Impact of Obstructive Sleep Apnea Treatment on Marital Relationships: Sleeping Together Again?

Objective We assess the impact of obstructive sleep apnea (OSA) treatment on the quality of marital relationships. Moreover, we evaluate the proportion of couples sleeping separately before treatment and whether there was any change after treatment began, which is still little explored in the literature. Methods A prospective study was conducted between April 2021 and April 2023, with users diagnosed with OSA in a level 2 hospital in Portugal. A questionnaire was applied before and after the start of treatment to both user and partner, which included questions on whether they slept together or separately, the disturbing factors of sleep quality, and satisfaction with the marital relationship. Statistical analysis was performed using R (version 4.2.2; R Development Core Team, Vienna, Austria). Results Seventy questionnaires were applied, 79% to male users. Forty-one percent of users reported that they slept at least once or twice a month separated from their spouse, and, of these, 41% always slept in separate rooms. The chief complaints of partners not sleeping together were snoring (86%), restless sleep (17%), and witnessed apnea (14%). After treatment, 72.4% started to sleep together again, with a statistically significant difference in the condition before and after intervention. Among all patients, 69% said that their personal lives had improved and, when asked the same question to their spouse, 74% recognized the benefit of therapy. Conclusion Starting treatment positively influenced the quality of the marital relationship of users and their partners, with a statistically significant proportion of couples sleeping together again.


Introduction
Obstructive sleep apnea syndrome (OSA) is highly prevalent in our population and worldwide, affecting an estimated 10%-17% of adults [1,2].Typical symptoms include daytime sleepiness, increased cardiovascular disease, depressive symptoms, and decreased quality of life [3][4][5].Nocturnal symptoms such as snoring, witnessed apnea, and frequent awakenings affect not only the patient's sleep quality but also that of their partners [3,[5][6][7], namely, due to concern over witnessed apnea [5,8].All these symptoms can contribute to changes in the dynamics of relationships between couples and may even lead to one of the partners leaving the bedroom [7,[9][10][11].
The preferred treatment for OSA is based on the application of positive airway pressure [1,11].Commencing the recommended treatment for OSA has a positive impact on patient quality of life, with emphasis on physical health, increased vitality, and improvement in mental health and social relationships [2,8,10,12].Despite all the positive effects described, the rate of nonadherence to positive pressure treatment ranges from 46% to 83% [3], which is often associated with higher morbidity, mortality, and economic costs [2].Conflict between couples may contribute to reduced adherence to treatment [12].Support from partners, friends, and family is a predictor of adherence, so marital status should be considered when approaching treatment [1].Thus, providing information to the partner about the disease and treatment can help increase adherence [11,13].
Data indicate that, for the partner, the use of positive airway pressure may also be associated with discomfort in the quality of sleep, namely, because of the noise it can produce.Nonetheless, the balance is positive because of the proven improvement in the patient's sleep quality [10].This benefit may lessen conflict between spouses [6], which in turn may lead to couples sleeping together again.However, evidence remains inconsistent regarding the benefits for couples [5].
The authors conducted a study to investigate the impact of the introduction of therapy for OSA on the quality of marital relationships.They also assessed the proportion of couples who slept separately and the effect of starting treatment on this specific and still little-studied aspect of relationships.

Materials And Methods
The authors conducted a prospective study between April 2021 and April 2023 using a convenience sample of patients diagnosed with OSA in a level 2 hospital in Portugal.
Upon obtaining written informed consent, a questionnaire was applied before and after the beginning of treatment (Appendix 1), which included questions about the age and sex of both user and partner, whether they slept together or separately, the disturbing factors of sleep quality, whether they considered that sleeping separately affected their relationship, and if they would like to sleep together again.We also applied the relationship assessment scale [14], validated in Portugal [15] before and after starting treatment.Incompletely answered questionnaires were excluded from the analysis.
Descriptive analysis of the quantitative variables under study was performed by obtaining mean and standard deviation, and the qualitative variables by counting and percentages.To assess the effect of the intervention (beginning of treatment) on binary qualitative variables, McNemar's test was used.Univariate logistic regression was used to analyze the association with the variable that records the occurrence of improvement in personal life after starting treatment.Subsequently, a separate analysis was made of users who previously slept separately, at least once or twice a month.Data on the overall satisfaction of the user's and partner's relationship were compared between patients who went back to sleeping together and those who continued to sleep separately.
A comparison of variables between groups was performed using Fisher's exact test and described using frequencies and counts for qualitative variables and median and interquartile range for continuous variables.A comparison was also made between the groups that never slept apart and those that sometimes/always slept apart with items from the relationship assessment scale using Wilcoxon's test.
Statistical analysis was performed using R (version 4.2.2;R Development Core Team, Vienna, Austria).

Results
A total of 70 questionnaires were obtained.Most respondents were male (79%) and married (97%), with severe OSA.The sociodemographic characteristics of the patient, including the severity of OSA and their partners, are represented in Table 1.Of all respondents, 41% (n=29) slept apart from their spouse at least once a month, of which 21% (n=6) slept apart about one to two times a month, 38% (n=11) slept apart about one to two times a week, and 41% (n=12) always slept apart.In 31% (n=9) of cases, it was the patient who left the room; in 52% (n=19), it was the partner; and, in 17% (n=5), it was variable.
Of the patients who did not always sleep together, the partner's main complaint was snoring (86%), followed by restless sleep (17%), and witnessed apneas (14%).
On a scale of 1-5, patients who slept separately considered that doing so affected the relationship with a median of 3 (range between a minimum of 1 and maximum of 4) and would like to sleep together again at a median of 5 (range between a minimum of 4 and maximum of 5).
Commencing treatment led to a change in the condition of sleeping apart with statistically significant differences (McNemar's chi-square test=19.048,df=1, P value=1.275e-05).Of the 41% (n=29) of users who slept separately, 72.4% (n=21) began to sleep together.In no case did the initiation of treatment lead to patients starting to sleep separately.
After starting treatment, of the 70 patients questioned, 69% (N=48) considered that their personal life had improved and 74% (N=52) of partners also answered affirmatively to this question.This benefit reported by either patients or partners was not influenced by gender, age, OSA severity, reported symptoms, or the person who left the room.
Among couples who slept separately, in those who started sleeping together again, both patients and their partners reported greater improvement in their personal lives (38% versus 81% and 25% versus 95%, respectively), as demonstrated in  In the relationship assessment scale, there were no statistically significant differences between before and after treatment (Table 3).

Before treatment
After starting treatment