Night and Day: The Essential Role of Sleep Medicine

Dr. Dimitriu was published in Psychology Today on the topic of The Essential Role of Sleep Medicine.

Sleep is truly the other half of our waking lives, as well as an essential half of modern psychiatry. During sleep, our brains recharge the neurotransmitters that are so important to our mood and thinking—dopamine, norepinephrine, and serotonin, to name a few. Training in both psychiatry and sleep medicine has allowed me a unique perspective on these two highly related fields of medicine, which, unfortunately, tend to be practiced in isolation of each other. Through this unique perspective, I have seen some truly remarkable breakthroughs in difficult, treatment-resistant cases. A careful analysis and understanding of sleep and sleep architecture has made this possible. “If there is no gas in the tank, you can’t push the gas pedal,” is something I often say to my clients, because indeed, if you are not well-rested and recharged, not much will work.

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Shocking Sleep Statistics

Sleep is truly the other half of our waking lives as well as an essential half of modern psychiatry.

During sleep, our brains re-charge the neurotransmitters that are so important to our mood and thinking – dopamine, norepinephrine, and serotonin to name a few. “If there is no gas in the tank, you can’t push the gas pedal,” is something I often say to my clients, because indeed, if you are not well-rested, recharged, not much will work.

This article points to the alarming sleep epidemic that we have seen over the past several years, where indeed, most of us, may not be getting enough sleep. The good news is that it is indeed an alarming article. A 2015 study of preindustrial societies, living without light, heat, wifi, and Netflix, show that sleeping 5.7 to 7.1 hours per night may actually be quite “normal,” and natural. The long lines at Starbucks, and marked increase in stimulant prescriptions, do point out, we could all sleep a little more.

If you tell people they can sleep 7 hours, they tend to sleep 6. So be alarmed.

Sleep Statistics Infographics

When Sleep Won’t Come…Do You Need Help?

By Dr. Alex Dimitriu, July 11, 2019

We all have occasional trouble sleeping. Anxiety, jet lag, something we ate, or any number of other things can have us tossing and turning restlessly now and then. Most of the time, these episodes of sleeplessness are of brief duration and with resolution of the root cause we once again sleep for seven to nine hours a night. But for millions of Americans, a night of restorative sleep is elusive and with prolonged difficulty sleeping they suffer both immediate impairment to daytime functioning and long-term risks to health and cognitive function. Read more

smiling depression

Smiling Depression: Masking the Pain

Smiling depression isn’t an oxymoron. It’s a serious atypical manifestation of depression in which the sufferer masks typical depressive symptoms like sadness and lethargy with the outward appearance of a happy, successful, productive life. While approximately 10 percent of the U.S. population suffers from depression, not all sufferers experience it in the same way. Typically, depression is associated with a deep sense of sadness, despair, and lethargy, a figurative and sometimes literal inability to get out of bed that depletes energy and impacts all aspects of life. In contrast, someone living with smiling depression feels the same sadness inside but is able to function normally and present a facade of contentment and happiness to the outside world. Read more

Overcoming Insomnia Without Drugs

By Dr. Alex Dimitriu, March 12, 2019

Sleep isn’t optional. It is one of our most basic physiological needs, right up there with air, water, food, and shelter. It isn’t heroic to go without sleep and it isn’t true that many people need only four or five hours a night. Most of us need seven to nine hours. Critical functions needed to maintain life and health occur while we sleep and insufficient sleep doesn’t just cause daytime fatigue, irritability, and sleepiness but is associated with a broad range of health risks including heart disease, obesity, diabetes, and a weakened immune system. Sleep is a natural function and critical to our health yet millions of people struggle to get to sleep, stay asleep, and get sufficient restful, restorative sleep. Read more

Sleep Restriction Therapy

Sleep Restriction Therapy for Insomnia: Can Spending Less Time in Bed Help You Sleep More?

By Dr. Alex Dimitriu, March 12, 2019

Insomniacs know all about good sleep hygiene. They’ve lowered the temperature in the bedroom, hung room-darkening shades, eliminated nicotine, caffeine, and liquids before bedtime, taken warm baths, and banished electronic devices from the bedroom. Many have tried prescription sleeping pills but were groggy the next day. Natural relaxation and sleep remedies may have been calming and soothing but otherwise unhelpful as regular nights of restful, restorative sleep have remained elusive. Trouble falling asleep or long periods of wakefulness during the night or too-early awakening or combinations of all three persist for millions of people. These sufferers from chronic insomnia may be candidates for a seemingly contradictory therapy known as “sleep restriction.”  Read more

Natural Sleep Remedies

Natural Sleep Remedies: Do They Work?

By Dr. Alex Dimitriu, February 21, 2019

We all have occasional trouble sleeping. Stress, anxiety, a change in routine, something we ate, …any number of things might be responsible for a night of restless tossing and turning. For most of us, bouts of insomnia are of short duration. But for many millions of people, sleepless nights are a regular occurrence, as are the daytime sleepiness, irritability, impaired job performance, accidents, and health risks that follow. In search of a good night’s sleep, many are tempted by the quick fix of sleeping pills but while they can be effective in the short term, they don’t offer a long-term solution.

Sleeping pills come with troublesome side effects and most people quickly build up a tolerance to them and must take higher and higher doses to achieve the same effect. No wonder many ask if natural, herb-based sleep remedies might be a better choice. They may be but your first order of business should be to develop better sleep habits and make lifestyle changes that are conducive to better sleep. If you still feel you need help, a natural sleep remedy might be useful, particularly in helping you relax at bedtime. Here are some suggestions that will help you achieve restful sleep. Read more

agitated depression

Coping with Agitated Depression and “Rockstar” Histories

Millions of people experience episodes of depression every year, making it one of our most common mental disorders. Although its symptoms may look similar, clinical depression differs in its intensity and duration from the ordinary sadness that we all experience from time to time. Sadness triggered by a loss, disappointment, or a major life change is typically short-lived, fading over time as we adjust to new situations. Clinical depression, also known as major depressive disorder, can be precipitated by a specific event but can also result from a change in brain chemistry that makes it difficult to maintain mood stability. Depression is a long-lasting, serious medical condition that must be diagnosed and treated by a medical professional. Read more

reducing anti-anxiety medications

Reducing Anti-Anxiety Medications : Risks and Rewards

By Alex Dimitriu, MD, January 22, 2019

With anxiety disorders ranking as the most common mental illness in the United States – affecting 18% of the adult population every year – perhaps it’s not surprising that more than 1 in 10 Americans take antidepressants, the class of medications used most often to combat anxiety. Read more

Is There a Place for CBD in Treating Insomnia?

By: Alex Dimitriu, MD, January 6, 2019

With the rise in states legalizing the use of both medicinal and recreational marijuana, more attention is now being given to a component of the cannabis plant that’s been scrutinized for decades – CBD, or cannabidiol. But far from seeking a “high,” many of those giving fresh consideration to using CBD – available in supplement form and legal in all 50 states – are pursuing another elusive benefit: a good night’s sleep. Read more

Overcoming the Stigma of Psychiatric Medication

By Dr. Alex Dimitriu, 12/20/18

Even as the stigma associated with mental illness has – thankfully – dissipated over the last decade, millions of people still fail to get the help they need because the stigma around the medication that can alleviate their suffering endures. Fueled in part by celebrities talking about their struggles with depression, anxiety, and other conditions, openness about mental illness has become more acceptable. But even as people find understanding and support for their illness, they are also subject to a host of unhelpful and stigmatizing attitudes about medication, ranging from the implication that they’re just not trying hard enough to overcome their condition, to the recommendation that all they need is a certain diet, or exercise, or meditation, to the assumption that the cure for what ails them is as simple as taking a pill. Unfortunately, these attitudes are often internalized by the very people who could benefit from psychiatric medication and prevent them from seeking treatment.

The use of psychiatric medications, also known as psychotropics, has grown significantly in recent years. Various studies have estimated that 10% of American adults had taken an anti-depressant, anti-anxiety, or anti-psychotic drug in the previous thirty days and that as many as 17% filled a prescription for a psychiatric medication in the previous year. The growing usage of these drugs has led to widely shared and incorrect attitudes. At the same time, that many people see the use of psychiatric medication as a weakness or a failing on the part of the patient, others downplay the struggle of overcoming mental illness because ‘there’s a pill for that. It’s important to dispel misconceptions about mental illness and the best way to treat it.

Many years of research and clinical experience have proven that the best outcomes for those suffering from mental illness result from a comprehensive approach that combines a medically crafted and supervised regimen of psychiatric medication with psychotherapy. Medication and psychotherapy work together. By relieving severe symptoms, medication gives patients the clarity and stability that enable them to benefit from psychotherapy that can address emotional and behavioral issues and bring about the changes needed. Medication treats the physical aspects of mental illness, managing the levels of certain chemicals in the brain just as a statin manages levels of cholesterol in the blood. Taking medication for mental health is no different than taking it for physical health. With chemical imbalances in the brain under control, the patient is free to work on improving behavioral and emotional imbalances.

Common misconceptions that stigmatize psychiatric medication:

“Isn’t medication a crutch for people who are too weak to manage their problems?” A psychotropic medication relieves the symptoms of a medical disorder. It is no more an indication of weakness than taking medication for high blood pressure. Stigmatizing the taking of medication as a weakness implies that if the patient would just get it together and work harder, medication wouldn’t be necessary. This is akin to advising someone with high blood pressure to just relax. In fact, it takes strength to recognize that you have an illness that can be helped with medication and that you need to use every tool available to take care of yourself.

“Won’t a psychiatric medication change my personality, dull my senses, turn me into a zombie?” There is nothing more destructive to a person’s sense of self, to the unique characteristics that define a personality than a mental illness. Motivation, concentration, even the ability to get out of bed, are often gone. Medication can alleviate the symptoms of illness that sap energy and impair functioning and restore a sense of self. That said, some medications do have troublesome side effects, and the same drug can affect people differently. The medication that works for one person might not be tolerated well by another. That’s why we sometimes have to try several medications until we find the one that works.

“Is medication masking my problem rather than fixing it? Is it just a temporary solution, a quick fix?” Psychiatric medication is not a miracle cure. It doesn’t produce an instant change in mood. It takes a while for the drugs to build up in the system and causes a gradual change that alleviates symptoms enough to improve functioning and enable getting the therapy that will help over the longer term.

Psychiatric medication has helped countless people reclaim their lives. It is an important support for the journey to well-being, not an easy way out. And taking every step necessary to get well is nothing to be ashamed of. Bringing medication out of the shadows will overcome the stigma associated with it and encourage millions of people to get the help they need.

Alex Dimitriu, MD, is founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, CA. He is dual board-certified in psychiatry and sleep medicine.

Anxiety Disorders: When to Worry about Anxiety

By Dr. Alex Dimitriu, 12/13/18

We all worry. Occasional anxiety is part of everyday life –- an upcoming test, a job interview, a troubled relationship –- and anxiety may have a beneficial effect, helping us focus and problem-solve by studying for the test, preparing for the interview, or working on the relationship. But for millions of people, anxiety is excessive, disproportionate to the situation, generalized, and impossible to alleviate or control. Anxiety disorders are the most prevalent mental disorders and take an enormous toll. Read more

Combining Insomnia, Depression Treatment May Improve Outcome By Lynne Lamberg

In people with both depression and insomnia, determining which disorder surfaced first may be key to improving clinical care.

Studying the timing of emergence of symptoms in people with both depression and insomnia may help identify differences in patients’ clinical presentation and aid treatment decisions, according to experts at the joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Baltimore in June.

Insomnia is both a risk factor for depression and a symptom of depression, noted Rachel Manber, Ph.D., a professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

Manber reported preliminary findings from the multisite Treatment of Insomnia and Depression (TRIAD) clinical trial, for which she is the principal investigator.

TRIAD, funded by the National Institute of Mental Health, seeks to determine whether combined treatment of major depressive disorder and insomnia improves depression outcome.

Started in 2008, TRIAD has enrolled about 150 participants, Manber told Psychiatric News. Recruitment recently concluded. Treatment will continue through the end of this year at Stanford, Duke University, and the University of Pittsburgh.

Participants receive 16 weeks of treatment with the antidepressants citalopram, sertraline, or desvenlafaxine. Choice of medication is based on the individual’s previous medication use, response, and tolerance. Participants also receive either cognitive-behavioral therapy for insomnia (CBTI) or desensitization psychotherapy for insomnia.

A pilot study, published by Manber and colleagues in the journal Sleep in April 2008, found that augmenting an antidepressant medication with brief, symptom-focused CBTI helped alleviate both depression and insomnia in individuals with both disorders.

About half the TRIAD participants reported at baseline that their insomnia started before their current depressive episode, Manber said. The remainder said their insomnia started at the same time as their depression or afterward. Members of both groups reported comparable severity of insomnia and depression.

In the first group, Manber said, insomnia may be independent of depression and require separate treatment.

If insomnia has emerged as a symptom of depression, she added, one might expect that treating the depression adequately will prompt the insomnia to resolve. While that often occurs, insomnia persists in some patients even after the depression remits. People who toss and turn often come to view the bed as a cue for poor sleep, she noted, and develop an insomnia disorder that needs additional sleep-focused treatment.

TRIAD participants who reported having insomnia before they experienced depression had higher scores on the Childhood Trauma Questionnaire, indicating childhood adversity such as sexual or other physical abuse. This surprising finding, Manber said, raises the possibility that events that disrupt sleep in childhood may foster both insomnia and depression later on.

In another report on TRIAD findings at the sleep meetings, Andrew Krystal, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine, analyzed participants’ responses to the Ford Insomnia in Response to Stress Test (FIRST).

The FIRST asks respondents about their likelihood of sleeping poorly after a bad day at work or an argument, before leaving on vacation, and in other situations. It assesses trait-like vulnerability to developing insomnia under stress.

“We were attempting to test a bias in the field that is not empirically based,” Krystal said, “that insomnia occurring in people with depression is driven by the depression and that there is a diminished etiologic role of factors that precipitate and/or perpetuate insomnia where depression or other conditions are not present.

“Our analysis appears to speak against that bias,” he said. It suggests that the same factors that seem to precipitate and/or perpetuate primary insomnia—which include dysfunctional beliefs and attitudes about sleep, worrying about sleep, stress, and anxiety—play a comparable role in insomnia that develops in people with depression.

The findings, he said, provide the first evidence that there is a trait vulnerability to developing insomnia under stress among at least some patients with major depression, similar to that in people with primary insomnia.

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.

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.

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