Psychology Module

Track mental health assessments using Beck inventories and Athens Insomnia Scale

Overview

The Psychology module tracks mental health assessments for sleep apnea patients, focusing on depression, anxiety, and insomnia severity. These psychological factors significantly impact PAP therapy adherence and treatment outcomes.

Model: Psicologia
Location: apps/exams/models.py:68-96

Depression and anxiety are common comorbidities in sleep apnea patients and can significantly reduce treatment compliance. Regular psychological screening is essential for comprehensive care.

---

Assessment Tools

Beck Depression Inventory

Standardized questionnaire measuring depression severity

Beck Anxiety Inventory

Standardized questionnaire measuring anxiety symptoms

Athens Insomnia Scale

Measures insomnia severity and sleep quality

---

Data Fields

Beck Depression Inventory

inventario_depre_beck · IntegerField · required

Beck Depression Inventory (BDI) score

• Range: 0-63
• Form Label: “Depresión de Beck”
• Assessment Type: 21-item self-report questionnaire
• Administration Time: 5-10 minutes

Score Interpretation:

Score Range	Severity	Clinical Significance
0-13	Minimal	No or minimal depression
14-19	Mild	May benefit from counseling
20-28	Moderate	Requires psychological intervention
29-63	Severe	Urgent psychiatric evaluation needed

Beck Anxiety Inventory

inventario_ansiedad_beck · IntegerField · required

Beck Anxiety Inventory (BAI) score

• Range: 0-63
• Form Label: “Ansiedad de Beck”
• Assessment Type: 21-item self-report questionnaire
• Administration Time: 5-10 minutes

Score Interpretation:

Score Range	Severity	Clinical Significance
0-7	Minimal	No or minimal anxiety
8-15	Mild	Mild anxiety symptoms
16-25	Moderate	Moderate anxiety, intervention recommended
26-63	Severe	Severe anxiety, urgent treatment required

High anxiety scores (BAI ≥16) are strongly associated with poor CPAP adherence and mask claustrophobia. Early identification enables targeted interventions.

Athens Insomnia Scale

escala_atenas · IntegerField · required

Athens Insomnia Scale (AIS) score

• Range: 1-10 (typically 0-24, but form indicates 1-10)
• Form Label: “Escala Atenas (1 a 10)”
• Assessment Type: 8-item self-report questionnaire
• Focus: Sleep induction, awakenings, total sleep duration, sleep quality

Score Interpretation:

Score	Severity	Clinical Significance
< 6	No insomnia	Normal sleep patterns
≥ 6	Insomnia	Clinically significant sleep difficulty

The Athens scale helps differentiate insomnia from sleep apnea symptoms. Some patients have both conditions, requiring combined treatment approaches.

---

Relationships

ingreso · ForeignKey

Links to the patient’s active admission record

Related Name: psicologias
On Delete: CASCADE

registrado_por · ForeignKey

User (psychologist or clinician) who registered this assessment

Related Name: psicologias_registradas
On Delete: SET_NULL

created_at · DateTimeField

Timestamp when this psychological assessment was recorded

Auto-generated: Automatically set on record creation

---

Registration Workflow

View: register_psicologia (apps/exams/views.py:121-149)

def register_psicologia(request, patient_id):
    patient = get_object_or_404(Patient, id=patient_id)
    
    # Find patient's active admission
    ingreso_actual = patient.ingresos.filter(estado='ACTIVO').first()
    
    if request.method == 'POST':
        form = PsicologiaForm(request.POST)
        if form.is_valid():
            # Save without committing to database first
            exam = form.save(commit=False)
            
            # Link to active admission (prevents orphaned records)
            exam.ingreso = ingreso_actual
            exam.registrado_por = request.user
            
            # Now save to database
            exam.save()
            
            messages.success(
                request, 
                f'Consulta de psicología registrada para {patient.nombre} exitosamente'
            )
            return redirect('patient_clinical', patient_id=patient.id)
    else:
        form = PsicologiaForm()
    
    return render(request, 'exams/register_psicologia.html', {
        'form': form, 
        'patient': patient
    })

Key Workflow Considerations

Active Admission Requirement:

• Psychology assessments are linked to the current treatment cycle
• View retrieves ingreso_actual with estado='ACTIVO'
• Prevents data mixing between treatment cycles

Two-Stage Save Process:

1. form.save(commit=False) creates object without database write
2. Link object to active admission (exam.ingreso = ingreso_actual)
3. Set registering user (exam.registrado_por = request.user)
4. Final save to database (exam.save())

This ensures all required relationships are established before database commit, preventing integrity errors.

---

Clinical Applications

Impact on PAP Therapy Adherence

Depression & Adherence

High Depression Scores:

• Reduced motivation to use CPAP
• Poor self-care behaviors
• Lower perceived treatment benefit

Intervention: Cognitive behavioral therapy, antidepressants if indicated

Anxiety & Adherence

High Anxiety Scores:

• Mask claustrophobia
• Panic with pressurized air
• Fear of dependence on device

Intervention: Desensitization therapy, relaxation techniques, gradual pressure ramp

Screening Recommendations

Initial Assessment (Baseline)

Timing: Before or immediately after basal polysomnography

Purpose:

• Establish psychological baseline
• Identify pre-existing mental health conditions
• Predict adherence challenges
• Guide therapy planning

Clinical Note: Many patients don’t realize their depression/anxiety is related to untreated sleep apnea. Symptoms often improve with successful PAP therapy.

Follow-up Assessment (1-3 months)

Timing: After PAP therapy initiation

Purpose:

• Measure treatment psychological benefits
• Identify therapy-related anxiety (e.g., mask claustrophobia)
• Assess if adherence issues are psychologically driven
• Adjust interventions based on response

Expected Changes: BDI and AIS scores typically improve with effective PAP therapy. If scores worsen or remain high despite good adherence, consider independent mental health disorder requiring treatment.

Ongoing Monitoring (Every 3-6 months)

Timing: Throughout long-term therapy

Purpose:

• Monitor sustained psychological benefit
• Early detection of relapse
• Correlate mental health changes with adherence patterns

Red Flags: Rising BDI/BAI scores despite good adherence may indicate life stressors or independent psychiatric condition needing attention.

---

Clinical Interpretation Guidelines

Depression (BDI)

BDI Score: 0-13 (Minimal)
→ No intervention needed
→ Continue routine monitoring

BDI Score: 14-19 (Mild)
→ Brief counseling or support groups
→ Monitor adherence closely
→ Re-assess in 1 month

BDI Score: 20-28 (Moderate)
→ Formal psychological referral
→ Consider cognitive behavioral therapy
→ May benefit from antidepressant
→ Adherence intervention likely needed

BDI Score: 29-63 (Severe)
→ URGENT psychiatric evaluation
→ Screen for suicidal ideation
→ PAP adherence highly compromised
→ May need supervised therapy initiation

Anxiety (BAI)

BAI Score: 0-7 (Minimal)
→ No intervention needed
→ Good prognosis for mask tolerance

BAI Score: 8-15 (Mild)
→ Reassurance and education
→ Gradual desensitization to mask
→ Emphasize pressure ramp feature

BAI Score: 16-25 (Moderate)
→ Structured anxiety management
→ Relaxation techniques
→ Consider short-term anxiolytic
→ Smaller mask or nasal pillows
→ May need multiple mask trials

BAI Score: 26-63 (Severe)
→ Psychiatric referral
→ Address anxiety before PAP initiation
→ High risk of mask claustrophobia
→ May need sedation during initial nights
→ Consider alternative treatments if PAP intolerable

Insomnia (Athens Scale)

AIS < 6 (No Insomnia)
→ Sleep complaints likely OSA-related
→ PAP therapy should resolve symptoms

AIS ≥ 6 (Insomnia Present)
→ Comorbid insomnia diagnosis
→ May need cognitive behavioral therapy for insomnia (CBT-I)
→ Avoid sedative-hypnotics (worsen OSA)
→ PAP therapy alone may not resolve all sleep complaints

High Athens scores (≥6) suggest primary insomnia in addition to sleep apnea. These patients often report persistent sleep dissatisfaction despite excellent PAP adherence and apnea control. They require specialized insomnia treatment (CBT-I) alongside PAP therapy.

---

Data Retrieval

View: patient_clinical (apps/exams/views.py:29)

# Get all psychology sessions for active admission
sesiones_psicologia = Psicologia.objects.filter(
    ingreso=ingreso_actual
).order_by('-id')

Psychology assessments are filtered by the patient’s active admission and ordered by ID (most recent first) to track psychological changes over time.

---

Research Evidence

Depression & Sleep Apnea Bidirectional Relationship

Research Findings:

• 20-30% of OSA patients have clinical depression (vs. 7% general population)
• Untreated OSA increases depression risk by 2-3x
• Treating OSA improves depression scores in 40-60% of patients
• Residual depression requires independent treatment

Clinical Implication: Always screen for depression in OSA patients. Many patients experience dramatic mood improvement with PAP therapy alone, but some need combined treatment.

Anxiety & CPAP Adherence

Research Findings:

• Moderate-severe anxiety (BAI ≥16) predicts poor CPAP adherence
• Mask claustrophobia occurs in 5-10% of patients
• Anxiety about suffocation is common misconception
• Desensitization therapy improves adherence by 30-40%

Clinical Implication: Early identification of anxiety (especially claustrophobia) allows for proactive interventions like gradual mask acclimation, smaller interfaces, and psychological support.

Insomnia + OSA (COMISA)

Research Findings:

• 30-50% of OSA patients have comorbid insomnia
• COMISA patients have worse outcomes than OSA or insomnia alone
• PAP therapy alone rarely resolves insomnia symptoms
• CBT-I + PAP is optimal treatment combination

Clinical Implication: Athens scale helps identify COMISA patients who need dual treatment. Don’t assume all sleep complaints will resolve with PAP therapy.

---

Related Modules

Monitoring

Correlate psychological scores with adherence patterns

Nutrition

Rumination and eating behaviors linked to mood

Polysomnography

Sleep quality assessments complement Athens scores