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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.

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

Pachamama – Celebrating Earth Day 2018

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


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

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

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

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

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

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

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

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

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

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

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

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

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

Another powerful and profound reminder, from Chief Seattle:


The Universal Declaration of the Rights of Mother Earth

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

  1. Mother Earth is a living being.
  2. Mother Earth is a unique, indivisible, self-regulating community of interrelated beings that sustains, contains and reproduces all beings.
  3. Each being is defined by its relationships as an integral part of Mother Earth.
  4. The inherent rights of Mother Earth are inalienable in that they arise from the same source as existence.
  5. Mother Earth and all beings are entitled to all the inherent rights recognized in this Declaration without distinction of any kind, such as may be made between organic and inorganic beings, species, origin, use to human beings, or any other status.
  6. Just as human beings have human rights, all other beings also have rights which are specific to their species or kind and appropriate for their role and function within the communities within which they exist.
  7. The rights of each being are limited by the rights of other beings and any conflict between their rights must be resolved in a way that maintains the integrity, balance and health of Mother Earth.

Alex Dimitriu in the Sierra

And a some great links to how we can give back:

https://www.mensjournal.com/travel/17-non-profits-worthy-your-donation-this-earth-day-w203736/

Less Stressful Holiday Hosting

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

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

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 at: www.siliconpsych.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.

Weight Loss And Happiness – Serotonin And The Carbohydrate Connection

The bread rolls at restaurants may actually help you eat less… Serotonin is an essential neurotransmitter – and acted upon by many commonly known anti-depressants which boost its levels. It has a myriad of effects- ranging from creating a feeling of satiety, sleep, mood, anxiety,  pain, blood pressure, and sense of overall calm. The highest number of serotonin receptors are actually found in our gut.Tryptophan is one of 22 essential amino acids and is the essential precursor to the formation of serotonin.

Studies now show that having a moderate dose of (low fiber) carbohydrates, can have mood elevating effects, and actually reduce our sense of hunger and food consumption. The reason lies in the “plasma tryptophan ratio” – which affects which amino acids get through the blood brain barrier. Eat a protein rich meal – and all the amino acids equally compete to cross into the brain (so less tryptophan, and less serotonin). Eat a carbohydrate rich meal, and the insulin drives a lot of amino acids into muscles – leaving less competition for tryptophan to cross into the brain (so more tryptophan and more serotonin). The proof? Work by Judith Wurtman has demonstrated that people served a carbohydrate rich pre-meal drink “became less hungry and were able to control their calorie intake” and this effect was not achieved with a protein rich drink (less transported serotonin). Additional studies have found impaired tryptophan transport in fibromyalgia, as well as a tendency to over-eat carbohydrates in patients with depression and during periods of anxiety – which may be a form of self medication by enhancing serotonin levels.

THE RECIPE:  For weight loss and happiness from the book: “The Serotonin Power Diet” by Dr. Wurtman

    1. Have your carb snack on an empty stomach so there is no competition from other amino acids
    2. Snack on 25-35 grams of carbohydrate- with low fiber to speed up absorption
    3. Protein content should be less than 4 grams, less than 3 grams of fat. Pretzels, chips, or crackers are a great option
    4. Wait 20-40 minutes to feel the effect – don’t keep eating!
    5. Aim for more protein in the morning and more carbs with dinner, to reduce snacking, and enhance sleep.

Read more here:

Serotonin: What It is and Why It’s Important for Weight Loss
Fat and Happy? Tryptophan Concentrations Reduced in Obesity
Brain serotonin, carbohydrate-craving, obesity and depression.
Plasma tryptophan and other amino acids in primary fibromyalgia: a controlled study

A Concise Review Of Behavioral Approaches To Insomnia

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

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

Common Cognitive and Behavioral Therapies for Chronic Insomnia

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

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

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

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

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

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

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

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

  • Maintain a sleep log and determine the mean total sleep time (TST) for the baseline period (e.g., 1–2 weeks)
  • Set bedtime and wake-up times to approximate the mean TST to achieve a >85% sleep efficiency (TST/TIB × 100%) over 7 days; the goal is for the total time in bed (TIB) (not <5 hours) to approximate the TST.
  • Make weekly adjustments: 1) for sleep efficiency (TST/TIB × 100%) >85% to 90% over 7 days, TIB can be increased by 15–20 minutes; 2) for SE <80%, TIB can be further decreased by 15–20 minutes.
  • Repeat TIB adjustment every 7 days.

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

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

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

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