Today's #Sleeptember FACT --- Sleep apnea and the brains of women

If you're hip on your sleep knowledge, then you probably already know that obstructive sleep apnea (OSA) is not just a man's disease, but rather common in women, too.

If this is new to you, listen up: For decades it's been thought that women did not normally get OSA, but recent findings and regular clinical observation in sleep labs shows that women not only suffer from OSA, but they often do not even know that they have it.

#SLEEPTEMBER

It's not just common in obese women, either (though carrying extra weight is a major risk factor). Age, physiological structure of the cranium and jaw, pharmaceutical interactions, estrogen levels, pregnancy status, and other medical conditions can all contribute to sleep apnea.

The consequences of untreated sleep apnea for women mirror those for men, as well:

• High blood pressure
• Increased risk for stroke
• Development of heart disease
• Onset of diabetes
• Depression 

However, women with untreated OSA have been shown to actually suffer higher degrees of brain damage as an outcome when compared to their male counterparts.

In a multi-year study conducted at UCLA, "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea," researchers confirmed that women, in fact, not only suffer brain damage from OSA (which is true for men, as well), but that they suffer it differently than men.

The areas in the front of the brain, which are responsible for decision-making and management of mood, were shown to have more OSA-related damage than in the same brain areas in men. This damage can lead to higher levels of depression and anxiety symptoms in women who have untreated OSA.

The differences were so pronounced in the study that its chief investigator, Paul Macey, concludes that "doctors should consider that [OSA] may be more problematic [for women] and therefore need earlier treatment in women than men."

Never assume that just because you are a slim young woman, that you are less likely to have OSA. If somebody tells you that you snore loudly and gasp or stop breathing in your sleep, take their observation seriously and consult a medical professional. Earlier treatment of hidden sleep breathing disorders like apnea is not only ideal, but critical for managing your overall health. 

Source: "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea." Macey PM, Kumar R, Yan-Go FL, Woo MA, Harper RM. Sleep. 2012 December 1; 35(12): 1603–1613. Published online 2012 December 1. doi: 10.5665/sleep.2228

INSOMNIA || Why is it linked to depression?

Image courtesy TMS NeuroHealth Centers

This could be a chicken/egg question, truly... which came first, insomnia or depression?

One can definitely lead to the other. Let's think about this for minute.

Depression can be its own illness, categorized in severity based on a wide range of physical and emotional symptoms and linked to physical illness, hormonal imbalance, stress and aging. When people experience the psychic symptoms of depression (feeling emotionally drained, agitated, anxious, worried, or suicidal, for instance), it makes sense that it could become either difficult for them to sleep or difficult for them to get out of bed feeling rested.

When it comes to insomnia, not being able to sleep due to physiological triggers (other underlying sleep disorders, transient illness, chronic illness, pain, stress, hormonal imbalance, aging) can lead to disorders of mood, thanks to shifting brain and body chemistry and processes that come from not getting adequate sleep. Sleep helps your body to heal itself at the cellular level as well as maintain the proper body and brain chemistry necessary for normal, balanced function. It makes sense that, lacking sleep, a person is more likely to become ill, either physically or mentally, or even suffer from both.

According to a study published in SLEEP in 2005, people with insomnia are 10 times more likely to develop depression than those who sleep well. This is a serious problem, as insomnia is the most common sleep disorder in the United States. Problems with insomnia range from having trouble falling asleep, staying asleep, fragmented sleep and day-after fatigue or excessive daytime sleepiness.

Major depressive disorder, according to the National Institute on Mental Health, is no small problem, either. As one of the most common mental health disorders in the United States, nearly 7 percent of our entire population suffers from it.

It seems there are endless ways in which insomnia and depression can pair up. Drug addiction or withdrawal, for instance, or even the side effects of some maintenance drugs people must take for chronic illness. Major life stressors, such as divorce or the death of a child or a lost job, will cause one or the other--or both--if not addressed. Poor diet or lack of exercise may lead to insomnia or depression. Another common and very specific relationship between sleep and mood--Seasonal Affective Disorder--has also been researched at length (see what SHC published on this topic in 2014).

Treatments for insomnia often mirror treatments for depression, which may simplify the process for many. They usually involve either a pharmacological therapy, cognitive behavioral therapy, or ideally, a combination of both. A medical doctor will review history, symptoms and ask for a thorough physical exam to help establish any biological causes for either sleep insufficiency or depression, to help determine a therapeutic course that serves to treat both.

The main takeaway is this: never think that ongoing symptoms of either insomnia or depression are best ignored. The presence of ongoing bouts with either--and especially both at once--is a major cause for concern and should not be overlooked.

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There is no badge of courage attached to going without sleep; the longer you go without it, the worse your brain and body will suffer. The human body can go for up to 11 days without sleep, and then it will die. Sleep is not optional.

Likewise, there is no shame in admitting to feelings of despair or chronic low mood; in fact, these could by symptoms of a physical condition you could easily treat. Often, the challenges of our lives also require outside help; even the strongest individuals will struggle to power through dark times.

If you are struggling with either condition, you are best advised to seek help regarding either via the healthcare professional you are most comfortable approaching, whether it's your primary care physician, a behavioral therapist you are already seeing, a naturopath, or a specialist who oversees any other chronic health conditions you might have.

(And please avoid going to online forums or private groups as these communities; even when they strive to provide support, they can often be the source of some of the worst, most dangerous misinformation out there. Members and moderators of these groups are generally not medical professionals.)

Ultimately, hope lies in the reality that both insomnia and depression, together and separately, are eminently treatable.

SHED SOME LIGHT || Insomnia Central: Are insomnia and winter depression linked?

"Sunset Winter" (2007) by Jonathan Hendrick

Insomnia can be its own primary sleep disorder, but sometimes it can also be a symptom of another health condition.

Seasonal Affective Disorder (SAD) is a kind of depression that ebbs and flows based on the changing of seasons. One of SAD's key symptoms is insomnia, which starts out mildly during the transition between fall and winter and which gradually worsens with the further darkening of the days.

(Interestingly, there are some people who suffer SAD only during the brighter spring and summer months.)

The changes in light that come with darker days and longer nights can negatively affect both mood and sleep patterns thanks to impacts on circadian rhythms, which align with the Earth's light and dark cycles.

The reduction in light can also alter emotional chemistry; lower light levels can lead to reduced levels of serotonin, a neurotransmitter which affects mood, resulting in depression. Another neurotransmitter, melatonin, is manufactured by the brain and this process may kick in well before one's typical bedtime as the nights grow longer, which can lead to adjustments in sleep habits that can be disruptive until the transition is complete.

Other symptoms typical to SAD include:

• Agitation
• Appetite changes
• Irritability
• Low energy
• Problems focusing
• Relationship problems
• Sleeping too much
• Suicidal thoughts
• Weight changes

If you have sudden insomnia during the transition between the fall and winter, and you have any of these other symptoms, you are best advised to see a doctor to determine if you actually have SAD instead of insomnia. Your doctor will likely ask a lot of questions and run some tests to make sure your symptoms are actually related to SAD. You could also have chronic insomnia, defined as sleepless nights that recur at least 3 times a week and over a span of 3 or more months.

Keep in mind that insomnia can also be a sign of other problems, including drug interactions or other health conditions you may not be aware you have. Don't presume that because you have some of the symptoms above that you have SAD; let your doctor help you figure that out so you can treat your issues appropriately.

Science on the Subject: 

• Depression and Sleep (National Sleep Foundation)
• The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls (Journal of Affective Disorders) [ABSTRACT]
• Seasonal Affective Disorder: A Review of the Syndrome and Its Public Health Implications (Biology Online) [ABSTRACT]
• Sleep and Depression. (Journal of Clinical Psychology) [ABSTRACT]
• Sleep in fall/winter seasonal affective disorder: effects of light and changing seasons (Journal of Psychosomatic Research) [ABSTRACT]

Sleep Hygiene Tip of the Week || Think carefully before napping

"Rosie and Jennie Took a Cat-Nap."
Harry Whittier Frees, 1915. Public domain.

There's lots of contradictory advice out there about napping. Who should nap? Who shouldn't nap? When is a nap a good idea? A bad idea? What's a good nap length? Let's take these one at a time.

1. Who should nap?

• Naps are good for children as their developing bodies often need the added rest.
• The elderly often nap, and it's not a bad idea. They may have multiple health conditions that lead to daytime sleepiness, and they may also be taking numerous medications that cause them to feel drowsy. 
• Anyone who is sick with a virus or infection can benefit from napping. The body is working hard at the cellular level to manage healing; sleeping gives the body an added opportunity to repair itself.
• Anyone with a chronic health condition or a serious disease like cancer can benefit from a nap. 
• Postoperative patients can benefit from naps while they are in recovery and/or rehabilitation mode.

2. Who shouldn't nap?

• Don't get into the habit of napping if you are suffering from insomnia. It seems counterintuitive ("don't sleep if you can't sleep?"), but regular napping may actually lead to chronic insomnia. Try to get most of your sleep at night and only nap if you really can't avoid it. 
• If you suffer from depression, taking a nap may not help matters as it may continue to alter already disrupted sleep patterns that arise from the condition or via the pharmaceuticals used to treat depression.

3. When is a nap a good idea?

• If you are unexpectedly drowsy, a quick nap can give you the recharge you need. Often we feel drowsy in the early to mid-afternoon. As long as you don't oversleep, you can benefit from a nap at this time.
• If you work night or overnight shifts, a nap prior to working can add some sleep to your "bank" so your recovery time afterward can be easier.
• If you have been diagnosed with idiopathic hypersomnia or narcolepsy, planned naps can help offset these conditions. (Please don't diagnose yourself: get a confirmed diagnosis from a sleep health professional. Excessive daytime sleepiness can be caused by any number of health conditions, many of them not related to sleep.)

4. When is a nap a bad idea?

• If you tend to wake up groggy from naps, then you might not benefit from taking them right before you need to perform tasks that require alertness. 
• If you have insomnia, you might consider how often you nap, and for how long. Naps, if not absolutely necessary for function or healing, can actually reduce your sleep drive at night and make it harder to fall asleep or to get most of your sleep at night.
• It's after 3pm. Any naps after this time may very well disrupt your nighttime sleeping patterns.

5. What's a good nap length?

• Quick naps are best. Ten to 30 minutes should do the trick.

Other things to consider:

• If you use a device for your nighttime sleeping, such as supplemental O2 through a cannula, a PAP mask, nasal strips or an oral device, make sure and enlist these tools for naps, as well. They are yours to use to improve all sleep, not just the sleep you get at night.
• Eating a meal right before a nap could aggravate any heartburn or gastroesophageal reflux disease you may suffer from. You may wish to take a medication for this condition prior to napping.
• Always opt for a nap if you are driving a motor vehicle or operating heavy machinery and find you are extremely drowsy. Do not think you can "power through" extreme fatigue. Your sleep drive is a physiological process which can't be denied. 
• A warm room might be conducive to sleep onset, but you may not have a very long nap if you are overheated. If your sleeping environment is overwarm, try using a fan and blankets to moderate ambient temperature.
• Make sure you nap in an environment conducive to sleep (make sure it is dark and quiet, for example) or you might be frustrated by your failure to sleep.
• If you are regularly fatigued and need to nap daily, this could be a sign of an underlying health condition. Contact your doctor to discuss your options.