Alex Dimitriu, MD

Menlo Park Psychiatry & Sleep Medicine

Pachamama - Celebrating Earth Day 2018

In a time of rapid change, and the decline of things sacred, our quiet time, our families, the nature around us, it is no surprise that anxiety and depression are as prevalent as they are. Indeed these conditions emerge, as we get further and further from our natural selves. We are indeed blessed to be the children of a most amazing and complex ecosystem, that is our little blue marble of Earth in the cosmos. We might find happiness by reuniting with our nature, and remembering the vast importance and meaning of the simple things. Nature, family, and basic human kindness and compassion. Let's take this opportunity to remember, we are one, and that is what makes us happy, healthy, and strong. And that there might still be something magical out there, or around and within us, that is far greater and more powerful than we can understand. 


This letter was sent in 1855 by Native American Chief Seattle of the Duwamish Tribe to Franklin Pierce, President of the United States in response to an offer to purchase the Dwamish lands in the North East of the US, currently Washington State. The Native Americans were powerfully bound to the earth; the idea of property was foreign to them, and they actually considered the earth to own humankind. This was the Chief’s moving, lucid letter:

The Great Chief in Washington sends word that he wishes to buy our land. The Great Chief also sends us words of friendship and good will. This is kind of him, since we know he has little need of our friendship in return. But we will consider your offer, for we know if we do not so the white man may come with guns and take our land. What Chief Seattle says you can count on as truly as our white brothers can count on the return of the seasons. My words are like the stars –they do not set.

How can you buy or sell the sky –the warmth of the land? The idea is strange to us. Yet we do not own the freshness of the air or the sparkle of the water. How can you buy them from us? We will decide in our time. Every part of this earth is sacred to my people. Every shining pine needle, every sandy shore, every mist in the dark woods, every clearing, and every humming insect is holy in the memory and experience of my people. The sap that runs through the trees carries the memories of the red-skinned man.

The dead among the white man forget their birthplace when they leave to walk among the stars. Our dead never forget this beautiful earth because she is the redman’s mother. We are part of the earth and she is part of us. The scented flowers are our sisters: the horned beasts, the horse and the majestic eagle are our brothers. The fields, the warm body of the foal and man, all belong to the same family. Thus when the Great Chief in Washington sends word that he wishes to buy our lands, he is asking for a great deal. The Great Chief sends word that he will reserve a space for us to live comfortably with each other. He will be our father and we will be his children. Because of this, we will consider his offer to buy our lands. But this will not be easy, because these lands are a sacred to us. The sparkling water that runs in the rivers and streams is not only water; it is the blood of our ancestors. if we sell you these lands, you must remember that they are sacred, and teach your children that they are, and that every ghostly reflection in the clear waters of the lakes speaks of the lives and memories of the life of my people. The murmur of the stream is the voice of my father’s father.

The rivers are our sisters, and calm our thirst. The rivers carry our canoes and feed our children. If we sell you our lands, you must remember and teach your children that the rivers are our kin and your kin; you must henceforth treat the rivers as kindly as you would your brothers and sisters.

We know that the white man does not understand our ways. One portion of land is the same to him as the next, for he is a stranger who comes in the night and takes from the land whatever he needs. The earth is not his brother, but his enemy, and when he has conquered it, he moves on. He leaves his father’s graves and his children’s birthright is forgotten. He strips the earth from his children and cares not. He forgets his father’s tomb and the rights of his children. He treats his mother, the earth, and his brother the heavens, as if they were things that could be bought, plundered and sold, as though they were lambs and glass beads. His insatiable hunger will devour the earth and leave behind a desert.

I do not understand. Our ways are different to yours. The sight of your cities pains the eyes of the redman. But perhaps it is because the redman is a savage and does not understand. There is no quiet place in the white man’s cities. No place to listen to the leaves of spring or the rustle of insect wings. But perhaps because I am a savage and do not understand –the clatter only seems to insult the ears. And what is there to life if a man cannot hear the lovely cry of the whippoorwill or the arguments of the frogs around a pond at night? I am a redman and I do not understand.

The Indian prefers the soft sound of the wind itself cleansed by a mid-day rain, or scented by a pinõn pine.

The air is precious to the redman. For all things share the same breath –the beasts, the trees, and the man. The white man does not seem to notice the air he breathes. Like a man dying for many days, he is numb to the stench. If we sell you our lands, you must remember that the air is precious to us, that the air shares its spirit with all the life it sustains. And, if we sell you our lands, you must set them aside and keep them sacred as a place that even the white man may go to to taste the wind sweetened by the flowers in the grasslands.

If I decide to accept your offer, I will make one condition. The white man must treat the beasts of this land as his brothers. I am a savage and I do not understand any other way. I have seen thousands of rotting buffaloes on the prairie left by the white man who shot them from a passing train. I am a savage and do not understand how the smoking iron horse can be more important than the buffalo that we kill only to stay alive. What is man without the beasts? If all the beasts were gone, men would die from great loneliness of spirit, for whatever happens to the beast also happens to the man. All things are connected. Whatever befalls the earth befalls the sons of the earth.

You must teach your children that the ground beneath their feet is the ashes of their grandparents. In order that they may respect the earth, teach them that the earth is full of the life of our ancestors. You must teach your children what we have taught ours: that the earth is our mother. Everything that affects the earth affects the sons of the earth. When men spit on the ground they spit on themselves.

We know this: the earth does not belong to man. Man belongs to the earth. Man has not woven the net of life: he is just a thread in it. Everything he does to this net he does to himself. What befalls the earth will befall the sons of the earth. We know this. All things are bound up in each other like the blood that binds the family.

Even the white man, whose God walks with him and speaks with him, cannot be excluded from a common destiny. We may even be brothers in the end. We will see. One thing we know that the white man may one day discover. Our God is the same God. You may think that you own him as you wish to own our land, but you cannot. He is the Body of man, and his compassion is equal for the redman and the white. This earth is precious to him, and to harm the earth is to heap contempt on its Creator. The whites, too, shall pass – perhaps sooner than other tribes. Continue to contaminate your bed, and you will one night suffocate in your own waste. But even in your last hours you will feel illuminated by the idea that God brought you to these lands and gave you a special purpose, and ownership over them and over the redman. When the buffalo are all slaughtered, the wild horses all tamed, the secret corners of the forest heavy with the scent of many men, and the view of the ripe hills blotted by the talking wires, where is the thicket? Gone. Where is the eagle? Gone. And what is it to say goodbye to the swift and the hunt? The end of living and the beginning of survival.

Another powerful and profound reminder, from Chief Seattle:

https://www.youtube.com/watch?v=0IomIER6pZY


The Universal Declaration of the Rights of Mother Earth

Presented by Bolivia for UN recognition outlines some of the fundamental rights earth.

(1) Mother Earth is a living being.

(2) Mother Earth is a unique, indivisible, self-regulating community of interrelated beings that sustains, contains and reproduces all beings.

(3) Each being is defined by its relationships as an integral part of Mother Earth.

(4) The inherent rights of Mother Earth are inalienable in that they arise from the same source as existence.

(5) Mother Earth and all beings are entitled to all the inherent rights recognized in this Declaration without distinction of any kind, such as may be made between organic and inorganic beings, species, origin, use to human beings, or any other status.

(6) Just as human beings have human rights, all other beings also have rights which are specific to their species or kind and appropriate for their role and function within the communities within which they exist.

(7) The rights of each being are limited by the rights of other beings and any conflict between their rights must be resolved in a way that maintains the integrity, balance and health of Mother Earth.

Alex Dimitriu in the Sierra.JPG

A concise REVIEW of behavioral approaches to insomnia

From the American Academy of Sleep Medicine. Below is the current recommendations for behaviroal treatment of insomnia. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576317/

Common Cognitive and Behavioral Therapies for Chronic Insomnia

Stimulus control (Standard) is designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry. These negative states are frequently conditioned in response to efforts to sleep as a result of prolonged periods of time in bed awake. The objectives of stimulus control therapy are for the patient to form a positive and clear association between the bed and sleep and to establish a stable sleep-wake schedule.

Instructions: Go to bed only when sleepy; maintain a regular schedule; avoid naps; use the bed only for sleep; if unable to fall asleep (or back to sleep) within 20 minutes, remove yourself from bed—engage in relaxing activity until drowsy then return to bed—repeat this as necessary. Patients should be advised to leave the bed after they have perceived not to sleep within approximately 20 minutes, rather than actual clock-watching which should be avoided.

Relaxation training (Standard) such as progressive muscle relaxation, guided imagery, or abdominal breathing, is designed to lower somatic and cognitive arousal states which interfere with sleep. Relaxation training can be useful in patients displaying elevated levels of arousal and is often utilized with CBT.

Instructions: Progressive muscle relaxation training involves methodical tensing and relaxing different muscle groups throughout the body. Specific techniques are widely available in written and audio form.

Cognitive Behavioral Therapy for Insomnia or CBT-I (Standard) is a combination of cognitive therapy coupled with behavioral treatments (e.g., stimulus control, sleep restriction) with or without relaxation therapy. Cognitive therapy seeks to change the patient's overvalued beliefs and unrealistic expectations about sleep. Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Common cognitive distortions that are identified and addressed in the course of treatment include: “I can't sleep without medication,” “I have a chemical imbalance,” “If I can't sleep I should stay in bed and rest,” “My life will be ruined if I can't sleep.”

Multicomponent therapy [without cognitive therapy] (Guideline) utilizes various combinations of behavioral (stimulus control, relaxation, sleep restriction) therapies, and sleep hygiene education. Many therapists use some form of multimodal approach in treating chronic insomnia.

Sleep restriction (Guideline) initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive. As sleep drive increases and the window of opportunity for sleep remains restricted with daytime napping prohibited, sleep becomes more consolidated. When sleep continuity substantially improves, time in bed is gradually increased, to provide sufficient sleep time for the patient to feel rested during the day, while preserving the newly acquired sleep consolidation. In addition, the approach is consistent with stimulus control goals in that it minimizes the amount of time spent in bed awake helping to restore the association between bed and sleeping.

Instructions (Note, when using sleep restriction, patients should be monitored for and cautioned about possible sleepiness):

  • Maintain a sleep log and determine the mean total sleep time (TST) for the baseline period (e.g., 1–2 weeks)

  • Set bedtime and wake-up times to approximate the mean TST to achieve a >85% sleep efficiency (TST/TIB × 100%) over 7 days; the goal is for the total time in bed (TIB) (not <5 hours) to approximate the TST.

  • Make weekly adjustments: 1) for sleep efficiency (TST/TIB × 100%) >85% to 90% over 7 days, TIB can be increased by 15–20 minutes; 2) for SE <80%, TIB can be further decreased by 15–20 minutes.

  • Repeat TIB adjustment every 7 days.

Paradoxical intention (Guideline) is a specific cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. The objective is to eliminate a patient's anxiety about sleep performance.

Biofeedback therapy (Guideline) trains the patient to control some physiologic variable through visual or auditory feedback. The objective is to reduce somatic arousal.

Sleep hygiene therapy (No recommendation) involves teaching patients about healthy lifestyle practices that improve sleep. It should be used in conjunction with stimulus control, relaxation training, sleep restriction or cognitive therapy.

Instructions include, but are not limited to, keeping a regular schedule, having a healthy diet and regular daytime exercise, having a quiet sleep environment, and avoiding napping, caffeine, other stimulants, nicotine, alcohol, excessive fluids, or stimulating activities before bedtime.

Less Stressful Holiday Hosting

holiday dinner blog.png

The holiday season is upon us. Along with the season, come many friends, family, trips, and social gatherings. The holidays can certainly be a spirited, nostalgic time that many look forward to.

But the holidays can also be trying times for many people, especially those who deal with overwhelming stress and anxiety during this time of year. That tension can manifest itself in the form of depression, weight gain, isolation, and so much more. The following are some ideas on how to lessen stress when you’re hosting a holiday party.

Stress Management

In order to keep yourself in good spirits this holiday season, try to maintain some perspective. When planning for a big event, you don’t need to change your routine that drastically.

●      Plan things out before: Dictate to yourself where your event will happen, what you will need, and how long you should prepare. Too many things done last minute is an unnecessary stressor for you and your family. Also, include a budget so you don’t overspend.

●      Take time for yourself: No matter what, remember to take a breather every so often. Look around and reflect on the goodness happening around you.

●      Get your sleep: Sleep is also very important during the holidays. No job should be so big and no event should be so significant that you should miss any sleep.   

Hosting a Big Party

Should you find yourself hosting a big event, keep in mind it should still be fun. There are many sources such as HGTV that can help you during the entire process of planning, preparing, and executing a stellar party at your home. Plan to include the basics into your party, such as easy decorations. Wreaths, tinsel, table runners, and candles are good options. Festive background music is a great addition to a party. In addition to any food and drinks you serve, you’ll want to include some holiday snacks. There are tons of recipes available that taste delicious and can be done together with the family.

Pinterest can also be an excellent resource for ideas involving holiday parties. There are many aesthetically pleasing do-it-yourself options such as placemats and center pieces that can make your party a talking point for the entire holiday season.

Preparing the Feast

Getting a large amount of food for many people can be a daunting task, regardless of what season it may be. Different people have different tastes, and it can be a headache trying to figure out who might want what. Still, there’s no need to worry too much. When faced with preparing a big meal, keep these things in mind:

●      Cook for the collective: Try to stick to typical holiday fare that most people enjoy. These options will likely be crowd-pleasers.

●      Include other options: Understand who will be in attendance. Research any special diets or restrictions guests may have. Including a vegan option is always a good backup.

●      Prepare enough food: Always make sure you have enough food for your guests. If needed, have backup dishes ready and prepared if you see signs you might run low.

●      Invite others to bring sweets: Having others bring their favorite dessert dishes cuts down on your work. It can also be a fun way for everyone to introduce their own sweet options.

Regardless of whether you are hosting a dinner party or just attending one of many this holiday season, remember to just be happy. Take many moments to simply breath and reflect upon the joy this season brings. Through your own happiness, you will be better fit to promote the happiness of others.

By Jennifer Scott

Photo Credit: Pixabay

Seasonal Affective Disorder and Addiction

Seasonal Affective Disorder and the Risk of Addiction

By Laura Baker: 

Seasonal affective disorder (SAD) is a form of depression that occurs only during certain times of the year. Most people will experience SAD during the winter due to lack of sunlight and the consequential lack of vitamin D, though spring and summer SAD also can occur. As with most mental illnesses, SAD creates an increased risk for addiction which can, in turn, worsen the symptoms. If you struggle with SAD or seasonal substance abuse, there are a few things you should know.

Self-Medication is a Concern for Those with Depression

Too many people with depression go untreated for their condition. Depression can become a very serious health concern and lead to suicidal thoughts and difficulty maintaining daily life. When a person goes untreated or undiagnosed, he may turn to detrimental forms of self-medication. 

Self-medication refers to the act of abusing substances in place of proper treatment for a condition. With the stigma attached to mental health care, it is all too common for those with mental illnesses to self-medicate. As a result, people with SAD may develop a habit of seasonally self-medicating through the winter months rather than seeking the help of a professional. If you are experiencing the symptoms of SAD, it is important that you speak to your doctor about a diagnosis and treatment plan.

Addiction Can Occur as a Result of Self-Medication

When a person turns to self-medication, he opens himself up to the possibility of developing an addiction. The habit of turning to a substance when depression strikes creates the perfect circumstances for a dependency to develop. With time, the brain will learn that when the symptoms of depression or SAD arise, it should expect substance abuse. The individual will begin to crave the substance whenever he feels depressed, even if the self-medication no longer seems to relieve his symptoms.

Unfortunately, addiction makes mental illnesses such as seasonal affective disorder worse. The result is a vicious cycle in which an untreated individual notices his symptoms growing worse and increases his substance abuse, thereby solidifying his addiction and worsening his symptoms even further. In order to fully recover from an addiction due to self-medication, it is critical that the person with the mental illness gets treatment. Without proper treatment for the illness, the individual will likelyreturn to self-medicating.

Proper Treatment Can Prevent or Eliminate Addiction

The best way to prevent and manage an addiction in those with depression or SAD is to get professional help. Without proper treatment, it is all too easy for a depressed person to turn to what he knows: substances. However, if he learns to manage his symptoms, the perceived need to self-medicate will decrease.

If the person in question has already cultivated an addiction, it certainly can be treated while effectively managing the symptoms of seasonal affective disorder. Dual diagnosis treatment programs are a great option for those who struggle with self-medication because they not only tackle the addiction but also focus on treating the cause of depression. If you struggle with self-medication or realize you may have an addiction, it is important that you seek help as soon as possible. The longer the addiction is allowed to continue, the more your depression will progress.

When you have a form of depression like seasonal affective disorder, it can be difficult to identify the pattern of self-medication. However, like any form of depression, it is important that you speak with your doctor about a treatment plan. Treatment for SAD is reasonably simple and could potentially save you from the process of addiction recovery. If you believe you have SAD, do not wait. Speak with a professional now and get the help you need before you also are seeking help for an addiction due to self-medication to treat your disorder.

Image via Pixabay by moritz320

For additional information, see: https://www.nestmaven.com/sleep/seasonal-affective-disorder/

Sleepwalking Through Life

I have often joked with my wife, that I have to keep quiet about what I do for a living at any gathering. Sleep and psychiatry, it turns out, are two things people really have on their minds; and in today’s fast times, everyone seems to be stressed by working too much, and sleeping too little. On the other hand, I am equally amazed by people I meet who exercise regularly, eat healthy organic food, use meditation apps, only to tell you, on line at Starbucks, that they often only get 5 to 6 hours a night of sleep in their busy lives. I wonder about myself sometimes, as I savor a good cup of coffee in the morning, after staying up too late reading the night before. A lot of times, I couldn’t even tell you what I read, as boldly fought off sleep to the very last minute, with the power of my smartphone and the internet behind it.

 

The tremendous importance of sleep to our well being has been a lesson I have learned numerous times in my career as a psychiatrist. I continue to advocate that it should be a vital sign, along with blood pressure and pulse, of our general state of health. It affects everyone, young and old, and here’s some fascinating stories, that have changed my practice of medicine.

 

The youngest patients, I recall, were the 10 year old kids that came to Stanford, diagnosed with attention deficit disorder (ADHD), with minimal improvement on stimulants, like Ritalin or Adderall, still struggling at home and in school. These kids, it turned out, had stuffy noses, and slept on 3 pillows, fitfully through the night. Something else was going on, their tonsils were huge; and sleep tests confirmed sleep apnea (fragmented sleep because of poor breathing). The tonsils came out, and within several months, I remember to this day being hugged by moms who were so happy that their kids were off medication, sleeping soundly through the night, and not “hyperactive” anymore. Miraculous, I thought.

Then there are the middle aged patients who come worriedly to see me asking the question “Doc, I think I have Alzheimer’s, I forget movies, words, and walk into rooms and forget why!” Much to everyone’s relief, it often turns out to be a sleep problem. Our minds package up memories and practice for upcoming situations in sleep, and the value of sleep is both in quantity and quality. So many amazing studies have tested people, asked to memorize a list of words, then given a chance to sleep. More sleep, has always resulted in better recall, improved ability to learn everything from word lists, to emotional responses, to swinging a golf club. Emotions? Let’s not forget that sleep deprivation is a form of torture - and I’ve also seen so many people become emotionally “unstable” - tearful for no reason sometimes, overreactive, and irritable. One man knew he needed to catch up on his Zzz’s when after a few nights of poor sleep, he would cry over a dropped paper clip.

And the comes the energy or depression question, “Do you feel like doing things and lack the energy, or just don’t feel like doing things at all?” Fatigue can all too often look like depression, and in many instances, there is a very fine line between the two. The next time you’re on your drive home, spacing out at a stopped traffic light, thinking “woe is me, and what’s the point of all this anyway,” ask yourself if what you’re really missing is your bed, and some shut eye. Indeed a very large proportion of people I have worked with, diagnosed as attention deficit, bipolar, or treatment-resistant depression, benefit tremendously from the optimization of sleep.

I have often joked that everything you need to know about sleep, your grandmother taught you. Indeed, this is half true, in the sense that more sleep and more regular hours of sleep are a good thing. Sleep is affected most often by our habits; electronics, television, and late night web surfing to the edges of the internet. Yes we all lack some degree of discipline. But for many people, it is hard to fall asleep despite their best efforts. Anxiety is so often an overlooked factor - and we call this “battlefield sleep” or “thin sleep.” It’s the vigilant sleep one would get, sleeping in a dangerous situation, like a battlefield - with a lot of trouble falling asleep, waking up often and easily, and trouble sleeping in (no matter how late you went to sleep). Life is not a battlefield, but for anxious people, it often can be, and this becomes a nightly pattern, with fatigue and large amounts of caffeine, sometimes alcohol by the day’s end, to counter. And so the cycle repeats, sometimes for decades of people’s lives; and important experiences can often  become lost in a sleep deprived, caffeinated blur.

What to do? Sleep more and sleep better. Make sleep your health priority. Focus on habits and the use of electronics, and keep sleep on a regular schedule. Besides the quantity of sleep, look into the quality - does sleep feel light? How many times a night do you wake? Do you snore, or kick around a lot during the night? A great app to start this investigation is called SnoreLab (free on the iTunes store) - which basically records audio all night, and can show you just what happened before you woke at 4AM last night - I use this app myself, and recommend it to everyone. You spend one third of your life sleeping, and it affects every aspect of your waking life, promise. From memory to mood, to immunity, to weight loss and diabetes, and even risk of cancer, sleep has profound effects. Even more exciting, several recent studies have found that sleep can be used as part of a protocol to reverse mild dementia, and increase longevity.

Alex Dimitriu, MD

The Connection Between Memory and Sleep

Through much of my training at Stanford, we often saw young patients come in complaining "doctor I think I have early Alzheimer's." They would forget entire movies or important events, forget why they walked into rooms, and at minimum had tremendous trouble remembering names and paying attention in conversations. A lot of times, these patients looked and essentially had, a lot of the symptoms seen in ADHD - Attention Deficit Disorder. One very important aspect that soon came into play became sleep quality. 

Restful sleep gives the brain time to reorganize and store information, and prepare the brain to learn. A new body of research (see link below) has shown that untreated sleep apnea, can often advance the onset of dementia by as much as 10 years. 

The good news, is that with adequate treatment, a lot of the patients seen here see markedly improved cognitive function - memory, recall, and ability for focus and sustained attention. 

And, according to the study below - treatment of sleep apnea (if present) can delay the onset of any dementia or cognitive impairment substantially. 

Take a look: 

http://www.neurology.org/content/early/2015/04/15/WNL.0000000000001566.abstract

 

"Psychobiotics" to naturally improve stress and memory

Again more evidence supporting the tremendous role of the gut biome in maintaing physical as well as mental health. "The emerging concept of the gut microbiome as a key regulator of brain and behavior represents a paradigm shift in neuroscience. Precise targeting of the microbiome-gut-brain axis with psychobiotics — live microorganisms with a potential mental health benefit — is a novel approach for the management of stress-related conditions," the authors of the study repot. 

In this small study, 22 participants took a probiotic strain of Bifidobacterium longum daily for 4 weeks versus a placebo pill. Participants taking the probiotic lead to a decrease in anxiety, cortisol levels (a known stress hormone), improved performance on a visual memory task, as well as notable changes measured in brain activity on EEG. 

Fixing sleep, greatly improves depression outcomes

CPAP therapy reduces symptoms of depression in adults with sleep apnea

DARIEN, IL - A new study shows that depressive symptoms are extremely common in people who have obstructive sleep apnea, and these symptoms improve significantly when sleep apnea is treated with continuous positive airway pressure therapy.

Results show that nearly 73 percent of sleep apnea patients (213 of 293 patients) had clinically significant depressive symptoms at baseline, with a similar symptom prevalence between men and women. These symptoms increased progressively and independently with sleep apnea severity.

However, clinically significant depressive symptoms remained in only 4 percent of the sleep apnea patients who adhered to CPAP therapy for 3 months (9 of 228 patients). Of the 41 treatment adherent patients who reported baseline feelings of self-harm or that they would be "better dead," none reported persisting suicidal thoughts at the 3-month follow-up.

"Effective treatment of obstructive sleep apnea resulted in substantial improvement in depressive symptoms, including suicidal ideation," said senior author David R. Hillman, MD, clinical professor at the University of Western Australia and sleep physician at the Sir Charles Gairdner Hospital in Perth. "The findings highlight the potential for sleep apnea, a notoriously underdiagnosed condition, to be misdiagnosed as depression."

Study results are published in the September issue of the Journal of Clinical Sleep Medicine.

The American Academy of Sleep Medicine reports that obstructive sleep apnea (OSA) is a common sleep disease afflicting at least 25 million adults in the U.S. Untreated sleep apnea increases the risk of other chronic health problems including heart disease, high blood pressure, Type 2 diabetes, stroke and depression.

The study group comprised 426 new patients referred to a hospital sleep center for evaluation of suspected sleep apnea, including 243 males and 183 females. Participants had a mean age of 52 years. Depressive symptoms were assessed using the validated Patient Health Questionnaire (PHQ-9), and the presence of obstructive sleep apnea was determined objectively using overnight, in-lab polysomnography. Of the 293 patients who were diagnosed with sleep apnea and prescribed CPAP therapy, 228 were treatment adherent, which was defined as using CPAP therapy for an average of 5 hours or more per night for 3 months.

According to the authors, the results emphasize the importance of screening people with depressive symptoms for obstructive sleep apnea. These patients should be asked about common sleep apnea symptoms including habitual snoring, witnessed breathing pauses, disrupted sleep, and excessive daytime sleepiness.

L-Methylfolate for depression

In an ongoing search to find increasingly effective treatments for depression, nutritional supplements often come up as a relatively benign, and possibly effective option. One supplement that has received significant attention is folic acid - readily available over the counter, and Deplin (L-methylfolate). Folic acid is converted to L-methylfolate, which is believed to play a key role in the synthesis of the neurotransmitters serotonin, dopamine and norepinephrine - targets of most anti-depressant treatments. Unlike folic acid, L-methylfolate is able to cross the blood brain barrier and play its role in neurotransmitter synthesis. Some people are believed to be poor converters of folic acid to L-methylfolate, for which reason PamLab markets the metabolite, L-methylfolate (Deplin) - a much more expensive alternative to the folic acid supplements available in most pharmacies. 

Most studies thus far have found a small but significant relationship between low folic acid levels and depression ( (Gilbody S et al., J Epidemiol Community Health 2007;61:631-637)) The data supporting the efficacy of L-methylfolate has been more impressive. 0.5mg per day of folic acid (not Deplin) in combination with fluoxetine, beat placebo by 38% vs 18%, but only 10 weeks after treatment. (Coppen A and Bailey J, J Affect Disord 2000; 60:121-130). Other studies have yielded mixed results - in 2012 - an analysis of 15mg Deplin added to an SSRI for treatment resistant depression, yielded no improvement in the first trial, and a marked improvement in the second ( American Journal of  Psychiatry. 169(12), 1267-74.)

Bottom Line: Folic acid supplementation is a relatively benign augmenting strategy for treatment resistant depression, and certainly worth a try, ideally with the inexpensive, readily available supplements first. Up to 10 weeks may be required to notice its effect. Recommended doses of Deplin are 7.5 to 15mg daily, while the recommended dose of folic acid is 0.4mg, or 400 micrograms per day - the latter is far less expensive, and certainly worth a try before Deplin.

Menlo Park Psychiatry has been working with patients for Depression over the years and the insight and experience collected has made us known as one of the best sources in the area for treatment. For more information on how we can help with Depression, contact us as: www.doctoralex.com

 

MENLO PARK  PSYCHIATRY & SLEEP MEDICINE  650-326-5888

CONDITIONS TREATED: anxiety, depression, attention deficit disorder, insomnia, bipolar disorder, and treatment resistant depression.

REGIONS COVERED:  We serve clients of the Bay Area, including the communities of Menlo Park, Palo Alto, Cupertino, Los Gatos, Los Altos, Mountain View, Portola Valley, Atherton, Sunnyvale, and San Jose