It is said that Americans have the worst sleep habits in the world. Sleep problems are rampant in our society and I see patients with sleep problems of one type or another multiple times each day.
Sleep science and physiology have come along way over the past 20 years. We have learned all kinds of interrelationships between sleep and the rest of the body's functions.
The human brain requires a certain minimum amount of "deep sleep" every night. If it doesn't get it, the brain lets you know about it in a number of various ways. Inadequate deep sleep can cause the obvious problem of excessive daytime sleepiness, but it can also aggravate weight gain, lower pain thresholds, reduce immune function, increase depression and anxiety, worsen chronic back and neck muscle tension, and cause foggy thinking and forgetfulness.
Inadequate deep sleep makes people feel sleepy during the day. So then they crank up their caffeine intake which then continues to erode their nighttime sleep patterns. Daytime sleepiness can get so bad that people can sometimes experience "microsleep:" Tiny, brief episodes of sleep where people just nod off for just seconds. Mostly, though, they just fight to stay awake and feel irritable, and without much mental energy to tackle more challenging tasks.
Inadequate deep sleep contributes to weight gain (or sometimes inability to lose weight) by stimulating the production of cortisol (a weight-promoting stress hormone), decreasing the production of leptin (a hormone that reduces the sense of hunger), increasing the production of ghrelin (a hormone that increases hunger). Also, people who are sleep deprived often just lack the motivation to exercise because they are tired.
I remember as a medical student and resident, when I'd have to work nights at the hospital, the night shift nurses and techs would always keep tons of junk food around--donuts, cake, rolls, cookies--usually high carb, high calorie stuff. They used to claim they had to eat to stay awake.
It has now become the third question I ask when assessing a patient with weight problems: Diet, exercise, and now--sleep adequacy.
Deep sleep deprivation reduces pain thresholds. Why this is so is not known. It has huge implications, though. For people with chronic pain problems, it drives a vicious cycle--these patients don't sleep well due to their pain problems, which reduces deep sleep time, which reduces pain thresholds, increasing the perception of pain, which worsens the sleep situation. Quite often, when I work with someone with chronic pain of any type, one of my primary goals will be to maximize their sleep potential.
Another vicious cycle occurs in the depressed or anxious person. One of the hallmark symptoms of depression or anxiety is awakening in the night being unable to get back to sleep. This, of course, decimates deep sleep time, and dramatically adds to the lack of mental energy, irritability, and fuzzy cognition that accompanies these entities. Sometimes just breaking the sleep deprivation cycle in anxiety or depression can make huge strides in improving how patients feel.
The brain sends nerve impulses continuously to muscles of the body when it is awake. Even in shallower sleep phases, signals are still telling the muscles what to do, especially the "postural muscles" of the neck and back. (We've all seen sleeping dogs make running movements and even small yips and barks.) The ONLY time these nerve signals cease is during deep sleep. Therefore deep sleep is the only time these postural muscles get a "break" from the boss (the brain) and a chance to really loosen up and carry out their essential "metabolic house-keeping" and repairs. So shortening deep sleep time tends to worsen tightness and spasm of the muscles of the back of the neck, the upper back (especially the muscles of the trapezius group between the shoulder blades) and the lower back.
This excessive muscle tension of the back, combined with the reduction in pain thresholds, means that I can practically guarantee that patients with chronic sleep problems are also going to have chronic neck and back muscle tightness, tenderness, and pain.
Okay, so now that we know the effects of inadequate deep sleep, what are the kinds of sleep problems people face?
Inadequate time alotted to sleep: Some people just don't let themselves sleep enough hours. This is what I call "self-inflicted" sleep deprivation. It is especially common among teens and young people in their 20s and 30s. The 20-something guy who is addicted to on-line computer games and stays up until 2 a.m., then gets up at 7 a.m. to get to work by 8 a.m. The over-worked executive who is up working on his business project until the wee hours. The harried mom who just gets her kids to bed at 10 p.m. then stays up until 2 getting the other things done around the house that didn't get done during the day.
These people view sleep as a tradable commodity. And they don't seem to value it very highly--or perhaps more accurately, value other activities much greater. So they short-change their sleep and often play "catch-up" on the weekends. It is true--people do develop a sleep "debt." After three or four days of short sleep time, the effects of sleep deprivation accumulate and can, to some extent, be "repaid" to the sleep bank by sleeping longer hours on the weekends.
An excellent sign of someone who is sleep-deprived (especially deep-sleep deprived) is that they tend to fall asleep "the minute my head hits the pillow." The time it takes to fall asleep is called "sleep latency time." I think the average sleep latency is between 15-25 minutes. If someone is deep-sleep deprived, they'll often fall asleep in just a few minutes.
Sleep initiation disorder: There are some patients who come to me complaining that they just can't fall asleep. They lay in bed, wide awake, tossing and turning and getting frustrated. They'll tell me that once they do get to sleep, they are fine and stay asleep fine. They just can't get to sleep in the first place.
Sleep maintenance disorder: This has got to be the most common presentation. "Doc, I fall asleep fine, no problem. But then I wake up at 2 or 3 a.m. and just can't get back to sleep. My mind is going and I toss and turn and I sometimes just get back to sleep and half an hour later my alarm is going off."
I read a great quote by a famous sleep researcher (and I can't recall the name): She said, "If we all got the right amount of sleep, we would never need an alarm clock."
This is the classic form of insomnia seen with anxiety. People will awaken for any of several reasons, then once they are awake, their minds start working and the adrenaline (epinephrine) levels start rising and they get more and more worked up. Sometimes they'll even start to get warm and sweaty as they lay there thinking about stressful stuff. Then they look at their bedside clock, realize it has been an hour since they awoke, think frustratedly, "I can't believe I'm still awake!" (Sometimes post a quick Facebook note to that effect.) Now their adrenaline is really cranking. I tell patients, "The minute you think 'I have got to get to sleep!' you are pretty well done sleeping."
Interventions for sleep problems:
From my point of view, I need to know what is keeping the person awake.
1. Is there poor sleep hygiene? Sleep hygiene is the term doctors use to describe the basic habits that we develop regarding sleep. A long list will be presented shortly that describes good sleep hygiene habits.
2. Is there a pain issue? Is the person awakening because of pain somewhere? Can we address that issue directly?
3. Is there anxiety or depression? Anxiety is the single largest cause of sleep maintenance problems in our society. Can we address the anxiety with counseling, exercise, stress reduction, or medication?
4. Are there medications causing sleep problems? Many medications can have negative effects on sleep. And I'm not just concerned with prescription medications. Alcohol has an adverse effect on sleep--some people use it to help get relaxed at night, but at about 2 or 3 a.m., brain alcohol levels fall, and can cause a little mini-withdrawal which incites an increase in epinephrine (adrenaline) levels which can wake people up. Caffeine can have effects for up to 12-18 hours in some people.
5. Are there obvious sleep interrupters? Are there young children needing assistance in the night? Patients having to get up to urinate at night (from bladder or prostate problems, perhaps).
Sleep Hygiene Rules:
The following list is what we refer to as basic sleep hygiene points that I want anyone with sleep problems to consider as basic first-line recommendations for improved sleep.
1. Keep regular sleep hours. Try to head off to bed pretty close to the same time every night.
2. Keep your bedroom dark and comfortable. Your brain responds to light by waking up. If you get up at night to use the bathroom, try not to turn on bright lights.
3. Avoid obvious nighttime interruptions. Personal story: our pets, with the exception of our terrier, have been banned from our bedroom because our cats would wake up in the middle of the night and have a party under our bed. If small children are waking you up through the night, address those issues with their doctor. Most children over the age of 1 year should not be requiring you to get up in the night except occasionally. If you have to get up at night to urinate (from prostate problems or bladder problems) these should also be addressed by your physician.
4. Mask unpredictable noises. I recommend sleeping with a noise generator such as a fan or electronic sound device. I actually use an iPhone app connected to my bedroom stereo system that plays sounds of gentle waves breaking on the shore all night long (among other options). I also will sometimes use a fan, especially in the summer. These noise maskers will keep me from hearing street sounds, or cats (out in the hallway) or other intermittent noises.
5. NEVER look at the clock. It instantly sends a jolt of adrenaline through your body and brain, making you anxious and waking you up. You are either thinking, "I can't believe I'm still awake," or, "I've only got 2 more hours before my alarm goes off."
6. Exercise at least 20 minutes every day. Physical exercise burns off excess adrenaline and stress issues. It makes your body physically tired.
7. Avoid eating a large meal within 2-3 hours of bedtime.
8. Avoid caffeine after noon.
9. Avoid alcohol after dinner time.
10. If you find your mind is thinking about all kinds of things, keep a diary or journal at the bedside, and jot notes about what you are worrying about. The idea is to take the worries out of your mind and put them down on paper. Think, "I can stop thinking about these issues--there is nothing I can do about them at 2 a.m. anyway. They are now in the book so I can deal with them in the daytime."
11. Your bed should be for sleep or for sex. It should not be associated with the misery of tossing and turning and not sleeping. If you truly cannot sleep and you've been awake for quite awhile, get out of bed, find a comfortable place where it would be ok to fall asleep, and read a book or magazine that is not too stimulating or exciting. Get your mind off the fact you are not sleeping.
12. Keep the one hour prior to bedtime as a protected "wind-down" period. This period should be free of work, free of stressful interactions, free of worry. Do not balance your checkbook in bed. Don't lay in bed reading your laptop and catching up with Facebook or Twitter. When laying in bed with your spouse, don't get into discussions about the stressful events of the day or family issues or finances. Consider a warm bath in the hour before bed. Consider a gentle stretching regimen before bed.
13. While laying in bed, make sure you (and your muscles) are relaxed. Starting at your toes, clench the muscles moderately for a few seconds and then let them really relax. Use the differentiation between contracting and relaxing to identify what "relaxed" really feels like. Work your way up through your legs (careful if pointing toes at the ankle--can trigger some mean calf cramps if too hard), buttocks, hips, abdomen, lower back, hands, arms, shoulders, upper back, and neck. I try to imaging that my body is gradually weighing several hundred pounds and is literally "sinking" into the bed. (Actually, I imagine I am falling asleep on a large planet where gravity is 2-3 times stronger than Earth--I am a nerd!).
Relax neck muscles as much as possible. See if your head wants to roll a certain direction. Adjust your pillow to prevent your head from rolling too far once muscles relaxed. We often maintain tension in our neck that is unconscious to prevent unwanted head movement.
Check your back teeth. Upper and lower molars should never be in contact. This suggests that you are clenching your teeth unconsciously.
14. Do not watch TV if you can't sleep. Numerous studies have concluded that TV actually increases heart rate and excitement levels and overall stimulates you to be more awake.
15. Do not nap during the day.
Medications for Sleep
Over the Counter: There are several over-the-counter (OTC) medications or supplements for sleep problems. None of the OTC meds are dangerous or habituating. Most of my patients have tried one or several of these prior to seeing me. I don't usually care if my patients try these options as they are across the board safe.
Antihistamines: Benadryl (diphenhydramine) at doses of 25 to 50 mg is the mainstay of the OTC market. Other brand names make use of the fact that antihistamines make people drowsy. Unisom and others use other antihistamines. ZzzQuil similarly uses an antihistamine. Tylenol PM and Advil PM simply add antihistamines to their product to promote drowsiness.
Melatonin: This is a brain hormone that signals to the brain the need to sleep. It is available as a supplement OTC. Doses range from 2-6 mg typically. I suggest people try it--it is safe, and sometimes works well depending on the situation.
DreamWater: this is a relatively new liquid supplement containing GABA, melatonin, and 5-HTP. I found a good review of this:
http://supplement-geek.com/dream-water-review-side-effects/
Prescription Medications for Sleep
I only consider prescription medications if ALL OTHER avenues have been exhausted. There are really only a limited number of medications for sleep. They fall into roughly 3 families.
Tricyclic Antidepressants (TCAs): These are also discussed in my post on anxiety and depression. At low doses, TCAs such as amitriptyline, nortriptyline, doxepin, and a related medication called trazodone improve sleep through an anticholinergic effect much like the antihistamines. They also increase levels of serotonin in the brain somewhat. These medications are relatively safe, not habit-forming, and can be used for years with no adverse effects other than possibly dry mouth, dry eyes, slower bowels, and some morning grogginess that usually goes away with continuing use. Trazodone is probably our most-used version--it seems to have less morning grogginess effect. Typical doses of trazodone are 50 to 100 mg at bedtime.
Ambien and Lunesta: These are relatively new on the sleep medication scene. Ambien is available generically as zolpidem, but Lunesta as of the time of this writing is not generically available. These medications are best used at low doses for intermittent use. They are potentially habituating.
Ambien should be used at as low a dose as possible, typically 2.5 to 5 mg (maximum dose of the regular-release product is 10 mg) at bedtime as needed for significant trouble sleeping. It has a common side effect: amnesia for events that occur in the first few hours after taking it. I tell my patients who start on it--"Do not do anything except go to bed once you've taken it." Patients may not make memories of events that occur within 15-30 minutes of taking the medication. For example, I have had patients take it and then suddenly realize they did not have food for breakfast the next day, so drove to the store to get groceries. In the morning, they come down to find food in the refrigerator and have absolutely no recollection of how it got there. They don't recall driving to the store or anything related to that event. This usually does not extend past the morning, but rarely it can.
There has been some new evidence that especially in women Ambien effects can "accumulate" and cause dizziness, drowsiness or cognitive dysfunction during the day after use. Because of this, the FDA has put out a warning indicating that physicians should use lower doses than previously recommended.
Lunesta works fairly similarly to Ambien. Side effects are similar. I often hear of Lunesta causing an unusual taste side effect. I don't get many patients interested in it as it is more expensive.
Both Lunesta and Ambien are potentially habituating--that is, the longer they are used, the more likely the brain is to become tolerant of the medication, and the desired effect of the medication starts to "wear off." So not uncommonly, after many months or even years on these, patients will return to me and complain that they are only sleeping for 3-4 hours then they cannot remain asleep. If that occurs, we are in trouble, because I won't increase the dose of the product.
Benzodiazepines: These were previously discussed in the post on Anxiety. These are considered medications of "last resort." The usual benzodiazepine medications for sleep include lorazepam (Ativan), clonazepam (Klonapin), and temazepam (Restoril). These have been used for decades, especially for short-term use. In fact, they are really only recommended for short-term use (typically no more than 1-2 weeks). Use beyond two weeks is associated with a significant increase in the risk of habituation. These medications quickly become tolerated by the brain, thus they quickly lose their effectiveness, requiring escalating doses to maintain their effect.
I will use this group (typically clonazepam) only if we are in a complete "bind." That is, nothing else has worked and we are at the end of the line for medication trials. If I get to this point, the medication will be monitored extremely closely. I set a limit on the maximum dose and I will not cross that line. These medications are associated with an increased risk of death from all causes. They can contribute to confusion, fall risk, drug interactions, overdose (accidental/intentional) risk--numerous potential risk issues. These risks get multiplied tremendously in older patients.
Beyond this, someone with intractable sleep problems would need to see either a sleep specialist or a psychiatrist. I have no further medications that I will or can use for sleep problems.
Other Forms of Deep-Sleep Deprivation:
Sleep Apnea: Sleep apnea occurs when a person stops breathing for long periods (several seconds) while sleeping. This causes blood oxygen levels to fall precipitously, which then triggers survival signals in the brain to WAKE UP OR WE ARE GOING TO DIE! The blood pressure can skyrocket, adrenaline levels shoot up, stress hormones crank out. The brain may actually not wake up entirely--it may just move from deep sleep into a shallower stage of sleep that restarts the breathing process, which improves oxygen levels, at least until the brain falls deep enough to sleep to start the cycle over. There are two flavors of sleep apnea: Obstructive sleep apnea and Central Sleep Apnea.
Obstructive sleep apnea (OSA) is the case where someone stops breathing because the muscles of the neck and throat relax in deep sleep (remember?) and allow the patient to block their own airway. This is usually accompanied by significant snoring. OSA has several warning signs and symptoms that we ask about:
--Is the patient observed to have persistent, consistent snoring that is not just positional or with a cold?
--Has the patient had witnessed breath-stoppage by an observer? Often a spouse will describe that while the person is raucously snoring, there will be periods of silence and lack of breathing movements. This will sometimes be followed by that spouse violently kicking and pummeling the snorer so they don't die.
--Does the patient awaken with headaches? This occurs due to the roller-coaster effect of the low oxygen levels (and perhaps the elevated blood pressures) that have occured through the night. If I have a migraine headache patient that is awakening with migraines, I am thinking obstructive sleep apnea until proven otherwise.
--Does the patient awaken in the night with a sense of choking or not being able to breath? This is pretty self-evident.
--Does the patient have a neck circumference greater than 20 inches? A heavy neck aggravates the collapse of the airway which contributes to snoring and airway obstruction.
--Does the patient have significant daytime sleepiness? People with signifant sleep apnea will report difficulty staying awake through the day. There is actually a sleepiness scale--the Epworth Sleepiness Scale--that we can use to quantify this issue:
http://www.stanford.edu/~dement/epworth.html
If my patient reports most or all of these "red-flag" symptoms, then I'll get them set up to see a pulmonary medicine specialist for a consultation for a sleep apnea evaluation, which almost always includes a formal sleep study.
If they have just a few of the symptoms, I might suggest a home "ApneaLink" study. This is a home study using a pulse-oximeter and a breathing monitor that are easy to hook up and fairly nonobtrusive. This home study will measure oxygen levels during the night, and how often the patient stops breathing during the night. From this data we can get some idea of whether or not the patient has dangerous sleep apnea or is just snoring.
Patients with true blue, full-fledged OSA usually are treated with some form of CPAP: Continuous positive airway pressure. This involves some type of mask for the nose (or mouth and nose) that constantly blows air into the airway to keep it from collapsing and blocking airflow. I know, it sounds horrendous, but it works wonders the vast majority of the time. I have sleep apnea patients who sing the praises of their CPAP machines. I frequently hear testimonials like, "I don't know why I didn't do this 5 years ago!" "I sleep better now than I have in years!" "My wife can now sleep in the same bed with me!" " I have energy I never knew I could have." "I won't even go on an overnight trip without my CPAP!"
Other treatments for OSA: Of course, the single largest factor in OSA is weight. Almost all OSA patients are obese. If we can get their weight down substantially, the obstructive process goes away. However, that takes time.
Surgery: There is a surgery that Ear/Nose/Throat surgeons can do which shaves off the back of the soft palate and removes the uvula (the hangy-downy thing at the back of the throat), and also reduces the size of the back of the tongue, and removes the tonsils if still present. Basically, everything that can be done to surgically open the back of the throat to improve air movement. Since this is a surgery that is irreversible, I view it as a "last resort" for OSA, if the person is unable to use CPAP.
Use of an oral apparatus: There are devices which are sold that are purported to keep the tongue properly positioned to avoid snoring, but I have limited experience with these. The problem is really farther down the hypopharynx than these devices can address, so I have my doubts as to their effectiveness. However, if my patient wishes to try one I'll certainly let them, as long as it works and we can prove it works.
Central Sleep Apnea: This is a very rare disorder in which the brain during sleep just shuts off breathing and blood oxygen levels fall. There are different forms and causes: medications, heart failure, brain stem injuries, and others. It is treated by dealing with the underlying cause whenever possible. Sometimes CPAP helps also.
Undiagnosed or untreated sleep apnea can have serious and even life-threatening consequences. Besides the obvious issues of the patient feeling tired all day and usually struggling with weight issues, there is an increased risk of high blood pressure, heart attack and stroke from the barrage of stress hormones released as well as the precipitous drop in blood oxygen levels. There is the significant risk of falling asleep while driving or operating dangerous machinery. We have no idea of the true numbers of traffic fatalities that have occured when a person has fallen asleep at the wheel because of undiagnosed sleep apnea.
Other weird sleep problems: There is a whole family of bizarre sleep disorders called parasomnias. Sleepwalking is the most common, and is usually seen in kids and almost always disappears around puberty. Sleeptalking is similar.
More frightening but very rare is sleep paralysis: The patient may awaken from sleep but still be unable to move or speak, for several minutes. This can sometimes be misconstrued as the person is having a stroke. There are other parasomnias like awake dreaming, where the patient is in sort of a half-awake state but still dreaming. They can have the frightening experience of not knowing if they are awake or asleep and if the dreams are real or just--dreams.
I have some patients who have "active dreaming." They move and act out their dreams by flailing or even making directed body movements, such as pummeling or hitting. I've had some terrified spouses say they were attacked by their husband or wife in their sleep. This could be intentional, I suppose, or it could be this unusual parasomnia. This problem is treatable with medication.
What I find so fascinating about sleep is why we need it. It is still not known completely why we must sleep. The really weird thing about sleep is that if you continue to deprive a person of sleep for long enough, they start to become delirious, have hallucinations, perhaps have seizures, and ultimately, they will die. Don't worry--it takes literally weeks of sleep deprivation to reach that point.
It is also fascinating to me that as we age, we don't sleep as well. My elderly patients almost across the board don't sleep solidly through the night. Increased daytime napping is a major contributor, aggravated by decreased physical activity. However, even beyond simply increased napping, older brains just don't seem to have good, consolidated sleep patterns. It was formerly thought that this was just a "normal" part of aging, and in some sense that is true. But that does not mean it is well-tolerated by the older person. The effects on the body and mind of chronic sleep deprivation are the same, perhaps worse, on an older, more frail population than on younger, more vigorous persons.
Sleep is absolutely essential to our physical, mental, and emotional health. Protecting the quantity and quality of sleep should remain a primary goal of any patient intent on promoting healthy living habits.
Lifestyle interventions--what exactly does that mean? It means, basically, living healthily. (Or, as many people say now in a way that would make my 5th grade English teacher cringe, living "healthy".)
Major disclaimer: Just because I am writing this post does NOT mean that I am some holier-than-thou-guru of lifestyle interventions. I am by no means perfect when it comes to healthy living habits. I have plenty of my own issues. I think I have an overall mostly healthy lifestyle, and I have been making improvements steadily over the course of my adult life.
Year after year, the primary care journals publish new reports and studies of just what healthy living can do. Plain old common sense tells us the same thing. Live right, eat right, and you should be healthier than if you don't.
So many of the problems I see in day-to-day practice are basically self-inflicted. The single biggest cause of self-inflicted medical problems is being overweight. Obesity or being overweight is the largest contributing factor towards hypertension, diabetes, arthritis, sleep apnea, and back problems. It is a significant contributor to depression. The second leading cause of self-inflicted medical problems is smoking.
One of the biggest political issues these days is health insurance and health expenditures. The Affordable Care Act, Medicare, Medicaid, etc. Everyone knows that we spend tons of money on health care yet the U.S. ranks 17th among the 17 wealthiest countries in the world in terms of life expectancy. We also rank near the bottom in infant mortality, injuries, homicides, teen pregnancy, STDs, HIV, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability. So many of these issues are related to lifestyle. I firmly believe that we could cut healthcare expenditures vastly if we could simply get Americans to live a healthy lifestyle. If we could get people to get their weight down before they are obese. Get people exercising, eating right, reducing stress, stopping smoking.
Obesity is insidious. The most common form of trouble I see is the thirty-something patient who every winter gains 10 lbs and every summer loses 7 lbs. This goes on for the next ten years, and the next thing they know they are 30 lbs over where they were. It just snuck right up on them. Now they are feeling overwhelmed by the fact that they are 30 lbs overweight.
It doesn't take much of a loss of control to snowball into a major loss of control. Many of the medical problems related to obesity involve a vicious-cycle effect: The weight is now up, so the person feels more sluggish, and doesn't want to exercise. They might start to have more joint pains, making exercise more uncomfortable. They may be getting depressed because they are not happy with how they look and feel.
Obviously the best way to prevent this scenario is to be vigilant about it happening in the first place. As people get on in their lives, they tend to eat more, exercise less, and their metabolism ratchets down considerably. It seems rare these days to see someone in their 50s who is at a "normal" weight.
There is some good news: In a meta-analysis study (a study of many studies) published recently in the Journal of the American Medical Association (JAMA 2013;309:71-82), it was found that people with a Body Mass Index (BMI) between 25 and 35 actually live longer than people with BMIs under 25. Not by much--about 6%, but the results were statistically significant. (My current BMI is 25.7.) It is not clear why this is so. The pattern does not continue, however. For people with a BMI over 35, their risk of dying earlier than a normal weight person goes up by about 30%.
According to this study, this means for an average 5 foot 10 inch tall male, once the weight starts moving over 235-240 lbs, the risk starts climbing. For an average 5 foot 6 inch female, weights over 200-210 lbs become risky.
The self-evident recommendation is to not let your weight creep up in the first place. I am a firm believer in weighing yourself every day, if not every few days. If the weight is slowly moving up, then take steps to get it back down while it is still just a couple of pounds. Of course, this recommendation only works for people already at an appropriate weight.
For the large percentage of my patients that battle weight problems, the answer is nowhere that straightforward. Probably one of the most difficult problems I face in my interaction with patients on a day to day basis is when they ask me, "What can I do about my weight?"
Of course, there is a flippant, off-the-cuff answer that is basically true but entirely unhelpful: Eat less, exercise more. That is the basic physics of the problem. It takes a deficit of 3500 calories to lose one pound, in most people. Therefore, theoretically, if you burn off 500 more calories a day than you take in, you SHOULD lose one pound a week. The problem comes in how you accomplish that.
It takes perhaps a good 45 minutes of hard physical exercise, with sweating and moderately hard breathing, to burn up 250 calories. On my elliptical machine, in 30 minutes of moderate resistance, I am pushing just over 170 calories. So one option that makes some sense is to exercise hard for about 45 minutes a day, and keep your calorie count about 250 calories lower than "normal" on a daily basis, to try to reach that 500 calorie a day deficit. Sounds so simple, right?
It is, in actuality, so much more difficult than that. First, it is very hard to get people motivated to exercise. I exercise regularly, but only for about half an hour a day. And I don't exercise every day--I average about 5 days a week. I try to shoot for daily, but sometimes my schedule just doesn't allow it. Peoples' schedules are often highly restrictive. In this economy, work is a priority. People have to figure out where to schedule their exercise. Some of my patients get up really early and work out in the morning. I personally prefer to exercise right when I get home from work. However, sometimes that means my family members have to delay their dinner plans for half an hour or so.
The other challenge to exercise is the transition to winter. I would say a large proportion of my patients have no problem being active or exercising during the summer and warmer weather months. However, come October/November when the sun goes down at 5:30 and the temperatures drop, all that activity ceases. I always encourage my patients to have a winter option for their exercise plan.
This is only part of the challenge to maintaining a healthy lifestyle. Under the pressures of work schedules, family responsibilities, and financial limitations, most of my patients have a great deal of difficulty trying to work exercise into their lives. The barriers to improving patients' diets are far more complex.
Dietary Habits:
Eating habits are tremendously personal. Unhealthy diet habits are as individual as each person who has them. The most common I encounter in my patients:
1. Eating on the run: "I don't have time for breakfast, and then I'm on the road and traveling from meeting to meeting, and I'm never sure when I'll get a chance for lunch so I grab a quick something at a fast food place and gobble it down." The problem here is two-fold. Skipping breakfast tends to make people very hungry earlier in the day (10-11 o'clock) so by the time lunch time arrives they are ravenous, and that drives bad decision-making as they rush through the drive-thru. Also, skipping breakfast primes the body into thinking it is in "starvation mode," so it tends to want to hold on to and save every calorie coming in, lowering metabolism and promoting fat storage.
2. Inappropriate portion sizes and meal timing: "I gotta have my big plate of meat and potatoes for dinner, then I park myself in front of the TV until I go to bed." Our general tradition in western civilization is metabolically backwards. Breakfast should be the most substantial meal of the day. Instead, many of us downplay breakfast, have a substantial lunch and our "main meal" of the day is dinner, just as we are becoming inactive prior to going to bed.
Metabolically speaking, the evening meal should more appropriately be sort of a healthy snack. Portion sizes are a (no pun intended) huge issue. People routinely over-estimate an appropriate portion size. Studies show that obese people have a significantly inflated estimate of what an appropriate portion size is compared to non-obese people.
3. We eat not because we are hungry: "I love going out with friends for drinks and dinner." In our society, eating and food are important parts of a social culture, not for nutritional sustenance. Many overweight people admit that they eat not just when they are hungry. In fact, many people with weight problems cannot clearly recognize when they are satiated. I don't mean gut-busting, bloated, unbuckle-your-belt stuffed, but merely no longer hungry. It takes about twenty to thirty minutes during eating to allow blood sugar levels to come up and levels of satiety hormones (such as leptin) to rise to a point where the brain can say, "I'm not hungry anymore." So when we sit talking to friends over a multi-course meal, paying attention to the social interactions and not to our level of satiety, we keep eating even when we are no longer hungry.
The whole "psychology" of the multi-course meal is designed to subvert the normal physiology of replenishing needed nutrients. We start with a salad. Most people don't "love" salads. But because we are "starving," we are willing to eat something that isn't really super appealing. After our salad, we are a little less "starving," but still reasonably hungry, so the entree is served. It is often very appetizing, with a standard protein, starch, and vegetable typically (and usually a high fat content which pleases the palate), and we finish it off. Now, if this has taken a good 20-30 minutes, we probably aren't hungry AT ALL anymore. But now there is that wonderful sweet dessert calling to us. Humans have such a desire for sweets that our craving for them usually completely overpowers our sense of satiety. So here comes another 300 calories that, had we been in a non-social setting, wouldn't have even been considered.
Adding alcohol to the mix just increases the calorie intake, and not just because alcohol has 7 calories per gram. (Protein has 4 calories per gram, carbohydrates have 4 calories per gram, and fat has 9 calories per gram.) Alcohol dramatically dulls our sense of satiety, allowing us to pig out even more.
4. Convenience eating: The healthiest foods to eat are fresh and unprocessed. Fruits and vegetables straight from the produce section. Meats straight from the butcher section that haven't been meddled with (such as processed into sausage). Whole-grained breads straight from the bakery or even better home-made. Keeping it simple reduces the addition of excessive salts, preservatives, and hidden fats and oils. Pre-packaged, pre-prepared, and pre-processed "convenience" foods in cans, jars, freezer packages, and boxes tend to reduce nutritional components (with the exception of frozen vegetables) and add unnecessary components. (And adds to packaging waste, if you're trying to remain "green.")
5. Habit-eating: "If I'm watching a movie at night, I gotta have a bowl of ice cream." The human brain loves associations. Movie = snack and relaxation. My wife and I are guilty of this. If we are watching a great movie in the evening, feeling all relaxed, we'll usually have a couple of cookies and a glass of milk. Or sometimes some parmesan crackers (those little Pepperidge Farm crackers shaped like goldfish). Sometimes both. It is just our "habit." We may not really even be hungry. We just associate that pleasure of movie + food. Sometimes I think the Superbowl is just an excuse to eat tons of chips, dip, sausage, tacos, shrimp cocktail, barbecue chicken wings, deviled eggs, beer, soda, popcorn...the list goes on. You see my point.
It seems to me, that if we changed our diet habits to the following, we'd be much more likely to not be overweight and unhealthy:
Eat a balanced breakfast consisting of some protein (dairy, egg, yogurt, cheese), and some carbs (whole grained toast or oatmeal), with some fresh fruit. Mid morning have a small snack of some fruit, a couple of whole grained crackers and a low calorie beverage (not a Venti Mocha). At lunch, a salad, soup or sandwich with an apple or banana or another yogurt. Perhaps a small piece of dark chocolate to reduce those sweet cravings. In the evening, a healthy "snack"-like dinner--perhaps tuna salad on whole grained crackers or single slice of whole grained toast. (Dinner is the real hard-core creativity challenge.) Snacking late at night, if allowed at all, should be non-carb snacking.
If you eat out, do not drink alcohol prior to the meal. Order only from the appetizer menu, avoiding things with creamy or cheesy sauces. If order from the entree menu, split it with a friend or divide it in half and take half home. Eat slowly. Put your fork down after every bite. Listen to your satiety center. Never order dessert unless sharing it with at least three other people at the table. Never eat at "all-you-can-eat" buffets.
So, healthy eating is not overly-difficult, it is just hard to adhere to. We've known for decades that "fad diets" don't work. The way you eat has to be something you can live with every day. Healthy eating habits have to be second nature. You shouldn't have to even think about it. It certainly should not feel like "work." It should not make you feel different or deprived. Combining healthy eating with reasonable efforts at daily or every-other-day exercise (again, where it gets to be second nature, just a part of your every-day routine) is the goal.
I counsel my patients who are truly serious about losing 40-60 lbs with the following advice that I've gleaned from 25 years of observing who in my practice actually does lose weight:
Part 1: Gradually move your exercise up to a goal of 1 hour of hard, sweating, breathing hard, aerobic exercise at least five days a week (and encourage some additional resistance work-outs also). The exercise needs to be fool-proof. No excuses such as the weather, boredom, inconvenience, or cost should be possible. So make your exercise plan work so that none of those excuses can derail you. If you are over 45 or have significant heart disease risk factors, we should consider doing a stress test first to make sure your heart can handle it.
Part 2: Join Weight Watchers with a friend. Weight Watchers is one of the most successful commercial weight loss plans out there. Their methods are psychologically sound, scientific, and proven. I have seen Weight Watchers members lose 20-60 to even 80 lbs and keep it off for years (if not for good) using their methods. (I have no ties to Weight Watchers--I don't own stock in them that I know of, and I get no kickbacks by referring patients to them.) A year ago, US News and World Report published an article reporting on a survey of various types of medical specialists from across the country and their preferred dietary recommendations for weight loss, high cholesterol, diabetes, and other conditions. Weight Watchers was in the top 1 or 2 across the board. Joining with a friend simply serves to provide you with potential "moral support" and someone who might be able to kick your butt to work on the program even if you are temporarily not self-motivated.
Part 3: Realize this is going to be really, really difficult. Probably around 95% of people who start out on this path will fail. You will have good weeks and bad weeks. You will get discouraged. You must not give up. It will be slow. Ideally no more than 1-2 pounds a week. You must make the changes in the way you live your life, and not look at it like a temporary means to an end. Have your radar up for excuses and rationalizations. They are your enemy. If you start making excuses for why you can't exercise, it is the beginning of the end. A slippery slope that just begets more excuses until you are back to your old unhealthy lifestyle again.
Life Balance:
Another major component of a healthy lifestyle is "balance." By that I mean balance between work and pleasure, work and family, outside commitments and time for self. Yes, there are only 24 hours in a day, so you have to budget your commitments wisely. Is it appropriate to take life balance advice from a physician? Do I practice what I preach? I think I do, most of the time. It is a constant battle, but I try to.
I work 4 twelve-hour days, and about 3-4 hours a week working at home on the computer. I try to get about seven hours of sleep each night. Of my four hours of "free time" on work days between coming home and going to bed, I spend half an hour exercising, half an hour to an hour preparing and eating dinner, and another two to three hours "unwinding:" watching TV with my wife, playing guitar or piano (a hobby), writing this blog, processing photographs (another hobby), drawing (another hobby) or reading.
On the days I don't work, it is a hodgepodge of running errands, keeping up the housework (or at least trying to help my wife with the "honey-do" list), seeing friends, attending to the activities of family members, and keeping up with the aforementioned hobbies. I admit my favorite cold-weather activity in the morning is laying lazily in bed with my wife and our dogs just talking, then fixing a nice leisurely breakfast (I love to cook).
I have to fight to resist the efforts of other competing causes to usurp my time. I could easily volunteer for more committees and causes. I could easily guilt myself into constantly reading up on medical issues and continuing medical education. There is always "more I could do" as far as work goes. However, I have seen burnout and stress creep into my life from time to time, and it makes me far less effective as a clinician and far less responsive to my patients.
When I am asking my patients about their "social history"--their work, their lives, their smoking and drinking habits, their kids, their routines--I always ask about hobbies and what I call "passions." I firmly believe that people should have some type of passion in their lives. It might be sports. It might be their kids or grandkids. Maybe it is quilting. Maybe it is volunteering at the animal shelter. Maybe it is their job (I have a lot of patients who truly love their jobs!).
Unfortunately, I have too many passions: my wife, my family, outdoor photography, off-road jeeping, music, reading, science, antiques, medical history. Prior passions included rock climbing, flying and sailing. (I gave up rock climbing when I got married and had kids. I gave up flying because it was too expensive and sailing because I no longer live near a sailable body of water).
Without a passion, life becomes drudgery. Hobbies, interests, and passions give people motivation and a source of rejuvenation. When I am deep in my photography work or playing the piano, time stands still and I am unaware of any other issues/problems/troubles, if only temporarily. Most athletes describe the same sense when they are participating in their sport.
Women much more than men tend to feel guilty about taking time for themselves. "A woman's work is never done." There is always something you could be doing. But equally important, I think, is the rustic adage, "If mama's not happy, nobody's happy!" Women, wives, mothers, girlfriends--whatever, are going to feel more positive and fulfilled if they carve out of their schedules at least a little "me time."
One of the most common complaints I hear from women in my practice is, "I do everything for everybody else, and never feel appreciated," and, "I never have time for myself." I urge them to rationalize taking time for themselves from a positive mental health standpoint. Go to a day-spa for a massage, go to a movie with a girlfriend, turn off the phone and take a long bath, take an hour to curl up with a great book and tell everyone to leave you alone.
In the spring and summer my wife will plug her earbuds into her iPod and work out in the yard, listening to Linkin Park and Evanescence (among others). She'll be rockin' out, gardening for hours until it gets dark. She has told me and all family members that she is NOT to be disturbed, even if a phone call is for her. This is her rejuvenation time--she LOVES it.
It is important to guard against over-commitment. That includes over-committing the kids. Over-commitment of children is really a topic for another post, but the point is: if you commit yourself to too many activities and responsibilities, you'll soon have no time to yourself. Even if the activity is something you enjoy, if it sucks up too much of your time, you will start to resent it. Especially if it demands your time out of your control.
It is important to watch out for what I call the "over-commitment spill-over effect:" You commit to some cause, that then demands more of your time, which then takes you away from responsibilities to which you previously attended. You then have to have others (family members/friends) take over those things that you used to do, simply because you no longer can. It may be fine if you asked the family member/friend if they mind taking over and they agree. However, if your overcommitment is now impacting other peoples' schedules and lives, you will be engendering resentment among those who now have to fill in the gap.
Vacations: I am a huge fan of vacations. I usually ask my patients during a physical if they take their vacations. An amazing number of Americans DON'T use their vacation time. Yes, when I go on vacation it sometimes barely seems worth it--I have to work harder before I leave to get everything tidied up, and when I get back there is a MOUNTAIN of unfinished work I have to catch up on. But I still feel it is worth it. I used to take only week-long vacations, but always came back feeling like I didn't really feel like I got away. I now make it a point to take at least one full two-week vacation in the summer. Usually by the beginning of week two I finally feel the weight of work starting to fall away.
I enjoy planning vacations almost as much as I enjoy vacations. As soon as I'm home from a vacation trip, I'm on line researching our next getaway. I have tried the concept of the "stay-cation." But it was too easy to just get into the "daily grind" of home chores and mundane stuff. I really think we need to get out of our usual environment for a vacation to have more of an impact.
Obviously, vacations can get expensive. In my younger days, though, I'd pack a kid or two into my Subaru Outback along with a bunch of camping gear and we'd car camp for days at a time, or spend an occasional night in an inexpensive motel just to get cleaned up. Those were pretty cheap trips, made a lifetime of memories, and were tons of fun. Anyway, the point is, get out of town!
Achieving balance in life is a goal, not always attainable all the time. It is a target to be aimed for. Mostly, be aware of the inner feelings that can signal your life is getting out of balance. Not sleeping as well, feeling sluggish, losing energy, not looking forward to things...hmm, sounds like the same list of symptoms of mild depression. Sometimes you have to shake things up a bit. Take time off, travel, go out on a date with your spouse, take a class from the community college in something you've always been interested in. Adopt an animal from the Humane Society.
Enjoy your life! It is the only one you've got.
Anxiety and depression are extremely common problems addressed by any primary care physician. I've seen data indicating that by the year 2020 mood disorders will be the number one disabling medical problem in this country (currently arthritis and back pain are the leaders). Fully a third of all my office visits are directed at the diagnosis and management of anxiety and depression.
Anxiety is much more common than full-fledged depression. Anxiety is usually manifest by a sense of constant worry--the patient just feels they can't stop thinking about things that stress them. They'll often awaken in the night and be unable to sleep because their minds "just won't shut off." They'll find themselves having difficulty relaxing, or finding pleasure in previously pleasurable activities, because they can't let themselves stop processing their worries.
Anxiety can have many forms: Social anxiety disorder is a variation where the patient becomes very uncomfortable in public situations where the patient might have attention of strangers drawn to them. They fear being judged or criticized. Other common forms of anxiety include the various phobias such as fear of flying or claustrophobia--there are many variations on this theme. I have patients who fear driving in bad weather to the point of being unable to drive if there is even the threat of bad weather. Of course one of the most intriguing forms of anxiety is Obsessive-Compulsive Disorder, where patients develop ritualistic behaviors that they feel compelled to do often over and over. Somatoform anxiety disorder is when anxiety morphs itself into recurrent and often unrelated physical symptoms--headaches, abdominal pain, back pain, tingling, numbness, nausea, etc.
Most forms of anxiety, however, are more generalized and "free-floating." Patients just don't feel like themselves. They can begin to feel overwhelmed. They can feel as though they have no tolerance for any further frustrations or stressors. They are often "fed up!" Like they are on their "last nerve." This can some times lead to them blowing up over small issues, or what I call "flying off the handle." The anxious patient may find themselves feeling unusually over-emotional--"emotional overload."
Of course, many patients develop anxiety due to life and situational stressors--a divorce, the loss of a job, financial stressors, ill family members requiring care. However, some patients simply are "wired" to be more anxious even without unusual life stressors.
I think of anxiety as the result of being constantly bombarded by perceived threats--whether real or imagined. Threats of job loss, financial ruin, loved ones in trouble, loss of quality of life. These constantly-perceived threats sort of soak the brain in adrenaline (epinephrine) and other stress hormones. Anxiety has an evolutionary benefit--if you were a paleolithic human it served in your best interest to keep a constant guard out for an invading hoard from the next valley, or a marauding saber-toothed cat. We had to keep ready to fight or flee at a moment's notice. There was a survival advantage to the brain being hyper-vigilant.
Anxiety can certainly be hereditary. I have several families in my practice where I have three generations of the family and all are treated for anxiety. However, there is also a sort of classic personality type that is particularly prone to anxiety: It has been given the acronym of SICK: S--Sensitive, I--Intelligent, C--Creative, K--Kind.
Patients who are sensitive tend to be empathetic--they feel and are aware of the emotions of others close to them. They may even sympathetically take on those emotions and can find them overwhelming.
Intelligent people tend to be more analytical--in their life experience, they have found that they can solve problems by teasing them around in their mind and coming up with a solution. However, with many of the stressors of daily life, there is no "solving the problem" and the person simply keeps thinking about the stressor in a cyclic fashion, getting nowhere closer to solving the problem.
Creative people tend to be imaginative--so when presented with some type of stressor, their imaginations can take them quickly to the worst-case-scenario. They play out the issues to ridiculous degrees and consequences even if they are not realistic. So that stress-related headache becomes a brain tumor, and that stress-related stomach ache becomes colon cancer.
Kind people generally don't want to "rock the boat." That is, they don't like confrontation and don't want to be the center of attention. They don't want to hurt other people's feelings. So that means they don't let their emotions out, or discuss how they feel. They generally just "swallow" their own emotional pain and hope it disappears. But of course, instead, it usually just festers.
Combining all these personality qualities into one person puts that person at significant risk for anxiety and depression.
Many people find ways to self-treat. Sometimes self-medicate. Many males often start to use alcohol more frequently. Females are more likely to seek help from friends, family or physicians. When discussing stress, physicians think in terms of systems: If you have any kind of system--a human being, a family, a business--and apply some type of stress to that system, there are two types of responses that system can make to recover: Adaptive responses are reactions to stress that reduce the stress and its effects in a way that promotes the well-being of the system (person, family, etc). A maladaptive response might initially reduce the effects of the stress, but in the long run makes the problems worse.
For example, a business in financial dire straits might have its accountant "fix the books," which might temporarily help, but in the long run screws things up in a major way. Similarly, if an anxious person starts drinking, they may temporarily reduce their anxiety in a haze of alcohol, but as they become addicted, an entirely new set of problems arises. Other frequently-encountered maladaptive responses to stress can be verbal abuse--"exploding" at others which can get others to back off and leave the stressed person alone, or isolation--shutting one's self off from society so that interaction is prevented. Bullying is also a maladaptive response to stress--the bullier is anxious or stressed and finds that by attacking others, they gain some temporary power and attention that reduces the effects of their own stress.
Adaptive responses to stress are many: Obviously, addressing the stressor and dealing with it to fix it or "make it go away" is an appropriate response. A supervisor is making life difficult for a worker. The worker seeks redress through their union or through Human Resources and gets relocated to a new position and the problem goes away.
Other adaptive responses to stress can be exercise--exercise burns off excessive adrenaline that builds up from persistent stress, and releases "feel good" neurotransmitter chemicals like endorphins and dopamine that can fight the effects of stress. I really cannot over-emphasize how effective exercise is in the treatment of anxiety.
Counseling is an exceptionally good adaptive response to stress. It allows the patient to learn new coping strategies, relaxation techniques, new ways to think about stressful issues in a more positive light, and ways of reducing the tendency toward "worst-case-scenario" thinking. The wonderful thing about counseling is that it teaches the patient new skills they can use for the rest of their life to counter anxiety-provoking vicious cycles of thinking. Unfortunately, counseling is somewhat cumbersome in that it requires moderately frequent office visits, and sometimes one patient may not "hit it off" with a specific counselor just due to personality quirks. Not uncommonly, the phenomenon of "projection" can be a problem--the counselor may remind the patient of their troublesome supervisor at work, so that a healing/trusting relationship is simply impossible. However, counseling in general is probably one of the most effective interventions for most types of anxiety.
The last resort in the management of anxiety is medication. There are two basic groups of medications for anxiety. For intermittent, occasional anxiety episodes such as acute anxiety or panic attacks, medications such as alprazolam or lorazepam can be prescribed. These belong to a family of medications called benzodiazepines (BENzo-die-AZ-uh-peens). They have been around for several decades. Unfortunately, they are potentially habit-forming and patients can develop a tolerance to their effects over time. I'm sure you have heard of Xanax (alprazolam) and Ativan (lorazepam) and Valium (diazepam).
The ideal use of alprazolam, a fairly short-acting benzodiazepine, would be when a patient uses it only during times of an impending anxiety attack or panic attack, to get quick relief from the attack--using it only once in awhile, no more than every few days. It is unlikely to become habit-forming when used rarely and intermittently like this. Benzodiazepines become potentially more worrisome if used regularly on a daily basis. They can sometimes cause confusion (more likely in older patients), increase the risk of falls, cause drowsiness, and can dramatically amplify the effects of alcohol.
I never use benzodiazepines as a first-line choice for the medication management of anxiety EXCEPT for situations that clearly indicate a rapid-response medication for only occasional use. For example, the patient who starts to get very anxious while flying, who will only rarely use it. I also warn patients who might be given a prescription for "as-needed" alprazolam to NEVER use it as a sleeping medication, as it can quickly become habituating if used frequently for sleep.
Our mainstay of medication management for anxiety is the family of medications called SSRIs--Selective Serotonin Reuptake Inhibitors. There is good scientific evidence that at least a large percentage of patients with anxiety have lower than normal amounts of serotonin in key parts of the brain. In parts of the brain that help dictate emotional responses, serotonin is a neurotransmitter--that is, it is a chemical that is essential to maintain the communication between brain nerves (neurons). Without adequate levels of serotonin in the physiologic gaps between neurons, the electrical signals that help people feel calm and relaxed and "warm and fuzzy" simply die out--the signals fade away and don't continue. Therefore, using medication that increases the amount of serotonin in those gaps--SSRIs--helps keep the signals strong and ongoing.
SSRIs came on the scene in the late 1980s--I'm sure everyone old enough remembers the "Prozac Revolution." Prozac (fluoxetine) was the first, and became a household name, and the subject of a lot of controversy. Prior to this time, we didn't have many good, safe medications for anxiety. So Prozac prescriptions were being written right and left. Despite the nay-sayers and the jokers, Prozac and its subsequent siblings have been just short of miraculous in helping reduce the burden of suffering from anxiety.
After Prozac came Zoloft (sertraline), then Paxil (paroxetine), then Luvox (fluvoxamine), then Celexa (citalopram), and then Lexapro (escitalopram). These all fell into the category of SSRIs. They all had some relative differences in side effects, which gave us physicians a nice array of options to select from to try to custom-tailor medication to our patients situations. The nice thing about SSRIs is that they are NOT habit forming, and they are not prone to significant overdose risk.
Common side effects of the SSRI family include initial low-grade headaches, sometimes mild nausea or dizziness, vivid dreams, increased sweating, looser bowel movements, and sometimes sexual side effects such as a lowering of sex drive and sometimes a change in the sensation of orgasm. Most of these side effects are very minimal and tend to improve with time as the patient adapts to the medication. There is a "Black Box" warning on all SSRIs mandated by the FDA: When used in persons under the age of 25, there can be an increased risk of suicidal thoughts. This is very very rare, but we take it very seriously and I always warn my younger patients about this issue.
Each of the various SSRIs tend to have some variations in side effects--sometimes predictable, but often not. I find that fluoxetine (Prozac) tends to be a little more stimulating and less likely to cause fatigue than say, citalopram (Celexa) or escitalopram (Lexapro). I tend NOT to use paroxetine (Paxil) very often as it can be harder to "wean" patients off of it if they want to come off. I also have found that many patients I've seen on paroxetine seem to just be overly complacent and "too laid back."
If I do start a patient on an SSRI, I always start with half the long-term maintenance dose, to sort of "break it in." That is, for example, if I intend for the patient to be on 50 mg of sertraline (Zoloft), then I'll start them on 1/2 tab (25 mg) each morning for 7-10 days to minimize side effects and let them get used to the medication before increasing to the full treatment dose. If they do experience side effects on the 1/2 dose, usually they are minor and settle down and go away over the break-in period, so that when we move to the full treatment dose, the patient does not experience excessive side effects (hopefully). I always ask my patients to call if they experience any problem side effects, especially if they feel they are not tolerable or settling down with time.
The positive effects of the SSRIs should become evident within a week or two of getting up on the maintenance dose. Most commonly, patients report that they are just handling stressful issues better. They often indicate they are not entering into "cyclic worrying" patterns of thinking. They say they "bounce back" after major stressors without feeling overwhelmed. I've heard patients use the analogy of "water off a duck's back" relating their ability to shed stressors and keep functioning.
Of course, I always want to make sure that the positive effects of the medication outweigh any negative side effects. I always schedule follow up visits pretty frequently at first when a patient is starting out on an SSRI so that we can keep tabs on side effects and positive effects, and make sure we are moving toward our goal. Sometimes I'll find that the patient is not responding as we'd like, or is having too many side effects. In that case, we'll discuss a change of medication--possibly to a different SSRI. But I will ALWAYS mention the other nonpharmacologic interventions: life-stressor adjustments, exercise, and counseling.
Other medications:
There is another family of prescriptions medications we will consider in the management of anxiety: the SnRIs. These medications work not only on increasing serotonin levels, but also increase norepinephrine levels. Norepinephrine is another but different neurotransmitter in the brain associated with anxiety and depression.
Examples of SnRIs are venlafaxine (Effexor), Cymbalta, Pristique, and Savella. Venlafaxine is, as far as I know, the only SnRI that is available generically. SnRIs have a slightly different side effect profile from the SSRIs: they can sometimes cause a little more dizziness or nausea, dry mouth or eyes, slower bowels, and more interrupted sleep. However, they tend to have fewer sexual side effects and less tendency toward fatigue when compared to SSRIs.
I always tell my patient that "they are in charge." That is, THEY are the one to decide if the medication is helping or not. THEY are the one to determine if side effects are tolerable or not. THEY are the ones who determine if they are going to remain on the medication. I point out that eventually, if things are going well and symptoms are well controlled and stressors are resolving, we can consider trying to reduce the dose and even come off the medication slowly. Once off the medication, if symptoms remain gone or controlled, then it is completely acceptable to remain off the medication. We know we can always consider it as an option again "down the road" if need be.
Depression:
Depression and anxiety are often, but not always, related. Depression is often described as a feeling of dark, negative mood. Patients who are depressed often do not want to do ANYTHING. They don't want to socialize. They don't want to work. They don't want to exercise. They can't concentrate. They often don't even want to get out of bed. They may cry a lot, but not necessarily. They often have thoughts of suicide--maybe not a particular plan, but may just think that if they were dead, at least they wouldn't be as miserable as they are now. Nothing has any positive value. They become a "shadow" of themselves.
I view depression as a state of brain "burn-out." Often depression comes on as anxiety burns itself out and the brain just cannot process anything anymore. The mind can no longer face the challenge of coming up with "mental energy" to make it through the day. It is a chronic mental energy crisis. Depressed patients are often apathetic, ambivalent, sometimes emotionless. They can see nothing positive, even if positive things are all around them. A. A. Milne, in his Winnie the Pooh characters, created a perfect example in Eeyore, the blue donkey. No matter how nice a day it was, Eeyore could see nothing but negatives everywhere.
The mental anguish and pain of the depressed patient can never be overestimated. Unfortunately, to most people who have never suffered from depression, the day-to-day agony of the depressed patient is hard to understand. You really have to imagine how severe the suffering of someone can get when they actually start to favor death or non-existence to carrying on the same way day after day.
Depression is treated in somewhat the same way as anxiety. However, there is an even greater urgency to treating severe depression. Most patients, fortunately, have only what we call mild-to-moderate depression. We start with the same interventions: exercise, counseling, and medications. It is very hard to get a depressed patient motivated to exercise, however. Counseling can be very helpful, but takes time. I will almost always move forward with initiating medication for a depressed patient.
The SSRIs and SnRIs listed above are all excellent first line options in treating depression. There is also another medication that can be very useful for depression, called bupropion (trade name Wellbutrin). Bupropion is the only member of its class--it helps restore norepinephrine neurotransmitter levels in the brain. It can, within 2-3 weeks, help elevate mood and improve motivation and "mental energy."
Bupropion's side effects can be dry mouth and dry eyes, changes in sleep quality, excessive stimulation, tremulousness, slower bowel activity, headaches, and nausea. It generally does NOT cause sexual side effects or weight gain. If a patient has a history of seizures, they cannot take bupropion as it can lower seizure "thresholds" and make them more prone to have a seizure.
Other medications are also effective against depression. Since the 1970s, medications called "TCAs" or "tricyclics" have been used. These are medications such as amitriptyline, nortriptyline, doxepin, and others. Trazodone is a closely-related medication. TCAs can be just as effective as SSRIs, SnRIs, and bupropion; however, the TCAs tend to have perhaps more side effects and are more hazardous in overdose situations.
If after several weeks of trials and adjustments of the above medications are not working, then we have a major challenge. I will sometimes consider the addition of certain types of stimulants if a person is not improving adequately on a "first-line" antidepressant. Sometimes adding a mood-stabilizer such as lamotrigine (Lamictal) or Depakote will help stabilize mood or improve it.
The other important point is to make sure that the patient is not doing anything to subvert our efforts: recreational drug use and alcohol can virtually render prescription medication powerless to treat depression. Chronic sleep deprivation due to other problems such as sleep apnea can aggravate depression. Hypothyroidism and other metabolic dysfunction can aggravate depression. I try hard to rule those problems out at the very early evaluation of a patient presenting with depression, but sometimes patients are less than forthcoming about certain things, especially alcohol and drug use.
If these further efforts are not working, and we've exhausted all our other options such as counseling, then it is time for a referral to a Psychiatrist. There are other medications available such as Abilify and others, but I don't feel comfortable as a Family Practitioner managing them.
I always explain to the patient that if, despite our best efforts, depression symptoms are worsening and the patient is starting to seriously contemplate ending their life, then they MUST seek care through the Emergency Department. (In McLean County, IL, that number is 211 or 1-800-570-PATH (7284)).
I feel that the vast majority of patients coming in to see me or my partners for anxiety or depression see significant improvement within a matter of a couple of months, if not sooner. However, it takes honesty on the part of the patient when explaining symptoms, life issues, and health history for the physician to try to come up with a "best-fit" plan for treatment. It may take a few trials of medication adjustments to fine tune things, but usually we can custom-craft a plan that works.
Sleep initiation disorder: There are some patients who come to me complaining that they just can't fall asleep. They lay in bed, wide awake, tossing and turning and getting frustrated. They'll tell me that once they do get to sleep, they are fine and stay asleep fine. They just can't get to sleep in the first place. 
5. NEVER look at the clock. It instantly sends a jolt of adrenaline through your body and brain, making you anxious and waking you up. You are either thinking, "I can't believe I'm still awake," or, "I've only got 2 more hours before my alarm goes off." 
11. Your bed should be for sleep or for sex. It should not be associated with the misery of tossing and turning and not sleeping. If you truly cannot sleep and you've been awake for quite awhile, get out of bed, find a comfortable place where it would be ok to fall asleep, and read a book or magazine that is not too stimulating or exciting. Get your mind off the fact you are not sleeping. 
