Thursday, February 3, 2011

Sleep -- The Real Antidepressant

Your sink has backed up three times in as many weeks.  This time the plunger won't work, and it's beginning to stink.

The hardware salesman says you need a new garbage disposal -- $169.00.

Your plumber takes the pipes apart and clears the plug.  Depending on the plumber, she might show you how to do it yourself next time.  (My plumber is a woman.) -- $60.00 in my neighborhood.

Your brother says, stop putting banana peels in the garbage disposal.  (My brother owns rental property, and tells me what the plumbers almost always find in the plug.) -- $0.00.

The hardware salesman says a better garbage disposal could handle banana peels, and whatever else might also be causing that plug -- $249.00.

All of them are trying to help.  Each of them is working with the tools at his/her disposal.

Okay, now let's look at your depression.

Remember last week's list?

DSM On Depression -- The Chinese Menu

Column A:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
Column B:
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Last week's example was a miserable anorexic looking young woman who went to the doctor complaining that she isn't having fun, is tired all the time, doesn't sleep well, has no appetite and feels pretty worthless about her inability to exercise control over anything in her life.  Sometimes she feels like just ending it all.


I could just as well have used a middle-aged man who is having sexual difficulties, has quit the bowling league and sits around all day, is tired all the time, doesn't sleep well, feels like a failure at work, and is here under protest because his wife insisted -- she is fed up with his rages.  Finding the gun was the last straw. 

Who Is Treating Your Depression?

Both the skinny miserable looking young woman and the overweight angry man get the same diagnosis, major depressive disorder and the same medication, Zoloft if they have good drug coverage, fluoxetine if not.

Some would say they do not have the same illness, and should be treated differently.  Read John McManamy's work on this.  That is not my issue today.  Mine is that there are a variety of treatments that could indeed work for either of them.

Both went to the same hardware salesman.  Or in this case, a psychiatrist, who truly wants to help and has one solution, a prescription pad.

If they had gone to a plumber, AKA therapist, the therapist, who truly wants to help, would have opened up the pipes.  A cognitive behavioral therapist would have taught them how to clear their own pipes next time.

If they had gone to their mother, who truly wants to help, she would have said How many times have I told you?  Stop watching Fox News at night and go to bed!

Each caregiver truly wants to help, and uses the tools that he/she has to hand.  Depending on which helper is, each sufferer would pay accordingly.  There is a possibility that Mom may have the longest time to relapse rate.  Certainly her advice carries low to no risk of harm.  And is cheap.  Which makes it worth a try.  Even if it comes from your mother. 

The Problem With Antidepressants As A Cure For Depression

The psychiatrist is focused on symptom #1 -- the depression symptom of the mental disorder known as major depressive disorder.  The psychiatrist believes that if you take a medication which has been shown to have a significant advantage over placebo in relieving this one core symptom of depression, the other symptoms will go away.

Maybe.  Except antidepressants can cause some of these other symptoms.  First generation antidepressants (tricylics) cause fatigue.  Second generation (SSRIs, SNRIs) cause insomnia, which causes fatigue.  The latest fashion in psychopharmicology is augmentation, adding an anticonvulsant or antipsychotic to the chemical mix, either of which is a sledgehammer of fatigue.

Other symptoms of depression that are potential side effects of antidepressants include weight gain, agitation, poor concentration and suicidality.

Notice, we now have six out of nine items on the list.  If you complain about any of them, the psychiatrist will increase your dose.  Because they will go away when your depression goes away.  You won't complain about the liver damage, because you don't know about the liver damage.  And your doctor won't check.

The Chicken And Egg Of Depression

Think about your brain as a planet and your depression as an ecological issue to be addressed.  That menu of symptoms offers a whole variety of entries into that ecological system.

The trick is to find the entry that will work its way through the rest of the list -- a nontoxic intervention.

Here is another image that captures the goal, the Brunnian link.  The cool thing about the Brunnian link is that all of these colored strings are intertwined.  You can't pull any one of them out of the whole.  However, if you cut any one of them, all the rest will be released.

Will this really work for depression?  I don't know.  But let's start with the possibilities of one string -- sleep.

Insomnia And Fatigue

Insomnia leads to fatigue.  Well, duh.  We don't need research for that one.  I mention it because it is an easy start.  Then once the fatigue is addressed, others will follow.

Insomnia and Weight

Here is a study that may surprise you.  Insomnia contributes to weight gain.  This conclusion comes from that huge sixteen year study of 68,183 nurses.  Women who ate the same calories but slept less gained more weight than the women who slept more.  The amount of exercise didn't matter.

There is speculation as to other causes.  Perhaps less sleep leads to a slower metabolism.  Perhaps tired women sit more than stand.  Perhaps they fidget less.  Skinny people who fidget burn an extra 350 extra calories a day.  So people who are overweight burn less calories and gain more weight.  Regardless of the underlying mechanism, this weight gain is one of the strings in the link, binding together the other symptoms.

Overweight is one of the risk factors for sleep apnea.  This is a serious medical condition with a variety of causes, one of which is excess neck fat that constricts the airways.  When you stop breathing while asleep, you wake up -- ever so briefly.  You take a breath and fall back to sleep, over and over and over all night.

This stop breathing/wake up/breathe/fall asleep cycle is so short you don't even remember it the next day.  But you wake up exhausted.  Overall, your blood oxygen level plummets, leaving you fatigued, leaving you less likely to exercise or fidget, more likely to sit rather than stand, more likely to engage in other energy saving behaviors such as elevator instead of stairs, and thus more likely to gain more weight, leading to more fatigue...

See what I mean about a system?  #3 weight gain, #4 insomnia and #6 fatigue are intricately intertwined.

Fatigue, Overweight And Exercise

Here is another version of depression's Brunnian link:

People who are overweight feel self-conscious in the gym.  They also are too tired to exercise.  I'm not looking that one up, just going by what I hear.  Am I wrong?

Ironically, if they did exercise, they would feel more energized and less fatigued.   20% more energized, 65% less fatigued with a moderate intensity activity for 20 minutes, three times a week, according to Tim Puetz at the University of Georgia, beating the health claims of a Snickers Bar all to heck.


If you need a mid-afternoon boost to keep going at work because you didn't sleep well last night, so you didn't have the energy for your morning walk, so you reach for the Snickers Bar instead, then you gain weight.

Fatigue causes the brain to crave carbs.  The brain uses lots of energy, and carbs deliver it fast.  But the carbs in that Snickers bar are the kind that zip you up and then let you crash.  Now your brain is offline entirely.

Can anyone spell vicious circle?

I love that Betty White commercial.  But a handful of peanuts would be a better choice.

We are not finished with that symptom list yet.

Exercise And Brain Function

Lots of common sense about this one: less fatigue leads to more exercise leads to more oxygen in the brain leads to clearer thinking.

Turn it over, and it is also true.  Start with more fatigue, you get to poorer brain function.  This has been researched in various of work settings, including driving and, of all things, medicine.  You'd think that doctors would get it.  Surgical residents can work over 100 hours a week.  The result -- mistakes.  But maybe they don't get the connection, because doctors don't talk about their mistakes, lest it reinforce their excessive or inappropriate guilt.

From the positive way round, Dr. Catherine Davis, clinical health psychologist at the Medical College of Georgia studied 200 overweight, inactive grade schoolers.  After an intervention of daily vigorous activity for three months, their executive function (decision making) improved.  It showed up in their fMRIs.

#4 insomnia, #6 fatigue, # 7 inappropriate guilt, #8 poor concentration and indecisiveness.

Exercise And Depression

Having gotten a decent night's sleep, you get out and go for that jog.  Three decades of studies conclude that exercise will relieve your depressive mood.  In 1999, exercise went head to head with Zoloft.  Zoloft leaped out to an early lead.  At the sixteen week mark, they were tied.  But at six months, exercisers stayed healthier longer.  The pharmaceutical companies want to win the sprint.  I imagine you want to live the marathon.

How does exercise relieve depression?  A couple ideas.  Exercise increases the release of endorphins, a neurotransmitter that reduces perception of pain and is the source of the runner's high.  The other idea -- exercise stimulates norepinephrine -- one of the neurotransmitters that Zoloft is supposed to jazz up.

Except that, unlike Zoloft, exercise enhances self-esteem and doesn't deep six your sex life.

#4 insomnia, #6 fatigue, #2 anhedonia/lack of pleasure and #7 feelings of worthlessness.

Insomnia And Suicidality

Insomnia causes suicidality regardless of depressed mood.  That was the topic of The Insomnia Cure, a couple posts ago.

#4 insomnia and the biggie, #9 suicidality.

In the doctor's office, relief of depression is the carrot, threat of suicidality is the big stick -- the one-two combo sales pitch.

Sleep -- The Real Antidepressant

So here we go.  If we start with the sleep issue, we address:

Column A:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
Column B:
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

I didn't find anything about sleep and
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
But pick away at only a couple symptoms and you no longer qualify for the diagnosis, releasing you from the carrot (relief of depressive mood) and big stick (potential for suicide) sales pitch for the latest antidepressant.

Next Week -- Implications For Public Policy

By public policy I mean the behaviors of financial stakeholders.  Change the way the money flows, and you really change the ecology.


photo of miss-do-it-yourself by Nina Malyna from shutterstock.com 
photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
flair from facebook
clip art of planet with circles from microsoft
photo of walking the dog by federico stevanin
photo of Snickers Bar by Scott Ehardt who released it to the public domain
photo of Dutch queen Juliana riding a bike, July 11, 1967 is in the public domain
image of Brunnian link in public domain 
NASA screenshot of Amazon  River in public domain

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