Around 14% of American adults take antidepressant medication, which may be prescribed for major depressive disorder and other mental health conditions like anxiety. For some people, these medications result in weight gain that begins several months after beginning treatment.

Unfortunately, there’s much that remains unknown about why antidepressants can cause weight gain.  It may occur because the brain chemicals affected by antidepressants also influence appetite and food choices. It could also be linked to a positive change in mood, a person’s genetics, or other factors that play a role in body composition.

However, not everyone who takes these medications will notice a change in their weight, and the risk of weight gain varies across different types of antidepressants.

This topic is complex and can be confusing, especially since more research is necessary to fully understand exactly how antidepressants affect weight. In this article, we’ll demystify the topic and review what we know about why weight gain occurs with antidepressants, which types cause the most weight gain, and strategies for minimizing weight changes.

Introduction to Antidepressants and Weight Gain

Numerous studies have found an association between long-term use of antidepressants and changes in body weight, but the story here is complicated.

It is rare for an antidepressant to cause weight gain in the short term. However, most people who are diagnosed with depression are prescribed to take these drugs for many months or years, which can eventually lead to noticeable changes in weight.

When it occurs, weight gain usually starts after at least four to six months, and the gain typically ranges between 2 and 15 pounds.

This weight gain doesn’t affect everyone, though. In addition, not all antidepressant drugs have the same potential to influence weight. In fact, one antidepressant has been consistently linked with weight loss.

Before delving deeper into why antidepressants may affect weight, it may help to review the main types of antidepressants available for doctors to prescribe and their connection to weight gain.

It is rare for an antidepressant to cause weight gain in the short term. However, most people who are diagnosed with depression are prescribed to take these drugs for many months or years, which can eventually lead to noticeable changes in weight.

Main Classes of Antidepressants

Antidepressants work by modifying levels of certain chemicals in the brain called neurotransmitters. There are multiple ways that drugs can affect neurotransmitters, which is why there are many different antidepressant medications.

The most commonly prescribed antidepressants are designed to increase levels of the neurotransmitter serotonin, which plays a vital role in mood and state of mind. 

Selective serotonin reuptake inhibitors (SSRIs) work to raise serotonin levels. Specific SSRIs include:

• Sertraline (Zoloft)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Escitalopram (Lexapro, Cipralex)
• Citalopram (Celexa)
• Fluvoxamine (Luvox)

Another group of antidepressants called serotonin-noradrenaline reuptake inhibitors (SNRIs) affect the neurotransmitters serotonin and norepinephrine. Examples include drugs like:

• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)
• Mirtazapine (Remeron)
• Desvenlafaxine (Pristiq)

SSRIs and SNRIs can cause weight gain, but some of these drugs, such as paroxetine, have been associated with much more significant increases in weight.

Atypical antidepressants also affect neurotransmitters but in ways that are distinct from SSRIs or SNRIs. These drugs can include:

• Bupropion (Wellbutrin), which affects dopamine, a chemical in the brain that helps control pleasure and reward
• Nefazodone (Serzone), which operates differently to modulate serotonin

Bupropion is an especially interesting case because it has actually been associated with weight loss, not weight gain. Interestingly, unlike most other contemporary antidepressants, it doesn’t target serotonin.

Substantial weight gain was more common with earlier generations of antidepressants. Today, these types of drugs are usually only prescribed when other treatments have not been effective. These classes of antidepressants include:

• Tricyclic antidepressants (TCAs), including amitriptyline (Elavil), desipramine (Norpramin), and nortriptyline (Aventyl, Pamelor)
• Monoamine oxidase inhibitors (MAOIs), including tranylcypromine (Parnate) and phenelzine (Nardil)

The evolution of antidepressant medications has generally reduced the number and severity of side effects and made it easier for people with a mental health condition to continue taking their prescribed pills for an extended length of time.

Basic Mechanisms of Antidepressant-Induced Weight Gain

Although there are multiple studies linking antidepressants to weight gain, researchers still don’t fully understand the mechanism behind why this happens.

One open question among experts is whether weight gain happens as a direct side effect of an antidepressant drug or if it is a downstream consequence of an improvement in depressive symptoms.

There are a number of potential ways that antidepressants may influence body weight. One main reason it may occur is because neurotransmitters like serotonin don’t just affect mood. They also influence appetite, stress, sleep, and other elements of health.

Although more data is needed to draw conclusions, research to date offers some clues about why antidepressants may cause weight gain.

Impact on Hunger and Appetite

Appetite is largely regulated by hormones that can be impacted by changes in neurotransmitters. The result may be an increased drive to eat. Over time, this can lead to overeating and taking in excess calories, culminating in weight gain.

Appetite changes may also occur as a result of effective treatment for depression. If depression is causing a lack of appetite, an improved mood may account for greater food intake.

Carbohydrate Cravings

In addition to an increased overall appetite, some evidence suggests that people taking antidepressants may have cravings for foods that are high in carbohydrates, such as pasta, bread, and sugary snacks. Eating too many of these foods can play a role in weight gain.

Effects on Insulin Sensitivity and Blood Sugar Levels

Insulin is a hormone that works to regulate blood sugar levels in the body. Some research has found that antidepressants can modify activity in parts of the brain that are involved in insulin signaling. If normal processes of insulin production are disrupted, it may affect metabolism. In particular, it may play a role in insulin resistance, which can lead to higher blood sugar levels and is a precursor to diabetes.

At the same time, it is important to note that untreated depression is associated with an increased risk of developing type 2 diabetes. Some research has suggested that, in people who already have type 2 diabetes and depression, antidepressants may offer beneficial outcomes for overall health.

Psychological Factors and Emotional Eating

A person’s mood and emotional wellness can impact when, what, and how much they eat. One of the benefits of depression treatment is the ability to enhance a person’s mood. In changing the way that they feel, these drugs may effectively alter dietary patterns.

Another way to think about this possible mechanism is that instead of antidepressants causing unwanted weight gain, they may be reversing unwanted weight loss that can occur during depressive periods.

Genetics

Genetic variation is another possible explanation for the fact that not everyone gains weight when taking an antidepressant. Individual genes may make certain people’s bodies respond to antidepressants in ways that make them more susceptible to weight gain.

Other Factors Affecting Body Weight

Of course, body weight isn’t simply determined by the medication that someone takes. Numerous lifestyle choices play a critical role in body composition. Evidence points to greater risks of weight gain among people who take antidepressants and have unhealthy habits related to diet, sleep, and physical inactivity.

Weight gain also tends to occur in most people as they enter adulthood and middle age, regardless of whether they take antidepressants.

The Potential Impacts of Weight Gain

While a small amount of weight gain may not be an issue for some people taking antidepressants, for others it can be a cause for more serious concern.

Weight gain can affect a person’s self-image, and some people may discontinue the use of an antidepressant in order to limit perceived weight gain. Abruptly stopping the use of these drugs can have profound and sometimes dangerous effects on mental health.

For some users of antidepressants, substantial weight gain may contribute to obesity. Having obesity is associated with elevated risks of numerous health issues, including high blood pressure, cardiovascular diseases, and metabolic disorders like diabetes.

Which Antidepressants Cause the Most Weight Gain?

Based on recent research, it is believed that the drugs paroxetine and escitalopram are most likely to cause weight gain.

Modern antidepressants, including SSRIs and SNRIs, are generally regarded as causing less weight gain than older drugs. Among the newer medications, though, there is considerable variability in how they impact weight.

A recently published study has shed more light on which drugs cause the most and least weight gain. In what is known as a cohort study, the authors analyzed medical records of over 180,000 people taking different antidepressants to see how their weight changed over time.

On average, they found that two drugs, bupropion and fluoxetine, were actually associated with weight loss, and the drug sertraline had a neutral effect on weight. The drugs paroxetine and escitalopram were found to be tied to the most weight gain.

1. Bupropion (difference: -0.48 pounds)
2. Fluoxetine (difference: -0.15 pounds)
3. Sertraline (difference: 0 pounds)
4. Citalopram (difference: 0.26 pounds)
5. Venlafaxine (difference: 0.37 pounds)
6. Duloxetine (difference: 0.75 pounds)
7. Paroxetine (difference: 0.81 pounds)
8. Escitalopram (difference: 0.90 pounds)

As you can see in the data, the average amount of weight loss or gain was quite small across the entire study population. However, people taking paroxetine or escitalopram had a roughly 15% greater likelihood of gaining a more significant amount of weight compared to people taking the other antidepressants in the study.

This study certainly isn’t the final word on how these drugs stack up when it comes to weight loss, but it does offer insight that may help doctors and patients when choosing among prescription antidepressants.

Do Any Antidepressants Cause Weight Loss?

Several studies have found that the drug bupropion is associated with weight loss rather than weight gain. This antidepressant is in a class by itself because it does not act on the brain’s serotonin system. Combined with its mild stimulant effect, this may explain the weight changes linked to bupropion.

However, a downside of this drug is that some people find that it increases anxiety, a problematic side effect for people with mental health conditions.

Choosing an Antidepressant

Many antidepressants have comparable effectiveness, which means that your doctor or psychiatrist can choose among multiple options to recommend the best option for your care.

They may start by reviewing your health history and emotional well-being. If you’ve taken an antidepressant before, they may ask for details about that drug and dosage and your response to it.

Your doctor may ask questions about side effects and any concerns you have about how they may affect your quality of life. If weight management is an important issue for you, make sure to bring it up with your provider. They can take all of this information into consideration and give detailed advice about which antidepressant may best suit your situation.

After making a prescription, expect to have a plan for ongoing follow-up. That provides an opportunity to see how well the therapy is working, review the dose, and suggest a substitute medication if the initial antidepressant isn’t working or is causing unwanted side effects like weight gain.

Managing Weight Gain While on Antidepressants

Various strategies and tips may be helpful to reduce weight gain when taking an antidepressant.

• Try to find time for regular physical activity, which doesn’t have to mean intense exercise.
• Consider your nutrition and diet, and make changes where you can to include foods that are healthy and nourishing.
• Limit excess consumption of alcohol.
• Work to develop good sleep habits and eliminate sources of sleep disruption. Talk with your doctor if you experience symptoms of insomnia

Mindfulness about these habits can often encourage overall wellness and better weight management. When modifying health habits, though, it’s best to collaborate with a healthcare provider who can address the safety of different options and which are the top priorities in your situation.

Your doctor may also be able to refer you to a nutritionist, physical therapist, sleep specialist, or other provider for a consultation. These tailored services may help you identify a practical strategy for maintaining a healthier weight when taking an antidepressant.

Future Research Directions

While we know that antidepressants can influence body weight, there is a great deal that is still unknown about why this occurs and how to address it.

Researchers are working to obtain new information about the ways that different antidepressants affect the brain and body. This work promises to shed light on not only the incidence of weight gain and other side effects but also how these side effects impact specific populations, including women, adolescents, children, and people with certain gene variants.

In the meantime, it’s important to recognize that while weight gain can occur, it isn’t a given. Many patients experience little or no weight gain, which can be related to the specific antidepressant that they are prescribed. Working with an experienced doctor or psychiatrist can enable people with depression to get personalized care for their condition and for any side effects of treatment.

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Sertraline, also called Zoloft, is a drug known mainly as a treatment for depression. First approved in the U.S. in 1991, recently it has been prescribed nearly 40 million times per year.

Although Zoloft can cause side effects in anyone, it can affect women in specific ways. Knowing about the possible side effects of Zoloft in women can help patients know what to expect and play a more informed role in their mental health care.

Understanding Zoloft and Its Uses

Zoloft is the brand name of the drug sertraline. It is a type of selective serotonin reuptake inhibitor (SSRI). These drugs work by increasing the activity of a chemical in the brain called serotonin, which helps regulate your mental state and emotions. Selective serotonin reuptake inhibitors are a common antidepressant medication.

In addition to depression, Zoloft is FDA-approved as a treatment for post-traumatic stress disorder (PTSD), social anxiety disorder, panic attacks, obsessive-compulsive disorder (OCD), and the symptoms of premenstrual dysphoric disorder. In addition to these formally recognized uses, doctors may give Zoloft as an off-label prescription for conditions like generalized anxiety disorder, bulimia, and binge-eating disorder.

Zoloft is taken by mouth as a tablet, capsule, or liquid concentrate solution. It can be prescribed for children, adolescents, and adults.

Common Side Effects of Zoloft in Women

Both men and women can experience side effects from Zoloft. However, certain side effects only affect women or have different risks in women. These include sexual dysfunction, weight changes, menstrual changes, nipple discharge, and bone loss.

In my clinical experience, it is worth noting that depression and anxiety carry significant health risks as well, and these should be weighed against the side effects of medication like SSRIs. Additionally, side effects are often dose dependent, which is why we always aim to “test” the lowest dose that is effective for our patients.

Sexual Dysfunction

It is common for both males and females taking Zoloft to encounter difficulties in their sex life. In females, this sexual dysfunction may affect sex drive and libido, or the desire for sex. In addition, Zoloft can affect a woman’s ability to have an orgasm. In my practice, I often remind patients that untreated depression and anxiety can also negatively impact sex drive.

Studies suggest that 50% or more of patients who take SSRIs like Zoloft experience sexual problems. Sometimes these side effects continue even after someone stops taking these medicines.

Experts aren’t entirely sure why this happens, and in some cases, sexual dysfunction may be linked to the underlying mental health condition that Zoloft is intended to treat.

Weight Changes

Zoloft can induce changes in body weight, and some research has found that women express more concern than men about weight and body image.

Among all people taking Zoloft, the average weight gain is around 1% to 1.5% of their original body weight. This may relate to an increase in appetite and cravings for carb-rich foods. These dietary changes may be linked to improvements in mental health from Zoloft.

Weight gain may also have a genetic component or be a consequence of modified serotonin levels. Although not common, weight gain from long-term Zoloft use may contribute to a person’s risk of diabetes.

At the same time, some people experience weight loss when taking Zoloft. A small percentage of patients report a decrease in appetite. Weight loss could relate to gastrointestinal side effects like nausea, stomach pain, and indigestion.

Menstrual Changes

Zoloft can affect hormones in the body, which may alter the menstrual cycle. When taking Zoloft, a woman’s menstrual periods may stop or become irregular.

These issues are believed to relate to an increase in the production of a hormone called prolactin, which is mostly involved in lactation but affects other bodily processes. Serotonin levels are one of many factors involved in the production of prolactin. Excess prolactin in the body can disrupt the menstrual cycle, interfere with sexual health, and contribute to other side effects of Zoloft in women.

Nipple Discharge

Zoloft can cause the discharge of breast milk in women who are not lactating, a condition known as galactorrhea. This reaction to Zoloft is driven by prolactin levels that are too high.

Bone Loss

Some data indicates that there is an elevated risk of bone loss in people over the age of 50 when taking Zoloft. A lack of bone strength can result in osteoporosis, a condition that makes fractures more likely. Osteoporosis is more common in women than in men.

Doctors cannot fully explain the findings of bone loss in people taking Zoloft. It may be related to elevated prolactin levels or disruptions in the metabolism of cells in the bones. More research is needed to document, confirm, and understand the impact of Zoloft on bone health.

“In my clinical experience, it is worth noting that depression and anxiety carry significant health risks as well, and these should be weighed against the side effects.”

General Zoloft Side Effects

Side effects of Zoloft occur in both males and females. While every patient can have a different reaction to the drug, researchers have identified the most common side effects.

The most frequent side effects, which tend to affect between 10% and 25% of people, include:

• Gastrointestinal problems like nausea, vomiting, stomach discomfort, diarrhea, and constipation
• Headaches
• Dry mouth
• Feelings of fatigue or physical weakness
• Dizziness
• Insomnia or an inability to sleep normally
• Drowsiness or tiredness

Other side effects that have been found to impact up to 10% of people taking Zoloft include:

• Excess sweating
• Mood changes like restlessness, agitation, nervousness, or irritability
• Tremors
• Visual problems like blurred vision
• Fast heart rate

It is important to recognize that not everyone will experience significant side effects. The incidence of these adverse reactions is relatively low, and any given person may have a distinct combination of effects or very few effects at all. In general, Zoloft is well tolerated, and most people find that it provides more benefit than harm.

In addition, initial side effects are not always lasting. Some effects may start to improve after the first weeks of taking Zoloft.

Managing and Minimizing Zoloft Side Effects in Women

The first step in addressing any side effects of Zoloft is to talk with your doctor or psychiatrist. They can recommend an adjustment to your dosage, a change in medication, or other specific actions and tips that are most appropriate in your situation.

“In my practice, I often remind patients that untreated depression and anxiety can also negatively impact sex drive.”

Other things that may help manage or minimize the side effects of Zoloft in women can vary based on the nature of those effects.

• Sexual Dysfunction: If Zoloft is providing benefits in treating depression but also causing sexual problems, doctors may prescribe additional medications, which studies have shown may help with a low libido or difficulty having orgasms. Consulting with a sex therapist for advice may be effective for some individuals.
• Weight Changes: For weight gain, a number of steps may help, including making adjustments to your diet and exercise habits.
• Menstrual changes: When menstrual changes occur, your doctor may check for other potential causes and consider changing your medication or daily doses. If high prolactin levels are detected, you may be prescribed additional medication or hormone therapy.
• Nipple discharge: If this symptom is significant and affecting your daily life and activities, medication may be suggested to address elevated prolactin levels.
• Bone loss: Some steps to minimize bone loss can include taking supplements of vitamin D and calcium and avoiding cigarette smoking. If you have other risk factors for osteoporosis, your doctor may order a bone mineral density test. To prevent fractures, you can decrease the risk of falls by improving your balance and eliminating tripping hazards in your home.

Warnings and Potential Serious Side Effects of Zoloft

Although serious side effects are rare, anyone taking Zoloft should be aware of the potential risks so that they can take precautions and watch for possible warning signs.

• Worsening of mental health: Some people have a sudden exacerbation of their mental health problems after taking Zoloft. This may result in deep sadness and suicidal thoughts and behaviors. In people with a diagnosis of bipolar disorder, Zoloft may lead to swings between mania and depression. Bipolar disorder is relatively rare, but it is important that a provider screen for the condition to prevent adverse reactions from SSRIs. People with thoughts of suicide should seek help immediately.
• Low sodium levels: Zoloft can lower the amount of sodium in the blood, a condition known as hyponatremia. Some signs of hyponatremia include memory problems, confusion, headache, and physical weakness. The risk of this side effect is higher in older patients.
• Bleeding: Taking Zoloft makes people more susceptible to bleeding. This is more likely in people who also take blood thinners like warfarin or other drugs that thin the blood, including nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.
• Angle-Closure Glaucoma: Glaucoma occurs when fluid can’t drain from the eyes, raising pressure that leads to eye damage. Pain, vision changes, and redness of the eyes are symptoms of glaucoma.
• Serotonin syndrome: This condition can occur if serotonin levels get too high. It may result in confusion, changes to heart rate or blood pressure, tremor, seizures, and other symptoms. A risk factor is when Zoloft is taken with other substances that can increase serotonin, including amphetamines, other antidepressants like serotonin and norepinephrine reuptake inhibitors (SNRIs), tramadol, tryptophan, and St. John’s wort.
• Drug interactions: Although major drug interactions are limited, it is best to inform a pharmacist about all prescriptions, supplements, and over-the-counter medicine and ask questions about any potential interactions with Zoloft.
• Coexisting conditions: People with liver problems or a diagnosis of a seizure disorder may require more caution than others when planning the dosage and administration of Zoloft.
• Allergic reactions: As with any medication, allergic reactions are uncommon but may occur. Signs of allergies when first taking Zoloft can include hives or skin rash, fever, unexplained swelling, or trouble breathing.
• Withdrawal: Abruptly stopping the use of Zoloft may cause headache, mood and behavior changes, irritability, seizure, and confusion.

If any indications of severe reactions or complications arise, patients should seek prompt attention from a healthcare professional.

To reduce the risks of adverse effects, Zoloft should always be used according to the package directions. A regular dose should be taken as stipulated by the doctor and pharmacist, and patients should avoid suddenly stopping taking Zoloft.

Zoloft When Pregnant or Breastfeeding

Taking Zoloft and other SSRIs during pregnancy can affect a fetus. The risks of exposure during the first trimester are not clearly established. A baby who was exposed to Zoloft during the third trimester, though, is at risk of certain issues, some of which can be serious.

That said, untreated mental health conditions during pregnancy may also pose health risks for newborns. As a result, many pregnant women continue taking Zoloft with extra care devoted to watching for effects on the fetus. Consulting with a health care team can help women weigh the pros and cons of using Zoloft while pregnant.

In most situations, Zoloft is considered to be safe to use while breastfeeding. Only a small amount of Zoloft passes into breast milk, so it poses very low risk to infants. Zoloft is considered one of the best of the SSRIs for women who are lactating.

FAQs About Zoloft Side Effects

How long does it take for side effects to start?

Some side effects may begin within days of starting to take Zoloft, and others become more likely with long-term use. For example, stomach problems may arise initially. But when issues like weight gain or bone loss occur, it is normally only after many months or years of taking Zoloft.

Do women have more side effects from Zoloft?

Many reactions to Zoloft are similar for both men and women. However, some side effects, such as nipple discharge and menstrual changes, only affect women.

Does Zoloft have more side effects than other SSRIs?

With an extensive history of use, Zoloft has been found to be well tolerated overall. Within the SSRI group of antidepressant medications, most drugs have a similar side effect profile. But there can be some variation in the frequency or severity of certain side effects.

Other types of SSRIs include:

• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluvoxamine (Luvox)

A doctor or psychiatrist can review the comparative benefits and drawbacks of each of these drugs based on your diagnosis, health history, and personal concerns about specific side effects.

By Dr. Alex Dimitriu

You get an email from your boss asking you to meet later that day, and you immediately think you’ve done something wrong, and might get fired, then lose your home, then your marriage.

A lab result comes back slightly off, and you immediately think you might have some serious life-threatening malady, “what could this mean??” as you envision your funeral.

You believe in superstition or following certain rituals to make sure you either do well on a date, job interview, or upcoming exam. Not having your lucky pen or favorite shirt might spell failure.

When Daydreams Turn into Daymares

People daydream all the time, but certain people go down negative wormholes that can feel shockingly real. These fantasies can occur several times per day, leaving you feeling anxious or sick or tired or paralyzed in fear of some pending doom. In more intense experiences, out of desperation, people get compelled to action. They’ll call their doctor or boss for reassurance or lash out at someone close to them in an effort to unload a heavy burden of anxiety (which also makes people quite irritable, short tempered, and unemphatic, btw).

As a psychiatrist, I am privileged to hear about people’s inner dialogue all the time. I get a window into their thinking, and after seeing hundreds of patients, patterns become apparent, and certain solutions emerge as being highly effective. One pattern I see often in people who are either anxious, depressed, or have ADHD is the tendency to go down negative thought spirals. I have often called these “daymares,” as the daytime / daydream version of a nightmare. These can be rooted in reality, quite real, and quite scary.

Interestingly, anxious thoughts really come in 2 varieties – ones that are useful, and ones that are not. The immediate solution that has helped so many of my patients is asking one fundamental question:

Ask yourself: “What is the utility of this thought?”  2 possible outcomes emerge.

1 – Certain thoughts are useful. Like the thought that you might fail the upcoming exam or not meet the deadline for a work project if you don’t get working on it. Indeed. In those cases, you might listen to the anxious thought, and consider doing something about it. Some anxious thoughts have utility, they serve as healthy reminders to prepare or start getting something done. These thoughts are easier to work with because they are rooted in reality and have actionable steps that you have control to take. Important to emphasize here that these are real issues for which you are in a position to take useful action. This will differ greatly from the next type of thought.

2- Stabbing thoughts, or as previously described by Daniel Amen, “ANTS,” or automatic negative thoughts. I call these stabbing thoughts because it really is no different than stabbing yourself repeatedly with a fork. When faced with the question of “What is the utility of this thought,” these types of thoughts start to fail the test. There is often a greatly exaggerated outcome, and nothing you can do about it. If you can catch them, and label them for what they are, you might start to realize there is some tendency to poke yourself with a fork when there is nothing you can do about it. For some people, living in a state of stress or self-oppression becomes a default state. Patients of mine will sometimes wake in the morning and scan the news to find something to worry about. It is like stabbing yourself with a fork. Catch it and stop it. There is no utility to those thoughts, it’s your head messing with you.

“What if I drove off the cliff??” Lessons From OCD’s Intrusive Thoughts

We can learn a lot from people with high anxiety or OCD – because they often experience “intrusive negative thoughts,” which are more dramatic and easier to recognize. Let me give you some examples.

I’ve met a woman who while cutting fruit on a cutting board would have a sudden flash of cutting her husband’s throat with the knife. A nursing mother who would have a flash thought of throwing her infant at a wall when it was crying. A man who would often wonder what would happen if he jerked the steering wheel and drove the car off a cliffside road.

They were all ashamed and terrified of these thoughts and would never in their life act on them. But the more the thoughts scared them, the more they came back. Many of these patients were much improved just by talking to someone about it. By understanding that sometimes people get crazy thoughts, and the scarier they are, and the more you keep them secret, the more they come back to haunt you. You’d be amazed at how many people experience wild crazy fantasies or daymares like this if you ask. 99% know they would never act on it, but even a slight doubt can turn big and scary, “but what if…” The more the thoughts bite, the more they come back. Until you realize that the only thing you have to fear is fear itself. The thought is a fantasy that recurs because it gets your attention. Talk to your fears. Running never works.

Lastly, I want to point out a fascinating study which may also reveal the basis of some stabbing thoughts. The experiment looked at how people deal with boredom and found that “67% of men and 25% of women chose to inflict it on themselves rather than just sit there quietly and think.” Yes, people would rather painfully zap themselves with electricity than just sit there and think. Ref https://www.science.org/doi/10.1126/science.1250830.

Don’t Zap Yourself Repeatedly

Filter the thoughts, by asking about “what is the utility?” talk about them and identify and stop the useless ones in their tracks. Say to yourself, “I don’t entertain that type of thinking.” Mindfulness meditation, exercise, and journaling help. The RAIN method for dealing with these thoughts helps too. It stands for R- recognize the thought, A-accept the thought, I-investigate the thought, N- non-identification. Read more about RAIN here.

For more information, be sure to check out my post on “Bingeing on Negativity.”and also “Unwinding Anxiety,” by Judson Brewer is a great read on this topic.

If the negative thoughts are too much to handle (as is the case for depressed or significantly anxious people), or happen too often, speak to a professional soon.

By Alex Dimitriu MD

Finding an effective pharmacologic approach to alleviating obstructive sleep apnea (OSA) could revolutionize treatment of this complex, underdiagnosed, and life-threatening sleep disorder. Results of a study – the MARIPOSA trial — published in the October 2023 issue of the American Journal of Respiratory and Critical Care Medicine indicate a combination of two medications, oxybutynin, and atomoxetine, has been shown “clinically meaningful” in improving OSA.

The double-blind investigation involved more than 200 patients, including 176 who actually completed the four-week protocol. The drugs reportedly act together to increase what one physician describes as “the activity of the dilator muscles in the upper airways.” They do so by “activating the genioglossus muscle [a muscle of the tongue] with a synergic effect on the upper respiratory tract during sleep.”

Study authors report patients receiving the drug combination experienced significantly less sleep disturbance due to disruptions in their breathing and a higher quality of sleep. But neither medication taken alone proved effective and, in some cases, slightly worsened a person’s sleep disturbance score or lowered sleep quality, the scientists state. With CPAP compliance rates at about 50%, any alternative to improving airflow during sleep is a welcome addition to the field.

But No Pill Yet for the Problem

No FDA-approved pharmaceutical treatment option currently exists for treatment of OSA, an issue that continues to spur ongoing drug investigations. The MARIPOSA trial is only the latest of a series of OSA-related pharmacologic studies published during the past several years. Some scientists have likened the hunt for an effective OSA drug to a “search for the Holy Grail.”

One report — in a 2022 issue of the Journal of Clinical Sleep Medicine — suggests reboxetine, a drug formerly used to treat depression, shows positive action in reducing the severity of OSA. The National Sleep Foundation indicates that, in July 2023, the FDA approved further testing of an investigational sleep apnea drug, IHL-42X, in phase II and phase III patient trials. Advanced by Icannex Healthcare, IHL-42X contains dronabinol and acetazolamide. Dronabinol is a synthetic cannabinoid with effects similar to compounds in the marijuana plant. Preliminary research shows IHL-42X can cut sleep apnea patients’ episodes of disruptive breathing by more than half, according to the Sleep Foundation.

Also being tested for potential efficacy in decreasing the severity of OSA is a combination of AD109 and AD504, under development by the pharmaceutical firm Apnimed.

All About Obstructive Sleep Apnea

OSA is characterized by the narrowing and obstruction of the upper airway during sleep, causing a person to stop breathing repeatedly. The term “apnea” or “apnoea” applies to the cessation of breathing for 10 seconds or longer. Symptoms include excessive snoring, awakening from sleep gasping, daytime sleepiness and fatigue, morning headaches and sore throat, and problems focusing. If untreated, the disorder increases a person’s risk for stroke, cardiovascular disease, heart failure, pulmonary arterial hypertension, and development of neurobehavioral issues like mood changes and depression. The disease also may eventually lead to poor dietary habits, lack of exercise, altered insulin resistance, and systemic inflammation.

Obesity, older age, genes, alcohol use, smoking, and anatomical issues like a deviated septum, mandibular hypoplasia, or enlarged tongue or tonsils are all factors that can promote occurrence of OSA. The disease tends to be more prevalent in men, and, according to health professionals, affects between 9 percent and 38 percent of adults in the United States and nearly a billion people worldwide.

Less Sleep Quality Most Concerning

Perhaps, one of the most disconcerting aspects of the disorder is its association with a decline in sleep duration, sleep hygiene, and overall quality.

A study just published in December 2023 by JAMA Network Open indicates OSA patients with “shorter objective sleep duration had higher risk for all-cause mortality independent of AHI [apnea-hypopnea index] compared with those sleeping at least seven hours.” The research involved 2,574 OSA patients, representing men and women from a variety of races. AHI measures the average number of apnea (breathing stops) or hypopneas (incidents of abnormally shallow breathing) a person experiences in an hour. In other words, according to the researchers, lack of sufficient sleep plays a much greater role in an OSA patient’s morbidity and mortality than simply the number of times the person experiences a breathing episode during sleep.

OSA’s negative impact on sleep architecture and hygiene is a prime impetus for doctors’ efforts to find effective medications.

Current OSA Treatment Options

Until now, treatment for OSA has been limited to use of electrical devices that exert continuous positive airway pressure (CPAP machines), which an estimated half of OSA patients have difficulty tolerating; custom-fitted oral appliances to push the jaw forward and alleviate airway obstruction; lifestyle changes and correction of underlying medical conditions like obesity and atrial fibrillation; positional therapy for keeping patients sleeping in their side; and surgical procedures to eliminate anatomical defects like enlarged tonsils and create more breathing space in the oropharynx. The oropharynx is that part of the throat connecting the mouth and the upper portion of the airway.

Experts warn of the long-term consequences of uncontrolled OSA. In fact, some speculate that sleep apnea may have been the ultimate cause of the 2016 death of Supreme Court Justice Antonin Scalia. But who should be screened for the disorder? Many OSA patients are either asymptomatic or report only vague symptoms like daytime fatigue that is unaccompanied by any other obvious signs.

Authors of a 2022 article on the website of the National Center for Biotechnology Information indicate universal OSA screening for asymptomatic individuals is not recommended. However, they advise people who experience excessive daytime sleepiness or are told by a bed partner that they snore loudly, choke or gasp during sleep, or seem to stop breathing multiple times should contact a physician.

A Few Tips

Although not all factors that increase the potential for developing OSA can be eliminated or controlled, people may reduce their risks. Among important steps to take:

• Get enough sleep – sleep apnea is worse when you are sleep deprived or exhausted. Stick to regular timing, and a cool, dark and quiet bedroom.
• Increase physical activity, especially if much of the time is spent sitting in an office or at home in front of a computer.
• Undergo treatment for hypertension, chronic nasal congestion and upper respiratory infections, and other conditions that contribute to OSA.
• Achieve a weight and body mass index appropriate to age and height.
• Reduce consumption of alcohol, particularly just before bedtime, and
• Eliminate smoking as part of an overall healthy lifestyle.
• Be careful driving and avoid doing so if you have any tendency to doze off. Speak with your doctor immediately if you have trouble staying awake during the day.

When it comes to our health, American philosopher and historian Will Durant, perhaps, said it best: We are what we repeatedly do. Excellence [good health] then, is not an act, but a habit.”

Aug 22, 2023 Dr. Dimitriu was published in Psychology Today in an article titled:

Aromatherapy May Lead to a 226% Boost in Cognition

You know those small vials of fragrant oils sometimes placed on a hotel pillow to calm a guest and improve sleep? Well, science says they work, even suggesting certain aromas can help build better brains—and memories—during sleep. Researchers writing in a July 2023 issue of Frontiers in Neuroscience contend “olfactory enrichment”—inhaling pleasant fragrances during sleep—influences brain function in ways that significantly improve cognition and boost memory.

Click HERE for the full article.

By Dr. Alex Dimitriu, Mar 17, 2022

Top tips for consumers about managing medication costs

• Consider generic medication if possible to lower costs
• Check on GoodRx.com to find the best prices and pharmacies for meds
• When a generic request is denied due to prior authorization, ask about the cash price
• Pay cash over using insurance when the cost of the medicine is low to speed things up

I work as a physician. When I put my patient on a new medication which they need to start, the sooner the better. I also have existing patients who need refills of medications they are on, which are generic, and I try to order a refill. Often, the pharmacy tells my patient they cannot have their medicine, because “your doctor needs to speak with your insurance company.” The patient is sent away and left in a land of limbo, sometimes in urgent need of a refill which now has been denied. Read more

by Dr. Alex Dimitriu

Pioneering sleep scientist William Dement once called sleep deprivation “the most common brain impairment.” The research is proving him right.

Authors of the latest sleep study, just published (April 2021) in the journal Nature Communications, find that “persistent” sleep deprivation during the midlife years – 50s, 60s, up to age 70 – is associated with a 30 percent greater chance for developing dementia.  And this increase is independent of other sociodemographic, physical, behavioral, and mental health variables, according to the researchers.

The findings add supporting evidence to results of a 2018 study led by National Institutes of Health investigators who found that impaired sleep led to a build-up of metabolic waste in the brain, namely an increase in the protein beta-amyloid, which plays a role in Alzheimer’s disease.

Even more disconcerting is that these reports are only the latest in a series of studies, conducted during the past 15 years, linking chronic sleep deprivation with a variety of physical, mental, and psychological symptoms.

These include mood shifts and increased irritability; concentration and attention problems; failures in judgment and executive decision-making; physiological changes, such as impairments in brain function and hormone production, reduced immunity protection from disease, overstimulated appetite and weight gain, higher risk for diabetes, an overactive nervous system, chronic fatigue – even earlier death; and a range of psychiatric disorders, including elevated anxiety, depression, and obsessive-compulsiveness.

In fact, research appearing in a 2020 edition of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging suggests loss of just a half night of shut-eye decreases rapid eye movement (REM) sleep, which is important to memory consolidation, and is linked to reduced activity in a portion of the brain related to emotion control.

Those findings are in line with a 2016 eLife study indicating that repeated sleep deprivation interferes with the connectivity of brain neurons involved in memory and learning.  An earlier study by the American Academy of Sleep Medicine determined that chronic lack of sleep disrupts or slows a person’s ability to resolve moral dilemmas or make moral judgments.

Sleep Not an Extravagance, But a Necessity

Our high-tech, fast-paced, achievement-demanding society has come to view sleep as an extravagance, an impingement on our time and our lifestyle.  It is anything but.  Sufficient amounts of sleep – defined as seven hours to eight hours for the average adult and about nine hours for high-schoolers and college-age students – are critical to overall good health and proper brain function.

In the book Sleep for Success, three Cornell University researchers define sleep deprivation as a failure to “meet [one’s] personal need for sleep,” and include among the rank-and-file of the sleep-deprived those who have “difficulty falling asleep or staying asleep, waking too early, or having poor sleep quality.”

Indeed, we are a sleep-deprived nation.

Impaired sleep is reaching epidemic proportions; statistics bear this out.  The national Sleep Foundation estimates about a third of adults in the United States fail to sleep the required number of hours. The Centers for Disease Control and Prevention says the number is closer to 35 percent.  According to the online SleepAdvisor,

Americans in the early 1940s were averaging 7.9 hours of sleep per night; this dropped to 6.8 hours in 2013 – a decrease of 13 percent.  Meanwhile, experts equate lack of sleep to alcohol intoxication, saying sleep deprivation is a major cause of car crashes.  And, as reported by Fortune Magazine, a 2016 study by RAND Europe found that sleep insufficiency among U.S. workers costs the economy in excess of $411 billion annually.

So, Why Are We Not Sleeping?

The causes of impaired sleep are multiple, ranging from musculoskeletal pain and obstructive sleep apnea, which is a breathing disorder, to insomnia.  Insomnia is linked to a variety of cognitive and psychiatric issues, including depression as well as anxiety, bipolar, and attention deficit hyperactivity disorders.

In many instances, the issue is not medically related at all, but simply a failure to consider sleep all that important and to budget enough time for it because of workload or lifestyle.

Some teens and adults may even view “lying in bed too much” as a source of weight gain.

Yet the opposite is true.  Scientists have determined that sleep deprivation disrupts the production of hormones regulating appetite, causing a person to overeat and indulge in “junk” foods high in carbohydrates.  They report a 50 percent increase in the risk of becoming obese among those who sleep five or fewer hours per night.

Sleep deprivation even feeds into the current diabetes epidemic in this country.  After one week of deprived sleep, otherwise healthy young men showed evidence of being in a pre-diabetic state, according to a University of Chicago study.

What’s the Answer?

The solution to sleep deprivation may be as easy as working sleep time into that busy daily schedule.  Believing weekends provide the opportunity to “catch up” on sleep lost during the week is wrong thinking.

A 2019 study in Current Biology indicates that efforts at “recovery” sleep on Saturdays and Sundays not only fails to reverse some of the negative metabolic changes occurring during sleep-deprived weekdays but interferes with – and resets — the body’s circadian clock when a person returns to his or her lack-of-sleep ways during the week.

For those who have trouble falling asleep, staying asleep or waking too frequently and too early, here are some tips:

• Stick to a regular sleep schedule. Go to bed and get up at the same time every day.
• Stop constantly checking the time when you are in bed and worrying about falling sleep. The anxiety only increases your difficulties. Put a cloth over the clock on your nightstand, close your eyes, turn off your mind. Your sleepy brain will take it from there.
• Improve your sleep hygiene. You know the drill: darken the room, lower the temperature, move the television out of the bedroom, put the mobile phone where you cannot see it, and, yes, if necessary, buy a new mattress.
• Avoid alcohol consumption and caffeinated drinks several hours before bedtime.
• Depend on natural rather than medicated sleep. Some experts contend that use of sleeping pills is associated with higher risks for mortality and cancer.
• Finally, if you suspect depression, abnormal anxiety, or other mental issue to be the culprit for lack of sleep, contact a psychiatrist or sleep medicine specialist.

Remember: sleep is essential.  Your health – and your brain — depend on it.