August 20, 2014 by Steven Park
In the wake of Robin Williams’ untimely death by suicide, I think it’s appropriate to talk about the pink elephant in the room that no one seems to notice. Mr. Williams was known to suffer from severe depression, and there are reports that he also had early stages of Parkinson’s Disease. He also battled alcohol addiction.
It’s estimated that about 20 million people suffer from depression. It’s a consensus that depression is caused by a multitude of various factors, with a number of different brain biochemical and structural abnormalities.
Here are 7 known facts about depression, insomnia and obstructive sleep apnea:
1. We know that depression and insomnia and other sleep problems tend to go hand in hand. People with insomnia are found to have a ten-fold increased risk of developing depression later in life.(1) Treating insomnia in patients with depression resulting in almost double the rate of depression remission.(2) Another study found that the presence of depression and insomnia predicted a higher rate of obstructive sleep apnea.(3)
2. The hippocampus is one area in the brain (amongst many other areas) that is found to be smaller in people with depression.(4) This area controls long-term memory and recollection. Interestingly, this is the same area that is also found to be significantly diminished in patients with severe obstructive sleep apnea.
3. Men and women who reported stopping breathing during sleep more than five times per week were 3 times more likely to show signs of major depression. Numerous studies show a strong bi-directional link between obstructive sleep apnea and depression.
4. Patients with severe insomnia who don’t respond to prescription sleep aids have about a 75% chance of having undiagnosed obstructive sleep apnea.(5)
5. In people with obstructive sleep apnea and depression, CPAP resulted in significant improvements in depression scores.(6)
6. Obstructive sleep apnea is known to significantly raise your risk of heart disease. (Mr. Williams underwent open heart surgery in 2009).
7. Many people with obstructive sleep apnea compensate for fatigue by intense physical exercise. (Mr. Williams was an avid cyclist).
There’s now lots more research on the ravaging effects of obstructive sleep apnea and oxygen deprivation on various areas of the brain, including the pre-frontal cortex, hippocampus, and the thalamus. Not only is the brain deprived of vital blood flow and oxygen, but brain tissue density and volume are also found to be smaller. One small shining light amongst all the bad news is that the hippocampus can regenerate to some degree with improved cognitive abilities after many months of CPAP use.(7)
Granted, you could argue that depression can lead to obstructive sleep apnea, since lower levels of activity can lead to weight gain. But then poor sleep quality can lead to low energy levels and lack of motivation to do anything, Poor sleep is also known to cause weight gain. Certain antidepressant medications are also known to cause significant weight gain, which can also aggravate this vicious cycle.
In addition, many people with insomnia or obstructive sleep apnea use alcohol as a sedative to fall asleep at night. However, because alcohol relaxes your throat’s muscles, more apneas can occur.
In my practice, whenever I see anyone with clinically significant depression requiring medication, in the vast majority of cases, the upper airway is very narrow. Typically, they can’t sleep on their backs, and one or both parents snore heavily. They are never able to wake up refreshed.
All this is speculation, since no one has examined Mr. Williams for obstructive sleep apnea. But statistically speaking, given all of the above, and boing in his age group, he has a relatively high chance of having had untreated obstructive sleep apnea.
If you are diagnosed with depression and obstructive sleep apnea, which came first—depression or sleep apnea?
1. Ong, Jason C., et al. “Frequency and predictors of obstructive sleep apnea among individuals with major depressive disorder and insomnia.” Journal of psychosomatic research 67.2 (2009): 135-141.
2. Manber R; Edinger JD; Gress JL; San Pedro-Salcedo MG; Kuo TF; Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. SLEEP 2008;31(4):489-495.Taylor, Daniel J., et al. “Epidemiology of insomnia, depression, and anxiety.” SLEEP. 28.11 (2005): 1457.
3. Wheaton, Anne G., et al. “Sleep disordered breathing and depression among US adults: National Health and Nutrition Examination Survey, 2005-2008.”Sleep 35.4 (2012): 461.
5. Krakow, Barry, Victor A. Ulibarri, and Edward A. Romero. “Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables.” Primary care companion to the Journal of clinical psychiatry 12.4 (2010).
6. Schwartz DJ; Karatinos G. For individuals with obstructive sleep apnea, institution of cpap therapy is associated with an amelioration of symptoms of depression which is sustained long term. J Clin Sleep Med 2007;3(6):631-635.
7. Canessa, Nicola, et al. “Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment.” American journal of respiratory and critical care medicine 183.10 (2011): 1419-1426.
August 13, 2014 by Steven Park
One of the most common complaints that I hear about is that you keep waking up at night during sleep. Even if you don’t consciously “wake up,” the sleep study hypnogram (a graphic summary of your sleep stages) shows that your sleep is interrupted 10 to 20 times every hour by obstructed breathing, snoring, leg movements, and even teeth grinding. Frequent, interrupted sleep can lead to unproductive sleep, leading to increased fatigue, poor body healing and lack of brain regeneration.
As I was looking at a patient’s hypnogram, I realized that it also looks like our daily work schedules. With constant interruptions, it can be difficult to get any productive work done. It’s been said that only 20% of our time at work is truly productive. With the barrage of emails, colleagues and staff dropping by, phone calls and pages, It’s a wonder that we can get anything done at all. If you plotted all the interruptions through an 8 hour workday, I bet it’ll look very similar to what you see on a hypnogram with interrupted sleep. The first figure is a relatively “normal” night’s sleep, except that it took a while to fall asleep. Notice that the person reached all the sleep stages and for the most part, had extended periods of all sleep stages. In the second figure, notice how the person keeps waking up repeatedly.
Even during a session with a patient, there are just too many interruptions. Here are the 5 most common interruptions that can disrupt your visit with your doctor:
1. Phone calls for the doctor or the patient. Needless to say, they can be really annoying, and counterproductive to developing a positive patient-doctor relationship. I make it a point not to take any phone calls, unless it’s a true life-or-death emergency.
2. Staff members popping in for various reasons, such as asking a non-urgent question, or getting supplies. I consider the time that I spend with patients precious, and any interruptions can be very disruptive.
3. The doctor is looking at the computer screen rather than looking at you. Unfortunately, it’s one of the necessary evils of modern medicine. Until Apple creates their own electronic medical record, patient visits will become more impersonal.
4. Computer/technology glitches. For me, it’s rare that an hour goes by without minor or major computer problems. It can range from hardware issue to software glitches. Calling tech support is painful while seeing patients. Once in a while, the electronic medical records goes down, and we have to use (gasp!)—paper.
5. Missing or broken medical equipment. There are dozens if not hundreds of supplies, instruments or equipment that must be stocked, maintained or serviced. Even one missing ear speculum size can be disruptive, even in the best of circumstances.
For the writers out there, you know that it takes about 15 to 30 minutes to get into the creative “groove.” Even is you can start writing again, you’ve lost about 30 minutes of your best material. Similarly, once you’ve developed a productive patient-doctor interaction, any interruption will diminish the quality and outcome of the relationship. As you can see, frequent interruptions during the work day can can be just as damaging as interrupted sleep.
When you see your doctor, what’s the one most annoying thing that interrupts your visit?
August 7, 2014 by Steven Park
Sleep position is a perennial topic that you’ll see often talked about in the media. In most cases, your sleep position is thought to predict your personality type. However, there’s a simpler explanation for why you may prefer to sleep on your side or on your tummy. This has to do with the shape of your face, and in particular, the size of your upper airway.
About once every few months, I’ll see a woman who complains of 4 weeks of frequent sinus infections, facial pain and misery. She was given multiple courses of antibiotics and allergy medications, all with only temporary relief. When I examine her upper airway, it’s usually very narrow, especially when she’s lying flat on her back. I ask her about her sleep position, and she’ll state that she likes to sleep on her back. I don’t believe her. Then I ask her what her favorite sleep position was 3 years ago. She replies that she used to sleep on her stomach. When did she change? About 4 to 5 weeks ago. Why did she change? Her dermatologist told her that she’ll get wrinkles on her face if she sleeps on her stomach.
Not unexpectedly, after switching back to her tummy during sleep, her sinus problems get better. In addition, I make sure that she stop eating close to bedtime and that her nasal breathing is optimized. What’s happening is that on her back, her tongue falls back more due to gravity, and during deep sleep, with total muscle relaxation, she stops breathing and keeps waking up. Poor sleep quality over time will cause sinus migraines, and even more facial wrinkles.
In the video below, I talk about how your facial shape can predict your sleep position.
If you’ve had to change your sleep position for whatever reason, why did you do so, and did it affect your sleep quality?
August 5, 2014 by Steven Park
As I walked down the cereal aisle of my local supermarket the other day, I was amazed at how may options I had. I saw endless rows of cereal boxes, each claiming to be superior and more nutritious than others. In the same way, available treatment options for obstructive sleep apnea are exploding, and patients and health care professionals are now more confused than ever. You would think that having more options to choose from is a good thing, whether it’s about cereal, CPAP machines, dental appliances, or sleep apnea surgery. But patients as well as physicians are now even more confused and paralyzed with indecision. If you add the internet to this information overload, things get even more out of control.
In a recent Fiscal Times article, the sleep industry is projected to be a $32 billion industry this year. For the past few years, it’s been increasing about 8-9% per year. This includes not only medical products, services and devices, but also over-the-counter, consumer-based products. Bed Bath & Beyond has over 600 products in the sleep category. Resmed, one of the major CPAP manufacturers, had total revenues of $1.2 billion in 2011.
As we become inundated with options for better sleep, what can we do as patients and as professionals? Here are 5 suggestions for patients/consumers and 3 tips for health care professionals:
For patients and consumers:
- Take all product claims with a grain of salt. There’s no doubt that many of the touted success rates and claims on packaging labels my be true to a certain extent. However, marketers have a very low threshold for product claims. They just have to show that it’s true, whether or not it actually works for everyone. For example, if a nasal dilator strip company says, “Relieves nasal congestion and snoring,” they can say this even if only 1/10 people find any benefit. There’s no doubt that some people will experience significant benefits, but in my experience, most people have only slight improvement in symptoms. Objectively, it’s hard to quantify subjective improvement.
- Overcome paralysis by analysis. Having too many nasal dilator strip options can be frustrating. Choosing between CPAP and oral appliances can also be a challenge. Whenever faced with these issues, just pick one and give it a try. Usually, there’s one option that’s relatively easier to get (whether financially or logistically). Worse case scenario, it the first option doesn’t work, you can always go to the next option. Ideally, if possible you should try both options, since you won’t know what will work better. Some people end up using both CPAP and an oral appliance with better results.
- Don’t be afraid to try new things. If it works, keep using it. If you have the times and the resources, give both a try. Sometimes, a very good treatment option for sleep apnea won’t be covered by insurance. For example, a dental appliance for snoring or myofunctional therapy can help significantly, but you’ll have to pay out of pocket. Insurance will usually cover only the bare essentials for options that have a proven track record over many years. New and innovative options, no matter how good, usually won’t be covered.
- Trust your doctors, but take control and responsibility for your own care. Doctors are humans too, so despite years of training and education, they are prone to be biased. They are well-meaning, but they are not all-knowing. Use physicians as trusted advisors, rather than the old paternalistic way when you did everything your doctor recommended.
- Don’t give up. Time and time again, more people who are persistent end up reaching their sleep goals compared to those that either give up trying or try only a few things. In addition, don’t be afraid to fail. Nothing is guaranteed to work. Choose options that are most likely to work, but if it doesn’t work, go on to try another option.
For medical professionals:
- Take all research-based studies and results with a grain of salt. The fundamental concept of good research design looking at one variable while controlling for other confounding variables is something that scientists strive to achieve. The problem is that disease in humans is not due to a single variable, but a combination of millions if not billions of variables. This is why in many cases, if you apply research findings by the book to a patient, results are not always satisfying.
- Customize treatment recommendations to patients, and avoid template-driven medicine. If everyone followed to the letter practice guideline and recommendations, then we don’t need physicians. These recommendations are designed to be applied to the typical, routine, run-of -the-mill patient with classic conditions or symptoms. However, individuals are not statistical averages, and treatment options must be custom tailored to the patient’s unique life situations. For example, someone that travels frequently may be more inclined to use a mandibular advancement device over CPAP, despite the fact that overall effectiveness may not be as good.
- When things don’t make sense, trust your patients. This is the hardest lesson I had to learn, and it took me over 15 years to learn this. After years of training and practicing medicine and surgery, I thought that if I applied everything I learned from textbooks, journals and conferences, that’s practicing good medicine. Oftentimes, no matter how crazy I thought a patient’s explanation was, in the end, they were usually right. For example, one patient kept saying that it was his tongue that was obstructing his breathing. I didn’t see anything in the office. Sure enough, he had major tongue collapse that was seen under sleep endoscopy.
In the end, after going through dozens of different cereals in my lifetime, I’ve found one that I’m happy with (Honey Bunches of Oats). Similarly, if you keep an open mind about sleep apnea treatment options and are willing to try new things, then you’ll have a much higher chance of finding a solution to your sleep apnea problem.
What kind of frustrating experiences have you experienced as a patient or practitioner when faced with too many choices for sleep apnea care?
July 3, 2014 by dreamsmedia
Podcast #001 Show Notes
Welcome to the relaunching of my Breathe Better, Sleep Better, Live Better podcast. In this episode, I will reveal:
1. Why only humans have sleep apnea
2. How you can choke and die
3. 5 simple things you can do to sleep better tonight.
Acronym for obstructive sleep apnea: MOOSE Male Older Overweight Snoring Excessive Sleepiness.
4 Evolutionary / Anatomic Changes:
2. Anterior Migration of the Foramen Magnum
3. Laryngeal descent and loss of epiglottic and soft palate lockup
4. Vertical descent of the larynx.
As a result of complex speech and language development, only humans can choke and die.
3 Dental Important Concepts
1. Transition to soft, processed foods lead to dental crowding and malocclusion
2. Eating soft vs. hard foods and aggravate dental crowding
3. Bottle-feeding can cause dental crowding and crooked teeth.
Changes in our eating and infant feeding habits created more dental crowding and more narrow airways. All these concepts are described in more detail in my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired.
Facial profiling. Younger people have more triangular jaws and flatter faces. If our brains get bigger and our jaws get smaller, what will we look like in 50,000 years?
Sleep-breathing continuum. All chronic health conditions can be directly or indirectly connected to poor breathing and poor sleep.
Conventional treatment options for obstructive sleep apnea:
3. Dental appliances
2. Oral exercises
5. Tongue nerve stimulation / pacemaker
6. Functional dental appliances.
5 Practical Tips to Sleep Better Today
1. Avoid eating or drinking alcohol late
2. Improve nasal breathing
3. Adjust head position to improve the airway
4. Avoid migraine triggers
5. Practice relaxation / deep breathing techniques.
Reader Question: Dry mouth after starting CPAP. What to do?
Sleep Tip of the Day: How blue light can ruin your sleep and what you can do about it.
Resources mentioned in podcast:
Subscribe in iTunes @ doctorstevenpark.com/itunes. Thanks for reviewing my podcast and rating me.
June 13, 2014 by Steven Park
Since I stopped doing my teleseminars, I felt a bit out of touch with you. As a result, within the next few weeks, I’ll be re-launching my podcast, which will feature specific topics related to obstructive sleep apnea and upper airway resistance syndrome. My older teleseminars are already on my podcast. The ideas for future topics will come from you. This is why I recently sent out a reader survey, and the response was overwhelming. I got over 140 people who filled out the online questionnaire, when I was only expecting anywhere from 20 to 30 responses. It was truly gratifying to see how many people not only filled out the survey, but they also took the time to make some very helpful comments and suggestions. Here’s a summary of the major findings:
- Slightly more men than women (57% vs. 43%)
- Well over 90% are over age 40
- People responded from all over the United states
- 19 people from Canada, UK, Australia, Mexico, Jordan, France and Holland
- About 50% have graduate or higher level degrees
- About 1/2 read my book
- Most people liked accessing my information online, and video was #2
- About 2/3 of respondents initially found me through search engines or surfing
- The most popular future book title was tied between The Ultimate Sleep Apnea Manual and The 7-Day Sleep Apnea Solution
- 57% were using Windows, 29% on a Mac, 28% on a Mobile device using Safari, and 1% using Linus.
The range of suggested topics was so broad that I can’t print everything. However, the three most common frustration/suggestion themes were:
- Your doctors don’t listen, or they don’t take your sleep concerns seriously
- Massive frustration with CPAP
- Life and work stress issues
I’m going to cover these three topics in my upcoming podcasts, so please subscribe now in your podcast player or on iTunes. If you have any other topics that you want me to cover, please feel free to respond to this post in the space below.
June 9, 2014 by Steven Park
Things are a bit crazy as I ramp up my efforts to restart my podcast series as well to continue production of my second book, Your Ultimate Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You want.
As I was searching for information on the internet, I stumbled across an old interview that I gave for Sleep-Apnea-Guide.com. I highly recommend that you read the entire article. It give a great summary of the reasons why we have sleep apnea, my general treatment philosophy, and what you can do to help you get the help that you need to breathe better and sleep better.
If you have any comments or questions about it, please come back to this page to post your response or question.
May 5, 2014 by Steven Park
If you’re at your wit’s end with a young child who has major behavioral problems, you’re not alone. Before you consider placing him on medications, here’s something that you should know: Your child’s attention deficit hyperactivity disorder (ADHD) may actually be a problem breathing while sleeping. Here’s a powerful video of a young boy whose parents struggled for years before finding the right team of doctors to help their son.
Connor’s mom is organizing a cycling fundraiser to help donate $10,000 to Lurie Children’s Hospital of Chicago’s Sleep Medicine Department.
Do you have similar struggles with your child? Please feel free to comment below.
April 22, 2014 by Steven Park
One of my friends was worried about his health. He was getting sick all the time, and felt exhausted no matter how long he slept. His wife told him he was snoring and stopped breathing once in a while at night. He told his doctor that he suspected that he may have obstructive sleep apnea. His doctor told him that he’s too thin and doesn’t fit the typical profile.
This went on for many years. Finally, he came to see me, and sure enough, he had moderate to severe obstructive sleep apnea. He started using CPAP and felt like a new person. Needless to say, he went to a different doctor after this.
Patients will often tell me various symptoms that may initially seem unlikely, or even whacky. But one thing I learned over the last 15 years in practice is that usually, the patient is right. You as the patient will know your own body much better than your doctor.
What I found was that there was usually another more important issue that stood underneath the main symptom or complaint. If you feel like your doctor isn’t listening to you or understanding you, here are 5 thing you can do or say:
1. Try to rephrase your concern or symptom. Sometimes reframing your statement can not only get your doctor to listen, but it’s a gentle way of reminding him or her that you have something important to say.
2. Be direct and state that you feel like he is not listening. Different people will have different comfort levels with this, but in general, honesty is the best policy.
3. Explain in much more detail why this issue is so important to you. My friend’s father had similar health issues when younger and died early of a heart attack.
4. Be understanding and bring it up again the next time. Maybe she’s having a bad day, or he’s running late. Don’t take it personally.
5. Move on to another doctor. If this pattern continues despite multiple attempts to relay your concerns, then it’s time to find another doctor.
Have you ever been in this situation? If so, what did you do or say?
April 15, 2014 by Steven Park
It’s now official: The train engineer from last year’s deadly train derailment was found to have severe obstructive sleep apnea, where he stopped breathing 65 times per hour. To date, there’s no conclusive proof that the crash was a direct result of his untreated sleep apnea, since he was also taking a sedating antihistamine and had changed shift hours two weeks prior. However, federal transportation officials are convinced that driver fatigue may have played a role in crash that killed four and injured 70 people.
In an article about this incident, a transportation union official was quoted as saying the crash was a “tragic accident,” and that “there isn’t enough awareness of sleep apnea within the transportation industry.” This is an interesting comment, in light of the fact that recently, the National Transportation Safety Board (NTSB), Federal Motor Carrier Safety Administration (FMCSA), American Trucking Association (ATA), Federal Aviation Administration (FAA), and even Congress have worked tirelessly to bring more awareness about sleep apnea to the public.
Congress just passed a law (H.R. 3095) requiring investigation, data collection and gathering expert opinion into screening requirements for sleep apnea in various transportation industries. The FAA recently announced that they will be more vigilant about screening for OSA, especially in severely overweight pilots. In this press release, the FAA noted that there are almost 5000 pilots with OSA on treatment that have been issued special issuance certificates. Interestingly, the NTSB database reports 34 accidents, 32 of which were fatal, involving people who had sleep apnea and 294 incidents involving another type of sleep disorder.
Around 170,000 individuals are injured in trucking accidents each year. About 5,000 semi-trucks per year are involved in fatal traffic accidents in the United States. In a study conducted by the University of Pennsylvania and sponsored by the FMCSA and the American Trucking Association, almost one-third (28%) of commercial truck drivers were found to have OSA.
Given that the incidence of obstructive sleep apnea is so high in these industries, perhaps there should be universal screening. What do you think? Is it invading privacy to force mandatory sleep apnea testing, or does public safety take priority over individual rights?