Sleeping Your Way To Health

 

http://www.nytimes.com/2013/11/19/health/treating-insomnia-to-heal-depression.html?hpw&rref=health&_r=0

 

“Curing insomnia in people with depression could double their chance of a full recovery, scientists are reporting. The findings, based on an insomnia treatment that uses talk therapy rather than drugs, are the first to emerge from a series of closely watched studies of sleep and depression to be released in the coming year.”

 

Sleep is important. Yep! Sleep can help mood. Yep! “Insomnia treatment that uses talk therapy,” Nope! “The therapy that Dr. Manber, Dr. Carney and the other researchers are using is called cognitive behavior therapy for insomnia, or CBT-I for short. The therapist teaches people to establish a regular wake-up time and stick to it; get out of bed during waking periods; avoid eating, reading, watching TV or similar activities in bed; and eliminate daytime napping.” CBT-I, a “T” therapy is NOT “talk therapy”. The patient is taught life skills, which help with depression. That is fine! Being taught is not the same as talking, as a form of therapy. This is more aptly described as “listening therapy,” as the patient is told how to change their habits. I could write a letter to the New York Times, but I decided to rant here instead. Helping people to sleep is a worthwhile endeavor, but to compare this intervention to the Prozac revolution is absurd. “In the four larger trials expected to be published in 2014, researchers had participants keep sleep journals to track the effect of the CBT-I therapy, writing down what time they went to bed every night, what time they tried to fall asleep, how long it took, how many awakenings they had and what time they woke up.” Many depressed patients cannot follow-though with sleep journals or any tracking measure, for that matter. The severely depressed often have psychomotor retardation which makes doing tasks, including tracking, overwhelming and anxiety-producing. Again, I am all for tools to help healthful living, but the marketing and the limitations of these tools needs to be clear. need to be understood.

Sleep, Memory and The Brain: Science Validates Common Sense

Do you want to learn new material? Go to sleep. I knew that in college. An awake mind is more efficient. Do you want to do well on a final exam? Go to sleep. I knew that too. Sometimes  I think that my college success was based on knowing this principle and thereby shunning the notion of an all-nighter. It felt to me that I had better retention with more sleep, so sleeping was my tool to academic accomplishments. Yesterday, Matthew Walker MD said the same thing, http://psychology.berkeley.edu/faculty/profiles/mwalker.html at UCLA Psychiatry Grand Rounds. The hippocampus, the part of the brain responsible for memory, is more responsive after sleep, be it a nap or a night-time rest. He had pretty brain pictures, randomized controlled studies, and a videotape of a Harvard University undergraduate trying to get a thirty page paper done on no sleep at all, demonstrating that sleep changes brain function for the better.

Now, although he was a wonderful speaker, I felt like I already knew what he was saying, when of course, the science of it all, is brand new. The lecture became more engaging as he said we not only sleep to learn, we also sleep to “forget” the emotional association of memory. Sleep, he says, often strips the emotional aspect of the event, while still preserving the narrative memory. “What about PTSD, I asked my colleague/audience neighbor?” Almost immediately, as if he heard me, he said that “in PTSD, one is unable to strip the emotion from the memory, and hence the sleep in PTSD is characterized by nightmares.” Wow, that makes sense to me. The adage that “time heals all wounds” is mostly true, because as we sleep every night, the emotional aspects of memory fades, except in extreme trauma, where the emotion can persist for years and years after a devastating event. This was the most intriguing part of the lecture. Sleep not only refreshes the learning aspect of our brain, it also refreshes our baseline emotional state-most of the time. My take-away was that the value of sleep trumps almost everything and although sleeping medications are a last resort, getting people to sleep can be a key intervention for mending mental health. I knew that. Now, I have science to back me up. Thank you, Dr. Walker.

 

http://www.youtube.com/embed/giKIFuw5fy“

Mean, Mean, Mean

     Deidre, thirty-two, wants to sleep. She is single, recently sober, unemployed, and “desperate for a good night’s rest.” She takes five medications to help her sleep: Ambien, Seroquel, Trazodone, Neurontin and Celexa. Her father, Rand, pleaded with her to get a second opinion about “all those meds.” After hearing Deidre’s life story; a story filled with deep emotional traumas and heavy substance use, I feel for her and her struggles. At the same time, I am aware that sleep is largely about habit. It takes time to develop a lifestyle which allows a person to sleep well. Eating well is important, as is exercise along with mental and social stimulation. All of these lifestyle issues are off-center with Deidre. I explain that she needs to focus on lifestyle issues and then her body will naturally want to sleep. “I don’t think you should make any changes in your medication today,” I say, “but the long-term goal is to have you sleep on your own.” “You mean that you are not going to prescribe me anything?” She says indignantly. “Well, I am just getting to know you, and at this moment, I think we have to work on some behavioral changes to see if that would help you sleep.” “You are mean,” Deidre says as she gets up and walks out. Like https://shirahvollmermd.wordpress.com/2010/01/24/i-cant-sleep-saying-no-to-prescription-hypnotics/, I am aware that when I do not write a prescription, particularly when the patient is hoping for one, causes great disappointment and sometimes anger. How people manage this limit interests me. Deidre decided to call me “mean”. This was not my professional judgment about her sleep problem, but rather she felt that  my analysis of the situation was motivated by my wish to hurt her. Interesting.