Spousal involvement and CPAP adherence: a two-way street?

In this issue of Sleep and Breathing, Kelly Glazer Baronand colleagues of the University of Utah, in their paper“Spousal Involvement in CPAP Adherence among Patientswith Obstructive Sleep Apnea,” investigate the role ofwives’ support or lack thereof in their husbands’ continuouspositive airway pressure (CPAP) adherence. Dr. Baron andcolleagues previously reported that the role of the spousecan impact the afflicted partner, and while spousal pressureto seek treatment has been studied [1], this is the first studyexamining spousal involvement, such as support, control,and the context of the relationship, with regard to adherenceto CPAP treatment.In her recent review, Dr. Wendy Troxel [2] discusses thewealth of studies examining relationship quality and health,but rightly points out the minutiae of studies specific tosleep health and the role of the relationship. Dr. Baron andcolleagues are providing much needed data in this area byexamining the role of spousal involvement and CPAPadherence. The results of their study show that theperception of wives’ support aided in personal adherenceonly when the disease severity was high. Accordingly,following nights of low adherence, collaboration withwives increased the next day, but the largest increases incollaboration were reported in patients with low levels ofrelationship conflict. This study indicates that spousalinvolvement is limited in its role in adherence to CPAPtreatment, specifically modified by contextual variablessuch as the perceived quality of the relationship and diseaseseverity; however, when spousal involvement does matter,the type of involvement also matters—with support fromthe spouse predicting adherence.In spite of the utility of this study, there are severallimitations to consider. First, not all of the participants wereobjectively measured with CPAP adherence cards. Abouthalf of the participants were scored by self-reports alone.Although the self-reports and objective reports correlatedrelativelywell(r=0.64), multiple problems surface: (1) Werethere pretreatment differences between patients with CPAPmachines with objective adherence cards and those without?(2) What factors does the small variability in the correlationof the methods of adherence reporting represent? What is theroot of the misperception of patients with and withoutobjective reports? Secondly, the participants of this study arerather homogenous: all males and mostly Caucasian middle-aged men. Sex differences have been reported in relationshipconflict and health behavior, and the prevalence of obstruc-tive sleep apnea (OSA) in other races differs. The con-clusions of this study are narrowly restricted to one sex andrace, and therefore, it is important to replicate these findingswith objective adherence reports and to further investigatethe roles of sex and race differences.Future studies might also attack this worthy issue from adifferent angle by investigating the impact of living with aspouse with OSA on the spouse that does not have OSA.One of the driving factors for OSA patients to seektreatment is the snoring-induced sleep disturbance to thenon-afflicted spouse. The extent that the spouse hasinsomnia-related sleep problems may contribute to the roleof the relationship by creating resentment and anger. Alongitudinal study would be ideal, but a more cost-effectivecross-sectional study looking at changes in the role of therelationship at various relationship time points would alsoprovide valuable information. For example, looking atcouples who have began their relationships <1 year, from