Chicken or the Egg: Depression or Sleep Apnea?

August 20, 2014

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?

 

References

 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.

4. http://www.health.harvard.edu/newsweek/what-causes-depression.htm

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.

How Your Face Can Predict Your Sleep Position

August 7, 2014

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?

With So Many Sleep Apnea Treatment Options, What’s a Patient (or Doctor) to Do?

August 5, 2014

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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. 
  5. 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:

  1. 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. 
  2. 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.
  3. 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?

2014 Reader Survey Results

June 13, 2014

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.  

A Must Read Interview If You Have Obstructive Sleep Apnea

June 9, 2014

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.

If Your Child Has ADHD, You Must See This Video

May 5, 2014

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.

5 Things You Can Do When Your Doctor Doesn’t Listen

April 22, 2014

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?

Sleep Apnea May Have Caused Metro North Train Crash

April 15, 2014

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?

 

Peripheral Neuropathy and Obstructive Sleep Apnea

March 16, 2014

I just saw a patient 5 weeks after major tongue and soft palate surgery for obstructive sleep apnea, and as expected more often than not, his sleep quality was significantly improved. He did not suffer from brain fog anymore, and was able to think clearly again, something he was not able to do for more than 30 years. He was very happy with the results. As he was leaving the exam room, he wanted to show me something. He took off his shoes, and then his socks, and asked me what I thought.

I was a bit confused by his request, but then I remembered that he showed me his feet many months prior to his procedures. Compared to his right foot at that time, his left foot was more dusky, red and scaly, and not too healthy looking. He had peripheral neuropathy with pain, burring and numbness, for which he was being treated by another doctor. On the post-operative visit, his left foot looked much healthier. He also noted proudly that although he still had some numbness, his burning and pain were completely gone.

Peripheral neuropathy is a common condition seen usually in diabetics, but can also occur in non-diabetics. I wasn’t surprised by his result, but it was a bit unexpected. It not something that’s routinely described as a potential benefit of treating obstructive sleep apnea. We know that sleep apnea causes a stress response that clamps down on blood vessels of the distant extremities. 

I did a quick literature search of the connection between obstructive sleep apnea and peripheral neuropathy and found a handful of studies. One report found that patients with obstructive sleep apnea without any symptoms in the feet had objective measures of diminished nerve function, which improved significantly after CPAP therapy. Another paper described resolution of peripheral neuropathy pain (but not numbness) in a non-diabetic after CPAP. 

Knowing that obstructive sleep apnea and diabetes frequently go hand in hand, and that diabetes and peripheral neuropathy also go together, there’s a good possibility that the first and the last can also be linked as well. The real question that needs to be asked is, how many people with peripheral neuropathy have obstructive sleep apnea, and if treated adequately, how many can be helped or even cured? Another question that follows is, should all diabetics be routinely screened for obstructive sleep apnea? Knowing that obese diabetics can have up to an 80% chance of having obstructive sleep apnea, perhaps the answer should be yes.

If you’ve been diagnosed with obstructive sleep apnea, did your foot pain or numbness get any better after using CPAP, dental appliances or surgery?

 

Inflammation, PTSD and Sleep Apnea

March 5, 2014

Post traumatic stress disorder, or PTSD, is a commonly seen condition, especially in victims of sexual abuse, or in military personnel after deployment. For the most part, it’s categorized as a mental health disorder that’s treated with medications and/or psychotherapy. Personal or family history of anxiety or depression is though to increase your risk of developing PTSD.
 
In this new study, the presence of inflammation was found to predict later development of PTSD. In particular, each 10 fold level of C-reactive protein (CRP) was associated with a 51% increased likelihood of showing at least one PTSD symptoms after deployment to Iraq or Afghanistan.
 
When I came across this study, the first thing that came to mind was the numerous previous studies showing that having obstructive sleep apnea (OSA) is strongly associated with elevated levels of CRP, and that treating OSA with CPAP can lower CRP levels. 
 
In addition to higher levels of CRP, OSA is also associated with elevated levels of IL-1, IL-6, and TNF-alpha. CRP is a general marker of inflammation and can even be elevated after surgery.
 
A good analogy is to say that having a fever increase the chances that you have a cold. Your temperature can also go up if you have pneumonia. There’s nothing special about having an elevated temperature, since it’s a general marker of inflammation. In a similar way both obstructive sleep apnea and PTSD are both associated with elevated levels of CRP. 
 
But what if obstructive sleep apnea increases your chances of developing PTSD? Not too coincidentally, there’s a study showing that veterans with PTSD have up to 50% rate of OSA. Treating OSA can oftentimes improve PTSD symptoms. I’ve had numerous veterans report that their PTSD was completely gone after starting CPAP.
 
Something to always think about when you’re dealing with PTSD.

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The material on this website is for educational and informational purposes only and is not and should not be relied upon or construed as medical, surgical, psychological, or nutritional advice. Please consult your doctor before making any changes to your medical regimen, exercise or diet program.



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