As a brief disclaimer, while I do rely mainly on evidence and clinical trials, this blog serves as a platform where I can share my own anecdotal evidence. These are my opinions based on knowledge-sharing amongst colleagues, personal research and my own clinical experience in treating patients. No, I did not invent these concepts. Everything I practice is supported by quality evidence and research. Like anything else, I’ll encourage you to do your own research and will always welcome you to challenge my opinions - it creates meaningful conversation! That said, please excuse me while I rant a little bit….
I wanted to share my thoughts on a very relevant and timely topic, especially during these cold winter months where depression seems to affect many people often in the form of sleep disturbances and decreased energy. This time of year, people are indoors more with cold weather limiting outdoor activities. People are getting much less light exposure amongst other things that sometimes cause sluggishness and interfere with motivation.
There are many other diagnostic criteria and features of depression besides sleep disturbance and decreased energy. Contrary to popular belief, depression is a very complex disease. Personally, I’ve not met two patients whose depression is the same if you dig in enough. People are way too complex to lump into a single bucket. Furthermore, there are many subtypes of depression: unipolar, bipolar, melancholic, atypical, with or without psychotic features, peripartum, etc. While there is overlap, each of these have unique features with varying treatment strategies and they each warrant their own separate discussion.
To the average person, and even many medical professionals, depression is viewed as a straightforward diagnosis with limited treatment options. Way too often it goes like this:
Patient: “I am sad.”
Provider: “Ok, here’s a medication (probably an SSRI like Zoloft, Prozac, etc). Take this medication, go see a therapist, the end.”
Don’t get me wrong, there are many patients for whom this is a perfectly appropriate treatment plan. Aside from the fact that this is not a primary care provider's speciality, time constraints and other limitations often preclude providers from performing a thorough and proper evaluation. The result is too often a treatment plan that is either: 1) ineffective, 2) not optimized, or 3) actually harmful.
For today, I’m going to focus on sleep; the first of two prominent features of depression that I regularly see problems with. Stay tuned for my thoughts on energy later this week…
I mention sleep first because it is probably the most common symptom and issues here often cascade to many others. Sleep disturbances can take the form of difficulty falling asleep or maintaining sleep. Most people are not aware that early awakening is one of the biggest indicators of depression. So many people tell me they “wake up at 3 or 4am and have no clue why”. It sometimes takes others hours to fall asleep. I routinely see patients who experience sleep problems receive a simple, broad diagnosis of “insomnia” from other providers. In my experience, people are typically more comfortable being diagnosed with “insomnia” than depression. The problem that I see far too frequently is that insomnia treatment often leads to prescriptions for hypnotics like Ambien, or even worse a benzodiazepine, like Xanax. While these medications do have some utility, they tend to worsen depression. Benzodiazepines, for example, are categorized as central nervous system depressants. These medications stimulate receptors in the brain called gamma-aminobutyric acid or ‘GABA’, which causes inhibition and sedation.
You know what else works on GABA? Alcohol. This is the reason benzodiazepines are commonly used to help prevent alcohol withdrawal seizures. I won’t argue that alcohol won’t put you TO sleep. Most of us can recall having a drink (or a few) and feeling activated (ie. the buzz) for a short time until the drowsiness sets in… and then it’s lights out! We can also recall waking up at 3 or 4am that same night feeling groggy and unrested (ie. the hangover).
For all intents and purposes, in simple terms, benzodiazepines are barely different from alcohol in pill-form. Alcohol (and benzodiazepines) completely disrupt the sleep cycle and interfere with your ability to obtain restful sleep. This is why I will rarely offer this as an option for treating sleep disturbances. They will continue to potentiate and worsen depression (amongst other dangerous events which we don’t need to talk about here). I definitely do not hate benzodiazepines like some providers…not only do they help bail people out of crippling panic attacks, they can save lives. However, using them as a crutch to sleep when there are much safer and effective alternatives is something I will never offer... end rant about benzodiazepines/alcohol.
Other medications, many of which can be purchased over-the-counter - Benadryl, Unisom, etc - are not always innocent bystanders. Benadryl, something I’m seeing a LOT of people using for sleep, is an antihistamine. Antihistamines were developed to treat dangerous allergic reactions, but a side effect was that they cause sedation - so why not use them for sleep too, right? Nevermind the fact that antihistamines can interfere with efforts to lose weight, they can cause constipation and have other side effects. Again, I don’t hate antihistamines. They are safe and effective when used properly. I just believe they should not be used for sleep and they definitely do not help with depression.
My main points here are that a lot of the time serotonergic medications (antidepressants mainly) can HELP remedy sleep problems. However, medications are only a piece of the solution. Simply taking a pill is unlikely to make EVERYTHING better; most times it takes more work than that. We should have a thorough discussion and explore other effective treatment strategies: cognitive behavioral therapy specifically targeting chronic insomnia (CBT-I), proper sleep hygiene and ruling out commonly overlooked factors like obstructive sleep apnea or medications like beta blockers that can worsen lethargy and mood.
Therapy, particularly CBT-I, works. It is well supported by evidence/research, so much that American Academy of Sleep Medicine (AASM) and the National Institute of Health (NIH) believe that it works as well, if not better than medications for treating chronic insomnia (here's a great article on the topic).
Because CBT-I trained therapists can be hard to find, there have been some helpful apps and programs developed that can help with sleep coaching, mainly by helping calculate the amount of time you should spend in bed, how long to delay bedtime, when to wake, etc. One free app that some people are finding helpful is called ‘CBT-I Coach’. Other programs and medical devices, such as ‘Somryst’ for insomnia and ‘Nightware’ for PTSD nightmares are new to the market and have been evaluated and “approved” by the FDA. These are available by prescription only. Anything that is benign and backed by evidence certainly earns my approval, so I do plan to prescribe these. For full disclosure though, I have some research of my own to do here, mainly around logistics, cost, etc. I will provide more opinions on these options as I gain my own experience here.
If you’re still reading this, I just want you to know it is completely normal to experience less energy during these winter months. I think we're supposed to come alive a little in the spring! However, if your sleep disturbances and/or lack of energy are getting in the way of your functioning, consider evaluation and treatment for depression early. Also, remember that antidepressant medications are not “one size fits all”. There is a reason that many options for psychiatric medications exist. They each have their own characteristics that target depression symptoms in various ways and, when prescribed properly, they work! I have the pleasure of witnessing this first hand with my patients and some even find that the winter’s not so bad after all!
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