Alex Dimitriu, MD

Menlo Park Psychiatry & Sleep Medicine

Less Stressful Holiday Hosting

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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

 

Finally, a truly new sleep medication...

The FDA has recently approved a new sleep medication - Suvorexant - which works as a orexin receptor blocker. What is orexin? This is a key switch that keeps us awake, and is low in people with narcolepsy - so temporarily blocking it will put you to sleep. Because orexin is "the master switch" for sleep and wake - your sleep on this medication may be more natural than any other sleep aid on the market. The only issues so far - it may work too long; into the next day - but hopefully this is dose dependent. 

Exercise improves memory and increases levels of BDNF (brain growth hormone)

Alex Dimitriu, M.D. Menlo Park Psychiatrist|Blog-Excercise|doctoralex.com.png

A study published in Proceedings of the National Academy of Sciences in 2011 showed that we can actively modify the gene for the production of brain-derived neurotrophic factor (BDNF) with simple exercise. The investigators looked at 120 elderly nondemented individuals over a 1-year period who either stretched or did aerobics. They measured 3 variables: serum BDNF levels, memory function, and morphometric analysis of hippocampal size on MRI before and after the intervention period. After 1 year, the group that did the aerobic exercise had an increase in hippocampus size by about 2%, improvement of memory function, and higher levels of serum BDNF. Why makes BDNF levels so important? This protein growth factor is essential to keeping neurons healthy, and to the growth of new ones - most active in areas of the brain vital to executive function, learning and long term memory. 

Per the study "In sum, we found that the hippocampus remains plastic in late adulthood and that 1 y of aerobic exercise was sufficient for enhancing volume. Increased hippocampal volume translates to improved memory function and higher serum BDNF. We also demonstrate that higher fitness levels are protective against loss of hippocampal volume. These results clearly indicate that aerobic exercise is neuroprotective and that starting an exercise regimen later in life is not futile for either enhancing cognition or augmenting brain volume."

Here's the study: http://www.pnas.org/content/early/2011/01/25/1015950108.abstract

A Good Night's Sleep Could Ward Off Alzheimer's

Fascinating recent study; points to a significant function of sleep - housekeeping - of sufficient intensity that it cannot be performed while we are awake. Apparently, the brain has it's own lymph system - the glymphatic system, which is up to 10x more active during sleep, and readies things for the next day. Interesting to see which sleep stages this is linked to - slow wave (N3) is a likely candidate...

A Good Night's Sleep Could Ward Off Alzheimer's|blog|doctoralex.com

As we learn more about potential ways to ward off dementia and Alzheimer’s disease as we age, from exercise to diet to web surfing to marijuana use, a new study makes the case that getting a good night’s sleep just might be the most important thing we can do.

Our brain cells produce toxic waste products each day as they work. The new study, published this week in the journal Science, shows that while we sleep, the brain literally flushes out this gunk. The self-cleaning process, which scientists observed in resting mice, is a powerful illustration of the medical importance of sleep. Researchers had suspected that this self-cleaning went on in our heads each night, but the new study put the process, and its intensity, in far clearer focus. For example, the team witnessed that when the mice slept, brain cells actually shrunk in size, expanding the spaces in between them by as much as 60 percent and facilitating the flushing of waste.

“It’s like opening and closing a faucet,” said University of Rochester neurosurgeon Maiken Nedergaard, who directed the study.

At minimum, the research highlights the potential importance of regular sleep in slowing dementia, as well as the possible neurological risks of consistently getting too little sleep. When we stay up until late into the night, we may be preventing our brains from flushing toxins effectively. This may also explain why we can feel uncertain or cranky when we are sleep-deprived and perhaps why migraines and seizures appear to be exacerbated by poor rest.

A year ago, Nedergaard’s team identified the network for flushing waste from the brain and named it the glymphatic system. During this cleansing, cerebrospinal fluid circulates through brain tissue, carrying waste matter into the bloodstream toward the liver, where it is detoxified. Similar systems, she noted, have been detected in the brains of dogs and baboons. Neuroscientists now widely assume that this self-cleaning takes place in humans as well, but the next step will be to directly observe the process.

A New Window on Sleep
Scholars have long wondered about the biological purpose of sleep. The idea that we sleep to conserve energy has been somewhat debunked; studies have found that the brain uses almost as much energy at rest as it does when we’re awake. Another theory held that a full night’s sleep was necessary to lock in memories, but as Nedergaard and others have pointed out, seven or eight hours appears to be excessive for this purpose, given what we now know about the speed of human memory processing.

A body of research does connect consistent sleep to the maintenance of human metabolism, which is why experts typically recommend that people trying to lose weight always get a full night’s sleep. But the new study indicates that a primary reason for sleep, and the reason it feels so restorative, is that we awake with the remains of the previous day’s activity cleared from our heads.

A Step Toward an Alzheimer’s Treatment?
To observe the glymphatic system in mice, the research team injected rodents with beta-amyloid, a protein that builds up in clumps in the brains of Alzheimer’s patients, forming plaques. By tracking the animals’ brains in real time using an imaging process known as two-photon microscopy, they were able to watch fluid move between cells. Researchers found that waste was flushed out of the brain cells of sleeping mice twice as fast as in those of conscious mice. “It was almost like you opened a faucet,” Nedergaard said.

Experts expressed hope that the new findings could lead to treatments for neurological ailments associated with cell waste in the brain, including Parkinson’s disease as well as Alzheimer’s and dementia. Scientists will be following up on the tantalizing possibility that Alzheimer’s is exacerbated not as much by the buildup of beta-amyloid plaque in the brain as by an impaired ability to flush it out. If that turns out to be true, then the development of a drug to facilitate or force the self-cleaning process could be a major breakthrough. Doctors may also achieve better results by coordinating dementia patients’ treatments with their sleep schedules.

“I’d be a fool not to pay attention to this,” Washington University neuroscientist Randall Bateman, an expert in amyloid-beta research, told the Science News blog.
Gary Drevitch, Contributor

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