Sleep Apnea Secondary to Depression

If your depression is service connected and a sleep study has diagnosed sleep apnea, you can claim the sleep apnea as secondary to the depression. These claims usually run one of two ways: the depression itself raised your risk, or the depression and the medicine used to treat it led to weight gain that brought on the apnea or made it worse. Both can work. The catch is that research also shows sleep apnea leading to depression, so the medical opinion has to explain what came first in your records and why. This page covers the research, how VA decides the claim, the rating, the C&P exam and what a nexus letter has to say.

Can depression cause sleep apnea?

The research links the two conditions in both directions, and the newest genetic studies disagree about which way the cause runs.

• Studies that use genetic data to test cause and effect (Mendelian randomization) mostly point from depression toward sleep apnea. In one (Mi and colleagues, Frontiers in Psychiatry, 2024), genetically determined major depressive disorder raised the risk of obstructive sleep apnea (odds ratio 1.377), and the link held after adjusting for body mass index, smoking and alcohol. The study found no effect of sleep apnea on psychiatric disorders in the reverse direction.
• A second 2024 study (Wang and colleagues, Journal of Psychosomatic Research) found the same direction (odds ratio 1.29), with no significant effect the other way. Most of its results held after adjusting for smoking, alcohol, obesity, type 2 diabetes, insomnia, age, gender and codeine.
• Not every study agrees. A later genetic study (Liao and colleagues, European Archives of Psychiatry and Clinical Neuroscience, 2026) found the opposite: genetically predicted sleep apnea raised the risk of depression (odds ratio 1.22), with no reverse effect.
• A 2020 meta-analysis (Edwards and colleagues, Maturitas) also leaned the other way. Across five long-term studies, people with sleep apnea were more likely to develop depression during follow-up (risk ratio 2.18), though the studies varied widely. Six cross-sectional studies found no compelling link.
• In VA health records from 1998 to 2001 (Sharafkhaneh and colleagues, Sleep, 2005), 21.8% of the 118,105 patients with sleep apnea also had depression, and mood disorders were significantly more common than in patients without sleep apnea.

Weight gain and antidepressants

Weight is the best-documented path from depression to sleep apnea, and it has two sources: the depression and the medicine.

• A meta-analysis of 15 long-term studies (Luppino and colleagues, Archives of General Psychiatry, 2010) found that depression increased the odds of developing obesity (odds ratio 1.58).
• Among 294,719 adults followed for up to 10 years in the United Kingdom (Gafoor and colleagues, BMJ, 2018), people prescribed antidepressants were more likely to gain at least 5% of their body weight (adjusted rate ratio 1.21), and the higher risk lasted at least six years. The authors noted the association may not be causal.
• Drugs differ. A 2010 meta-analysis of 116 studies (Serretti and Mandelli, Journal of Clinical Psychiatry) found amitriptyline, mirtazapine and paroxetine carried a greater risk of weight gain, while bupropion, and fluoxetine early in treatment, were tied to some weight loss. A 2024 study of 183,118 patients (Petimar and colleagues, Annals of Internal Medicine) found small six-month differences, with bupropion consistently showing the least gain.
• Weight then drives apnea. In 690 Wisconsin adults followed for four years (Peppard and colleagues, JAMA, 2000), a 10% weight gain predicted about a 32% increase in breathing events per hour of sleep and a sixfold increase in the odds of developing moderate-to-severe sleep-disordered breathing.

One theory to drop: that sedating sleep medicine caused the apnea. A 2024 meta-analysis of randomized trials (Messineo and colleagues, American Journal of Respiratory and Critical Care Medicine) found common sleep medicines did not change sleep apnea severity.

In my read, the research supports a link and a plausible weight path. It does not settle which condition came first for any one veteran, and that is the question your opinion has to answer.

How VA decides sleep apnea secondary to depression

Secondary service connection is in 38 CFR § 3.310. VA grants it in two ways.

• Caused by. Your service-connected depression caused the sleep apnea, at least as likely as not.
• Aggravated by. Your sleep apnea is aggravated by your service-connected depression, meaning it would be less severe but for the depression (M21-1 V.ii.2.D). VA rates only the part above the baseline level of the sleep apnea before the aggravation, so the opinion should describe that baseline.

The file needs three things: a sleep apnea diagnosis from a sleep study, service-connected depression, and a medical opinion that links the two with reasoning.

When weight gain is the link

VA does not treat obesity as a disability on its own, but VA's General Counsel (VAOPGCPREC 1-2017) allows it to be a middle step. The opinion has to answer three questions: did the depression or its medicine cause the weight gain, was the weight gain a substantial factor in causing the sleep apnea, and would the sleep apnea not have happened without it. The Court of Appeals for Veterans Claims built on that framework in Walsh v. Wilkie (2020).

The records that carry this theory are dates and numbers: your weight at entry, separation and each VA visit, when each antidepressant started and at what dose, and when the sleep apnea was diagnosed. Weight that climbed after a specific drug was started is the kind of timeline a doctor can work with.

A Board grant on this theory

In Board citation A25032571 (April 9, 2025), the veteran was service connected for unspecified depressive disorder. Service records showed depression treated with antidepressants during service, treatment for weight gain, and obesity diagnosed in 1999 while still in service. A private doctor reviewed the records and the medical literature and concluded that the sleep apnea was caused and aggravated by the depression, with obesity from the psychiatric medicine as the middle step. Several VA examiners gave negative opinions. One said obesity and gender were stronger risk factors, and another did not consider the private opinion or the veteran's statements. The Board found the VA opinions conclusory or of limited value and granted the claim. Board decisions are not precedential, but they show what the Board accepts.

VA rating for sleep apnea secondary to depression

Sleep apnea secondary to depression is rated the same way as any sleep apnea. Diagnostic Code 6847 in 38 CFR § 4.97, "Sleep Apnea Syndromes (Obstructive, Central, Mixed)," reads as follows.

Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy: 100

Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine: 50

Persistent day-time hypersomnolence: 30

Asymptomatic but with documented sleep disorder breathing: 0

That is the current schedule. VA proposed new sleep apnea criteria in 2022 (87 FR 8474), but the proposal is not final. The sleep apnea VA rating page covers what "requires" a CPAP means and where the proposal stands.

VA rates the sleep apnea separately from the depression. Depression is rated under the General Rating Formula for Mental Disorders in 38 CFR § 4.130, which lists "chronic sleep impairment" among its symptoms, and 38 CFR § 4.14 says the same symptom should not be rated under two diagnoses. So keep the two apart in your records. Describe trouble falling or staying asleep as a depression symptom, and let the breathing pauses, the sleep study and the CPAP show the sleep apnea.

The ratings combine under 38 CFR § 4.25, larger rating first. A 50 percent depression rating and a 50 percent sleep apnea rating combine to 75, which VA rounds up to 80 percent. A 70 percent depression rating and a 50 percent sleep apnea rating combine to 85, which rounds up to 90 percent.

The C&P exam for sleep apnea secondary to depression

VA usually orders an exam or a medical opinion. The examiner is asked whether your sleep apnea is at least as likely as not caused by your depression and, separately, whether the depression aggravated it. An opinion that answers only the first question is inadequate under El-Amin v. Shinseki (2013).

The examiner looks at these things.

• The date of your sleep study diagnosis compared with when your depression began and was treated
• Your weight history and every antidepressant or other psychiatric medicine, with start dates and doses
• Other risk factors, such as age, neck size, smoking and alcohol use
• Whether your sleep complaints are apnea symptoms, such as gasping or witnessed pauses, or depression symptoms

Unfavorable opinions on this claim tend to follow three patterns. They call sleep apnea a physical airway problem that a mood disorder cannot cause. They blame obesity without asking what caused the weight gain. Or they say sleep apnea causes depression and stop there, without addressing the genetic studies pointing the other way or the weight timeline in your file. C&P exam prep can help you get ready, and the Board section below shows how the Board ruled on these appeals.

Why sleep apnea secondary to depression claims get denied

These are the usual gaps.

• The only medical opinion is a negative VA opinion, and nothing in the file answers it.
• The weight theory is asserted, but no doctor ties the depression or a named medicine to the weight gain.
• The opinion does not deal with the reverse direction, where sleep apnea came first and caused the depression.
• No opinion addresses aggravation or describes the baseline.
• Other risk factors in the file, such as age, smoking or alcohol, go unaddressed.

Nexus letter for sleep apnea secondary to depression

A strong nexus letter for this claim does six things.

1. States that the doctor reviewed your records, including the sleep study, your mental health treatment and your medication history.
2. Gives an opinion on causation: your sleep apnea is at least as likely as not caused by your service-connected depression, with the mechanism named.
3. Gives a separate opinion on aggravation: your sleep apnea is aggravated by your service-connected depression, meaning it would be less severe but for the depression, and describes the baseline, such as an earlier sleep study or lower CPAP needs.
4. If weight is the path, answers the three weight gain questions above with your weights and medicine dates.
5. Cites the research honestly, including the studies that point from sleep apnea toward depression, and explains why your timeline fits this direction.
6. Deals with your other risk factors and explains why they do not account for the whole picture.

Where these opinions break down at the Board is predictable: no rationale, a conclusion with no reasoning behind it, records the doctor never reviewed, or silence on the weight timeline. Raven Nexus can organize your records and the research into a draft for your doctor to review.

If PTSD is part of your mental health rating, sleep apnea secondary to PTSD has its own research. Other conditions claimed on top of service-connected depression are on the depression secondary conditions page.

Questions veterans ask about sleep apnea secondary to depression

Can depression cause sleep apnea?

Two 2024 genetic studies found that depression raised the risk of sleep apnea, and weight gain from depression or its treatment is a documented path. A later study and a 2020 meta-analysis pointed the other way, so a medical opinion has to show which came first in your records.

Can I claim sleep apnea secondary to depression and anxiety?

Yes, if your service-connected mental health condition covers both. VA rates mental disorders other than eating disorders under one formula, so the claim is secondary to that rated condition, and the opinion should name the path, such as weight gain from a specific medicine. One 2024 genetic study found a signal for major depression but no conclusive evidence for the other psychiatric conditions it tested. See anxiety for how that condition is rated.

Do antidepressants cause sleep apnea?

No study I found shows antidepressants cause sleep apnea directly. Some cause weight gain, mirtazapine and paroxetine among them, and weight gain is a strong driver of sleep apnea, so a doctor has to connect your drug, your weight and your apnea.

What is the VA rating for sleep apnea secondary to depression?

The same as any sleep apnea under Diagnostic Code 6847: 0, 30, 50 or 100 percent. Most veterans who require a CPAP are rated 50 percent, and the rating combines with your depression rating.

What if my sleep apnea came before my depression?

Then causation is hard to argue, but aggravation may still fit if the depression or its medicine later made the apnea worse. If your sleep apnea is already service connected, depression secondary to sleep apnea may match the research better; the depression VA rating page covers that path.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one.
• 38 CFR § 4.97, Diagnostic Code 6847, sleep apnea syndromes; 38 CFR § 4.130, General Rating Formula for Mental Disorders; 38 CFR § 4.14, avoidance of pyramiding; 38 CFR § 4.25, combined ratings table.
• Schedule for Rating Disabilities-Ear, Nose, Throat, and Audiology Disabilities; Special Provisions Regarding Evaluation of Respiratory Conditions; Schedule for Rating Disabilities-Respiratory System, proposed rule, 87 FR 8474 (February 15, 2022), not final.
• VA General Counsel Precedent Opinion 1-2017 (VAOPGCPREC 1-2017), obesity as an intermediate step; Walsh v. Wilkie, 32 Vet. App. 300 (2020).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Board of Veterans' Appeals citation A25032571 (April 9, 2025, granted). Board decisions are not precedential.
• Mi C, Hou A, Liu Y, Qi X, Teng J. Assessing the causal relationship between psychiatric disorders and obstructive sleep apnea: a bidirectional Mendelian randomization. Frontiers in Psychiatry. 2024;15:1351216. PMID 38426001.
• Wang X, Song S, Dong N, et al. The causal relationship between depression and obstructive sleep apnea: A bidirectional Mendelian randomization study. Journal of Psychosomatic Research. 2024;179:111620. PMID 38430795.
• Liao J, Gao X, Fang T, Li Y, Han D. Obstructive sleep apnea's causal links to depression, well-being, and negative moods: a bidirectional mendelian randomized study. European Archives of Psychiatry and Clinical Neuroscience. 2026;276(2):543-551 (published online 2025). PMID 40025155.
• Edwards C, Almeida OP, Ford AH. Obstructive sleep apnea and depression: A systematic review and meta-analysis. Maturitas. 2020;142:45-54. PMID 33158487.
• Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M. Association of psychiatric disorders and sleep apnea in a large cohort. Sleep. 2005;28(11):1405-1411. PMID 16335330.
• Luppino FS, de Wit LM, Bouvy PF, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Archives of General Psychiatry. 2010;67(3):220-229. PMID 20194822.
• Gafoor R, Booth HP, Gulliford MC. Antidepressant utilisation and incidence of weight gain during 10 years' follow-up: population based cohort study. BMJ. 2018;361:k1951. PMID 29793997.
• Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. Journal of Clinical Psychiatry. 2010;71(10):1259-1272. PMID 21062615.
• Petimar J, Young JG, Yu H, et al. Medication-Induced Weight Change Across Common Antidepressant Treatments: A Target Trial Emulation Study. Annals of Internal Medicine. 2024;177(8):993-1003. PMID 38950403.
• Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015-3021. PMID 11122588.
• Messineo L, Sands SA, Labarca G. Hypnotics on Obstructive Sleep Apnea Severity and Endotypes: A Systematic Review and Meta-Analysis. American Journal of Respiratory and Critical Care Medicine. 2024;210(12):1461-1474. PMID 39042859.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds, and of every decision since 1992 for the longer view.