June 25, 2012
Despite the medical community’s insistence that sleep apnea and depression are two completely unrelated conditions, it’s hard to ignore study after study showing that treating obstructive sleep apnea can significantly improve signs and symptoms of depression. Here’s another study that was presented at the SLEEP meeting in Boston last weekend.
Oftentimes, a very high proportion of people with obstructive sleep apnea have clinical depression. It’s estimated that about 24% of men and 9% of women have undiagnosed sleep apnea, going as high as 64% in people over 65. It’s also estimated that only a small fraction of people with sleep apnea are ever diagnosed, with an even smaller fraction of those that are diagnosed being treated effectively. Given these numbers, the implications are huge.
Yes, there are multiple other reasons for clinical depression, but knowing what we know about the prevalence of obstructive sleep apnea, shouldn’t all mental health professionals first rule out obstructive sleep apnea before prescribing medications or long courses of psychotherapy?
October 26, 2011
Everyone knows that teens are under intense pressure to not only produce stellar grades, but also excel in numerous extracurricular activities as well. The problem is that there’s only 24 hours in a day. Add to this 4-6 hours of homework in the most competitive private and public high schools, and the first thing to get sacrificed is sleep.
In this New York Times article on the stresses of too much homework in independent schools, one student newspaper at a prestigious private school published an article last year showing that upper school students slept an average of 6.5 hours per night. I was shocked to see this. You may think that this is not too bad, but consider this: A teenager should be sleeping 9 to 10 hours per night.
There are tomes of research showing what chronic long-term sleep deprivation does for people in general, but these negative effects are even more magnified in developing teens’ brains and bodies. It’s not surprising that rate of anxiety and depression are are at already too high levels, and a lot of students are just burning out (mentally and physically). Many of these problems will ultimately manifest when they get to college, where sleep deprivation and poor eating and sleep habits become even worse. This is why the incidence of depression peaks in the college years.
I realize there’s no easy solution to this problem, but someone has to take a stand and say enough is enough. What do you think about this issue?
September 19, 2011
In this Expert Interview program, Ms. Lisa Brateman will talk to us about the psychology of obstructive sleep apnea. This is an important topic that affects not only those of you with sleep apnea, but also your loved ones, your friends, and family members.
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September 17, 2011
With the start to the new school year, millions of college freshmen will begin their academic endeavors, gaining knowledge, newfound independence and new life skills. But there’s one more thing that many students will gain this year: 10 to 15 pounds. Weather or not the Freshman 15 actually exists (on average they gain about 5 pounds), this commonly seen phenomenon is thought to be due to a lack of exercise, eating buffet style cafeteria food, late meals and snacks, unhealthy diets, and excessive alcohol.
However, there’s one more important, but under-appreciated condition that is expected to occur when you gain even a small amount of weight: Fat cells take up space in your throat, leading to a gradual progression into obstructive sleep apnea. As I’ve mentioned before on numerous occasions, eating late promotes more obstructions and arousals, as well as increased gastric contents reaching the throat. This causes more swelling and damage to the protective upper airway receptors in the throat, leading to more frequent and prolonged breathing pauses. Poor quality sleep promotes weight gain, through hormonal, metabolic, and neurologic mechanisms. Drinking alcohol close to bedtime an also relax your throat muscles, leading to more frequent apneas. There’s no need to remind you about sleep deprivation and poor sleep hygiene in college students.
It’s also no coincidence that anxiety and depression peaks in college-aged men and women. Poor sleep quality can not only cause neuro-biochemical changes, but also promotes poor sleep habits and hygiene. It’s no wonder college students are at higher risk of delayed sleep phase syndrome, where one’s sleep clock cycle is shifted many hours later. I suspect that students who are most prone to weigh gain have narrowed jaws and dental crowding to begin with, prefer to sleep on their sides or stomach, and one or both parents probably have undiagnosed obstructive sleep apnea.
Have you or any of your children experienced the Freshman 15?
July 9, 2011
Recurrent sinus infections, throat pain, ear fullness and chronic cough are some of the most common conditions that I see every day. You may think that I typically diagnose and treat for routine bacterial infections in these situations, but in most cases, they’re not really infections at all. What I do find, however, is that if you probe and look back at the patients’ history, there’s always some major life change or recent event that acted as a trigger for their symptoms, especially if their upper airway anatomy is already narrowed or predisposed. Here are 5 common examples:
Sleepless nights from a newborn child
The birth of a child is always a joyous event, but everyone knows that your life will change drastically all of a sudden. Your normal routines, eating habits, exercise regimens, and especially the timing for all these events will change. The sleep deprivation, lack of exercise, and bad eating habits can promote weight gain, which can narrow your throat even further. This leads to more problems breathing at night, leading to less efficient sleep, leading to more weight gain. This applies to both the mother and the father.
It’s also a common phenomenon where a woman is never able to lose her pregnancy weight, despite extreme dieting or exercise. This leads to less effective sleep, increased fatigue, and various other health-related conditions.
Newfound independence, more depression
The freshman 15 is more than just an observation—there’s a good reason why college students gain weight all of a sudden during their freshman year. Dorm meals and cafeteria food tends to be starchy and very high in calories, and because of the buffet-style format, there can be problems with portion control. Home-cooked meals by parents, eaten at relatively normal times (5 to 7 PM), turns into eating later in the night: more episodes of pizza, take out food, and late night snacks while pulling all-nighters for exams.
Having stomach juices when you go to sleep will allow more acid and other stomach materials to regurgitate into your throat, leading to more frequent arousals and less efficient sleep. This leads to a cascade of metabolic, hormonal, and cardiovascular consequences that promotes weight gain. Drinking alcohol at night relaxes the throat even further, leading to more frequent breathing pauses.
This relative sudden change in your eating and sleep routines can definitely affect your mood and mental health. It’s not surprising that depression and anxiety peaks during the college years. This is also the time when the larynx (voice box) descends in the neck to its’ lowest position during maturation into adulthood. The lower your voice-box, the more the tongue can fall back, leading to more frequent breathing problems.
A new job or a promotion
It’s great to start a new job, or get that promotion that you’ve wanted. But just like any other major change in your life, your routines will change. You’ll stay later to impress your boss, skip meals, come home later and go to bed later. As a result, you’ll gain a few pounds. Some people can eventually adjust their schedules to accommodate a healthy sleep schedule, diet and exercise regimen, but others can’t. This is when things begin to go downhill.
Injury or surgery
Most people with sleep-breathing problems prefer to sleep on their sides or stomach. Any kind of injury or undergoing surgery can force you to sleep on your back, which causes more tongue collapse (due to gravity) and more obstructions and arousals (due to muscle relaxation in deep sleep). In fact, many patients have told me that their lack of sleep, physical activity and subsequent weight gain is what triggered a vicious cycle.
This applies mainly to women, but hormonal changes can affect men too. Loss of estrogen and progesterone can diminish their protective effects on the upper airway. In particular, progesterone is an upper airway muscle stimulant/dilator. As it begins to diminish in the early 40s, the tongue begins to relax more and more over the years, leading to less efficient sleep, and the typical vasomotor symptoms begin which includes hot flashes, night sweats, weight gain, mood swings, and irritability. Believe it or not, these symptoms can happen in young men, too. These are your body’s nervous system reaction to the changes with your sleep-breathing status.
As you can see, all of us will go through some or all of these events at some point in our lives. It’s natural as modern humans to be susceptible to these sleep-breathing related conditions. It may sound a bit depressing, but the good news is that now you’re aware of it, you can take preventive measures once it starts.
March 16, 2011
In this month’s Expert Interview, I interview Dr. Avram Gold, a pioneer in researching the link between upper airway resistance syndrome, chronic fatigue, and the functional somatic syndromes. Some of the topics will include:
- What are the functional somatic syndromes and how are they related to sleep-breathing disorders?
- What’s the relationship between central sensitivity syndrome and stress?
- How is sleep-disordered breathing related to stress?
- How is anxiety or depression related to functional somatic syndromes?
- How is chronic fatigue syndrome connected to the this condition?
Please enter your information below to gain access to the free recording:
January 5, 2011
Believe it or not, your skin is considered an end organ, meaning that it’s at the outermost reaches of your blood supply. It’s also a part of your body which can be deprived of blood flow if you’re under stress, similar to what happens to your digestive or reproductive systems.
Psoriasis is a common skin condition that affects about 34 million Americans, or about 3% of the population. It’s characterized by red, scaly patches of skin covered by white flakes. It’s thought to be a chronic autoimmune condition, where your body’s immune system can attack or damage your own tissues.
I’ve written before about strong links between psoriasis and obstructive sleep apnea, but here are a series of studies that further solidifies this connection. Some of the studies I’ve cited before. Others are new:
Metabolic syndrome (Syndrome X) is a combination of high blood pressure, insulin resistance, and high cholesterol levels. Having all three conditions has been shown to significantly increase your risk of heart disease, heart attack, or stroke. Numerous studies show that people with metabolic syndrome can also have obstructive sleep apnea. In fact, syndrome Z has been described as all the features of Syndrome X plus obstructive sleep apnea.
A study published in Archives of Dermatology showed that patients with psoriasis had a higher chance of having metabolic syndrome compared to people who didn’t (40% vs. 23). I’ve written in the past about how chronic physiologic stress due to sleep apnea causes diversion of blood flow and nutrients to the bowels, reproductive organs, and the skin, since they’re considered “low priority” organs. Low blood flow causes a relative hypoxia, creating oxidative stress, and along with a heightened immune system, so it’s not surprising that the skin can show psoriatic plaques.
Here’s a study showed that women who drank more than two alcoholic beverages per week had a significantly higher risk of psoriasis. Alcohol relaxes your throat muscles, aggravating sleep apnea.
Researchers from harvard showed that comorbid conditions such as cardiovascular disease, depression, diabetes, obesity, and hyperlipidemia all increased over time. Not too surprising if you already have sleep apnea.
Pregnant women with psoriasis were found by Harvard and Mass General researchers to have higher risk of pregnancy-related complications, including spontaneous abortion, preterm birth, preeclampsia, placenta previa, and ectopic pregnancy. Gaining weight can aggravate sleep apnea. Studies show that CPAP can help with preeclampsia.
People with psoriasis were found to have increased risk of depression (39%), anxiety (31%) and suicidal thoughts (44%). Sleep apnea can cause structural, metabolic, and biochemical changes in your brain due to hypoxia.
And lastly, young adults who are obese were found to have a higher risk of developing psoriatic arthritis later in life. Obesity is a major risk factor for obstructive sleep apnea.
Perhaps psoriasis should be placed on the ever-growing list of complications of obstructive sleep apnea. What do you think?
December 22, 2010
In this modern age of anxiety, it’s almost a given that you’ll have some anxiety over certain things, such as financial, health, relationship, or academic concerns. If you have a sleep-breathing disorder, it’s likely your stress and anxiety levels will be much higher. Any degree of sleep deprivation or inefficient sleep can heighten your nervous system, and make you over-react to situations that normally wouldn’t stress you out.
Looking back, I distinctly remember two episodes in my life, where I had some major panic attacks, beyond the typical life stresses or anxiety provoking states, such as death, relationship issues, or even job interviews.
I’ve always considered myself an introvert, but not shy. In high school, I was active in music (orchestra, symphonic band, and the jazz band), was captain of the track team, and was active in science research. I don’t remember having any problems giving presentations and speaking in public, but that changed once I got to medical school.
In the second year of medical school, I was sitting in a small psychiatry class, where each student had to interpret and critique an interview that was just observed. For some reason, as my turn came near, I could feel my heart pounding away, and broke out in a cold sweat. My heart was beating so fast and intensely, I though I was going to have a heart attack and die. Even my kidneys hurt. Fortunately, I said a few words about the interview, and didn’t die. This type of panic and anxiety persisted to some degree for the rest of the year. Fortunately, by my my third year clinical rotations, it problem went away completely.
The other situation that I remember was after a major highway car accident during residency. I was driving along with Henry Hudson Parkway at night in the express lane, and saw from the rear view mirror that there was a car that was zig-zagging from lane to lane. Within an instant, I saw that he was high beaming me on and off, and then he rammed into me while speeding over 100 miles per hour. My car got pushed onto the divider, turning almost 90 degrees, and I though I was going to flip over and die. Fortunately, my car slid back down and slid along the right side of the elevated highway for another few hundred feet. My car was totaled, and I was taken on a backboard to the ER at Columbia. I came away with only the shock of the experience, but for about a few months after this incident, whenever I saw a car change lanes into my lane behind me, I would have mild panic attacks.
Looking back at both incidents, I was in a period of time when I was majorly sleep deprived. During second year medical school, I was not getting enough sleep due to the various demands of all the courses. During residency, I was still taking first call, working about 100 to 120 hours per week. This is like having a short bout of PTSD, or post-traumatic stress disorder.
The point I wish to make here is that if you don’t sleep long enough, or if your sleep is inefficient (like with sleep apnea), then you’re more likely to suffer from anxiety or pain attacks. My examples are the more extreme conditions that can arise, but most people just get upset a bit quicker or over-react inappropriately in certain situations. This is why good, quality sleep should always be a top priority in your life.
Do you have any experiences where major sleep deprivation caused you to have increased anxiety or pain attacks?
January 4, 2010
There are studies linking sleep apnea with restless leg syndrome (RLS) and sleep apnea with erectile dysfunction, but now there's a study linking restless leg syndrome with erectile dysfunction. Not too surprising, since sleep apnea seems to be the common denominator for almost every imaginable disease, known or unknown. You may think that this statement is over the top, but you'll have to admit that not breathing well during the day, and especially not breathing well at night while sleeping can potentially lead to or aggravate almost every disease known to man.
In this particular study, researchers found that men with RLS had significantly increased risk for having erectile dysfunction (ED) compared with men who did not have RLS. The lead researcher, Dr. Gao, commented that the findings indirectly support the role of dopamine as a common pathway, in light of another study of his in the past that showed an association between ED and Parkinson's disease. He also points out that these same people with ED were more overweight, more prone to depression and anxiety, and had a greater chance of having hypertension or a history of stroke (sound familiar?)
It sounds like dopamine deficiency is a popular explanation for a number of different conditions. For both PLS and Parkinson's, giving dopamine-like agents help with the respective symptoms. The problem is that it never cures the problem completely, with a number of serious side effects.
This approach to medicine is the replenish what's missing method. If you're deficient in dopamine, replace it. If you're deficient in Vitamin C, B12, or thyroid hormone, replace it. The problem is that this approach works in some people, but not in everyone. Then the next step is to increase the dosage, and then even more people respond, but not everyone (with more side effects). Ultimately, you're not addressing what's causing the deficiency.
If you have a sleep-breathing problem, it's been shown that you can easily clot in certain small and large vessels of your brain very easily. If you happen to have a clot in the dopamine area of your brain, or if the brain biochemistry changes as a result of hypoxia, then you'll get various symptoms. But I think even the neurologists will tell you that a lack of dopamine itself won't lead to Parkinsons; it's just one part of a much larger picture. Could it be that obstructive sleep apnea may be that bigger picture, since by definition, all modern humans are susceptible to sleep breathing problems to various degrees?
What's your opinion on this? Should we continue to treat every medical condition in isolation hoping to target that one missing protein or gene, or should we step back and try to connect the dots until we see the bigger picture? Please enter your comments in the box below.
December 15, 2009
Sleep apnea is a major cause of physiologic stress. External stress of any kind (especially the holiday season) only aggravates the internal, physiologic stress that I describe in people who don’t sleep well.
To help you better manage your stress this holiday season, I’ve invited Dr. Niloo Dardashti, an integrative psychologist and holistic healer for this month’s expert interview, and I hope you’ll dial in and join us.
During this free information-packed hour, you’ll learn:
- What’s the interaction between stress, sleep problems and heart disease?
- What are some techniques for quieting "inner chatter" when stress has its’ hold on us?
- How can I stop unwanted thoughts?
- Which comes first – the chicken or the egg – does lack of sleep cause stress, or does stress cause lack of sleep?
- How can stress be handled returning to work after holidays or vacations?
- What are Dr. Dardashti’s thoughts on ADHD, Adderall and stimulants, especially for someone who has both anxiety and sleep apnea?
- How can I quit smoking if I’m very stressed and exhausted?
- What’s the best way of controlling work related stress?
- How can one reduce stress during a very stressful situation, such as being stuck in a large crowd, for example?
- How can I deal with being short on cash?
Tuesday, December 15th, at 8PM Eastern.
Register here to receive the call-in details.