as depression. Knowledge regarding psychological distress and coping strategies in patients with SRBD would be useful for developing a comprehensive treatment for such patients.
This study examined the following hypotheses:
a) Patients with SRBD are under higher stress and more depressed than is the general population.
b) Patients with SRBD are likely to use more emotion-focused than problem-focused coping.
c) Patients’ emotion-focused coping correlates positively with daytime sleepiness, perceived stress, and depressive mood, while problem-focused coping correlates negatively with these same parameters.
DISCUSSION
This study’s main results show that the patients with SRBD involving daytime sleepiness are under higher stress, report a more depressed mood, and, in general, use a greater number of problem-focused (as opposed to emotion-focused) coping strategies. The patients and controls used similar coping strategies; however, those who had higher scores regarding daytime sleepiness, perceived stress, and/or depressive mood used emotion-focused coping significantly more often.
As hypothesized, the patients’ reported daytime sleepiness complaints, perceived stress, and depressive moods were of a clinically significant level.
Excessive daytime sleepiness is an important SRBD symptom, since impaired alertness may lead to personal, familial, and social dysfunctions. Our patients had a mean ESS score of 10.7, which indicates clinically significant daytime sleepiness.
19 The patient subgroup complaining of daytime sleepiness was more depressed and additionally showed higher coping strategy mean values (except for in the Seeking Social Support and Accepting Responsibility strategies), compared to patients without excessive daytime sleepiness. Since the number of coping strategies utilized indicates the extent of the coping effort, these results suggest that the excessive daytime sleepiness symptom caused them to expend more effort on coping than did their counterparts.
This study suggests that patients with SRBD are under higher stress and perceived greater stress in daily life than did controls. Of the 170 patients and 71 controls, 104 patients (61.2%) and 25 controls (35.2%) reported that they were under a high level of stress, which was significantly different. Compared with their counterparts, the group with the higher perceived stress level was more likely to use all kinds of coping strategies and to be more depressed. It is not surprising that their responses to the WCQ reflect their greater need to cope by their engagement of a greater variety of coping strategies, which indicates a higher stress level.
Of the 170 patients, we classified 37 (21.8%) as depressed, using the BDI cut-off score of 14. This percentage is slightly lower than that the literature generally reports regarding medically ill patients.
23,
24 Patients with SRBD commonly report depression,
6,
7,
25 although some researchers do not find any evidence of depression in SRBD patients.
26,
27 Researchers think that the causes of such patients’ depression stems from physical and psychological distresses secondary to their SRBD symptoms, such as excessive daytime sleepiness, fatigue, poor cognitive function, and social dysfunction. It is also possible that SRBD-related symptoms alone do not lead directly to depressive mood but rather work indirectly, through their effects on stress and coping processes. For example, having symptoms of SRBD may lead to stress in personal, familial, occupational, and social aspects of one’s life, and coping strategies, in turn, influence these stressful conditions’ effects. Those who actively cope with these stressful conditions may not experience increased depression, whereas those who use detached coping strategies may experience increased depression. This interpretation is consistent with the theory that views coping processes as mediators of the relationship between stress and adaptational outcomes such as depression.
9 The depressed patients were more likely than the non-depressed patients were to complain of daytime sleepiness, to be under a higher stress level, and to use a wider variety of coping strategies. Stress associates directly with an increased depressive mood.
11
Counter to our expectation, we found no significant difference in coping strategies used between the patients and the controls. Based on the conceptual model and empirical studies, we expected emotion-focused coping would correlate positively with stress and depressive mood, while problem-focused coping would correlate negatively with stress and depressive mood. A review of the literature on general human adaptation indicates that many factors, e.g. age, gender, educational level, marital status, and ethnicity, play important roles as confounding factors in an individual’s choice of coping behaviors.
10,
12,
28–
30 The types of coping strategies both patient and control groups used, however, remained the same after controlling for the above socio-demographic variables. This may have been due to a selection factor, or perhaps SRBD patients used similar coping strategies as the control group used in general.
According to the findings of Folkman and Lazarus,
31 individuals more often use problem-focused coping in controllable versus uncontrollable situations and use emotion-focused coping as the primary strategy in an uncontrollable situation. The diagnosis and treatment of SRBD is the stressor, which, by nature, fits the definition of a controllable situation, as it is controllable through behavioral changes including weight control, continuous positive airway pressure treatment, upper airway surgery, etc. Discussing treatment options with the clinician at the patient’s initial evaluation and after confirmation of their diagnosis might have influenced the patients’ choices of a greater number of adaptive coping mechanisms (problem-focused), which can slow disease progression and reduce complications. Moreover, patients were predominantly Caucasian (68.2%), who reportedly prefer using problem-focused coping over emotion-focused coping.
32 Third, 78% of the patients were males, who reportedly use problem-focused coping more than females do.
10,
33
In our study, the type of coping strategies used was associated positively with daytime sleepiness severity, perceived stress level, and depressive mood level. The more individuals complained of daytime sleepiness, the more they used Self-Controlling, Distancing, Planful Problem-Solving, and Escape-Avoidance strategies. These results suggest the patients complaining of daytime sleepiness use Planful Problem-Solving to eliminate their sleepiness while also mobilizing detached coping, such as Self-Controlling, Distancing, and Escape-Avoidance. Detachment coping associates with higher levels of depressive mood.
11
The higher the perceived stress level, and the greater the reported depressive mood, the more participants used Escape-Avoidance and Self-Controlling strategies. Furthermore, daytime sleepiness, stress, and depressive mood correlated positively with emotion-focused coping. These findings suggest that the more patients complained of daytime sleepiness, perceived stress, and reported a depressive mood, the more they used emotion-focused coping over problem-focused coping. These findings are consistent with other studies and our expectation. In several cross-sectional studies, emotion-focused coping associates with an increased level of psychological distress in general,
34–
37 although in one study, emotion-focused coping for the purpose of affective regulation correlated with low levels of distress.
12 Problem-focused coping correlates negatively with psychological distress,
12,
35,
38 although stress and depressive mood did not correlate significantly with problem-focused coping in this study. Possibly those who were more sleepy, more highly stressed, or more depressed used more emotion-focused coping because they felt they could do nothing to modify their situations. This attitude may have led to greater stress and depression. However, emotion-focused coping might be the cause, rather than the consequence, of high stress and depression. Those who learned to cope through emotion-focused coping might be more stressed and depressed. Based on our findings, it is tempting to suggest that Self-Controlling and Escape-Avoidance are less adaptive forms of coping. Although little consensus exists regarding which coping strategies deal effectively with stress,
14 some evidence suggest individuals’ coping strategies function perfectly well in some situations, while in others they are insufficient. For example, denial of their disease was a psychological strategy of some patients. This could, of course, be classified as a poor strategy. However, in some situations, denial can be adequate and can later lead to more constructive strategies.
39 Therefore, we advocate caution when one interprets a patient’s coping.
Although the question of whether emotion-focused coping increases distress or whether higher distress levels lead to emotion-focused coping remains unanswered, we believe the relationship between psychological distress and emotion-focused coping is bidirectional, not unidirectional and static. This study supports this idea, suggesting that the relationship might be circular: emotion-focused coping increases depression, and that increase leads to an increase in the availability and use of emotion-focused coping.
40
Hooker, et al.
41 point out that psychoeducational and clinical interventions can increase patient use of effective coping skills. The present study suggests practitioners should target patients who complain of excessive daytime sleepiness and experience high levels of stress and depressive mood for such interventions. The present study also suggests practitioners working with SRBD patients need to consider their patients’ coping strategies in conjunction with daytime sleepiness, perceived stress, and depression levels. Effective coping contributes to successful adaptation to, and treatment of, SRBD, and an understanding of successful or maladaptive coping establishes a basis for the development of a holistic approach to treating SRBD patients.
Our findings may be limited in several important ways. Due to the cross-sectional nature of the present study, it cannot be determined whether specific coping approaches, such as Escape-Avoidance and Self-Confrontive cause psychological distress or whether those who experience such distress use these coping approaches. Coping styles may also change during the SRBD diagnosis and management trajectory. In addition, this study was based on a sample obtained at single site, a university hospital sleep disorders clinic. This limits the findings’ generalizability to other groups of SRBD patients, including those who do not seek professional help. Use of mailed questionnaires might also have induced a bias, and, finally, severely depressed, less knowledgeable, or less expressive persons may not have returned the questionnaires.
Despite its limitations, however, this study reveals some important information about the relationships among daytime sleepiness, stress, depressive mood, and coping strategies in SRBD patients. As we mentioned, those who complained of greater sleepiness, perceived higher stress, and/or reported more depressive mood used greater levels of emotion-focused coping than did their counterparts. Based on these findings, we might conclude that they coped less effectively at the time we acquired these measurements.
Conclusion
This study focused on SRBD’s psychological consequences and the coping mechanisms patients used in responding to it. The coping mechanisms used are important determinants of SRBD progression that researchers and practitioners should understand. Such understanding offers treatment tools against progression of a disease that psychological distress may complicate.