Link Between Sleep Disturbance and Suicide

Editor's note:  Below is another guest blog post. 
Here is a link to the actual journal article being discussed: http://www.ncbi.nlm.nih.gov/pubmed/21886352.
There has been a lot of research looking at the relationship between insomnia and depression.  Insomnia does appear to be a risk factor for depression, but it is difficult in these population-based studies to definitively demonstrate a causal relationship.  The fact that insomnia is one of the symptoms of depression makes it especially difficult.  The article being discussed looks specifically at suicide.
Michael Rack, MD
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Lack of good, solid sleep on a regular basis has been recognized by doctors as a risk factor for increased health problems for many years. For example, presence of untreated obstructive sleep apnea (OSA) greatly raises the risk of cardiovascular disease, stroke and premature death. More recent studies have established a link between insomnia and increased risk of suicide. This isn’t completely surprising, given that almost everyone has experienced a sour mood after a poor night of sleep. One can begin to imagine how it would feel for this to go on and on for months or even years.

The question of sleep quality and suicide is a difficult one to approach, and not just because of the emotional nature of the topic. Many studies have found such an association, but they were unclear about cause and effect, especially as depression and/or anxiety were also often involved. It has therefore been uncertain if poor sleep and suicide were, for example, two separate effects of depression or anxiety, versus there being a direct link between lack of sleep and taking one’s life. After all, depression and anxiety are risk factors for both poor sleep and suicidal thoughts and actions.

The newest study does a better job of teasing out the separate variables involved in sleep quality and suicide. The results suggest that even when depression and anxiety are factored into the analysis, people who slept poorly were still more likely to think about, plan, or actually make attempts at suicide. This was possible because tens of thousands of people were considered in the study, and this included many depressed or anxious people who were not bothered by poor sleep. Depressed and anxious people who managed to sleep fairly well were much less likely to commit suicide than similar folks who reported poor sleep.

The study was conducted in Norway, where extremely detailed records are kept of peoples’ health histories as well as all causes of death. Another aspect of the study that gives it significance is that there was a “dose-response” relationship – a term borrowed from tests of medications – between worse sleep and greater likelihood of suicidal thoughts, plans or actions. People who indicated they had poor sleep ‘almost every night’ had significantly more suicidal thoughts and actions than those who said their sleep was poor ‘two or three nights a week’ or ‘once a week of less.’

This most recent study comes on top of many others in the past decade or more that hinted at the same conclusion. While some of those studies were small or had other weaknesses to them, the Norwegian study corrected for virtually all such faults. The study was published in the peer-reviewed medical journal Sleep. It was accompanied by an editorial by Dr. W. Vaughn McCall, a sleep expert at Wake Forest University Health Sciences Center in Winston-Salem, NC. He noted that the cumulative studies on this topic had been done with many different populations of people, both old and young, and concluded bluntly, “The time has come to recognize insomnia as a risk factor for suicide, and to include it in the list of potentially modifiable risk factors.”

This study and the ones preceding it have practical ramifications. Dr. McCall urged doctors to ask more exploratory questions of those patients seeking sleep aids, to determine if there are signs of depression or actual thoughts of suicide that deserve treatment along with the insomnia complaint. As for the average person, those suffering from insomnia should make all reasonable attempts to sleep better, whether by getting more exercise during the day or by visiting their doctors to discuss their sleep problems.

Sometimes getting a better night’s sleep involves only simple behavioral changes, such as not exercising or watching TV right before bedtime. In other cases, a short-term course of medication, perhaps with some counseling sessions, may be in order. The outcome of such interventions may go well beyond simply giving someone a better night’s sleep, to actually having a life-saving effect.

SleepDisorders.com is an informational portal helping to educate sleep disorder sufferers and connect them to doctors in their area.

Sleep Apnea – NOT for Men Only!

Below is another guest blog post.  One clarification I would like to make to the guest articleby Alex Smith is that the increased frequency of night-time urination seen with OSA is often due to increased urine production (for an explanation, see http://www.thoracicandsleep.com.au/latest-news/115-obstructive-sleep-apnoea-osa-and-urinating-at-night )

Michael Rack, MD
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Doctors and patients alike are beginning to realize that sleep apnea in women is more common than previously thought. Men remain statistically more likely to develop obstructive sleep apnea (OSA), but instead of a ten-to-one ratio of men to women, it’s now thought to be three- or four-to-one. At the same time, women also remain more likely to have sleep apnea misdiagnosed as something else, such as chronic fatigue syndrome, depression or simple insomnia. 

OSA occurs when the soft tissues of the throat and at the back of the mouth become overly relaxed at night, to the point where one’s airflow is blocked upon breathing in. This results in a few seconds of not breathing, which may be evidenced by snoring or gasping for breath during one’s sleep, followed by daytime sleepiness. Though women with OSA may have these signs, they seem to appear more often in men. Women with sleep apnea may notice their mouths being very dry in the morning. They may also begin to wake up more often during the night with the need to urinate. This is not due to any real increase in urine production, but because the partial waking that often occurs in OSA allows a person to notice the state of their bladder more than when they are sleeping soundly.

The risk for OSA increases as a woman ages and it is sometimes said that menopause increases the risk for it. However, here again, appearances may be deceiving, with menopause getting the blame for simple changes in soft tissue tone that come with aging. Another risk factor for OSA in women, just as in men, is being overweight or obese. This is simply due to the increased thickness of throat tissues that begin to accumulate fat cells. In some studies, as many as 80% of obese women screened for sleep apnea were found to have the condition. It can also flare up due to the weight gain of pregnancy. Drinking alcohol before bed time also increases the likelihood of OSA, as does smoking.

Though women are still a bit less likely than men to have OSA, it unfortunately appears that their risk of mortality from it is greater than in men. The reason for this is not clear, but it seems to be especially true in regards to heart and circulation problems, i.e., decreased cardiovascular health. It was recently reported that OSA increases the risk of developing so-called ‘soft’ plaques in atherosclerosis (hardening of the arteries), which are more likely to come loose from blood vessel walls and form an embolus, blockage of an artery or vein.

If a woman has sleep apnea, especially if she is overweight or obese, she has a greater risk during pregnancy of developing the life-threatening condition called pre-eclampsia, or of needing to deliver her baby by caesarian section. Since pregnancy itself somewhat raises the risk of OSA, this seems a real life case of double jeopardy! A pregnant woman may also be more apt to attribute daytime sleepiness or fatigue to simply carrying a baby, rather than to other possible causes.  

For all these reasons, it is especially important for women to know that they, too, are at risk for sleep apnea. If there are signs of dry mouth, excessive daytime sleepiness, or any reports from her partner that she is snoring, a woman should not hesitate to ask her doctor if she might have sleep apnea. It is diagnosed definitively by performing an overnight sleep study at the hospital. Because OSA can have serious health repercussions if left untreated, insurance companies typically cover both the sleep study and the therapy the condition requires if found. Women and men alike thus have nothing to lose with a sleep study, and may also gain a much better night’s sleep for their efforts.

Guest article by Alex Smith of SleepDisorders.com.

Oral Appliances or CPAP, Which is Better?

The following is a guest blog post, see below this article for my thought on the issue:

Devices that provide CPAP, or continuous positive airway pressure, are often considered the “gold standard” of treatment for obstructive sleep apnea. After a sleep study is conducted and sleep apnea is diagnosed, a sleep specialist will typically prescribe CPAP machines and masks as the first line of treatment. Though the sleep disorder solution may be a blessing to many, others may find the device loud, restrictive and ineffective in getting them a better night’s rest. For patients who do not tolerate CPAP therapy, the American Academy of Sleep Medicine (AASM) has offered its recommendation for alternatives in the form of oral appliances.


In an issue of Sleep, researchers at the AASM released updated instructions for the treatment of obstructive sleep apnea with CPAP alternatives in an article entitled, “Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances.” Since the publication of these guidelines in 2006, patients diagnosed with mild to moderate sleep apnea have been able to take advantage of alternative devices. Physicians will prescribe the oral appliances to those who have already responded poorly to CPAP or to those who simply prefer another method. However, the AASM still advocates CPAP as the best form of treatment for patients with severe sleep apnea.

According to the AASM’s guidelines, the first step to treating sleep apnea of any severity is to have the sleep disorder diagnosed by a physician with ample experience in Sleep Medicine, particularly with sleep-disordered breathing. You can find certified sleep professionals in your area by searching local or online listings for sleep centers. To find a sleep dentist trained in oral appliances, experts such as Ira Shapira, DDS recommend that you find a sleep specialist that is a Diplomate of the Academy of Dental Sleep Medicine (ADSM).

If you have ever had to wear a mouth guard or an orthodontic retainer at night, you won’t have too much trouble adapting to an oral appliance for sleep apnea. The devices are designed to prevent the airway from collapsing while you sleep. This is most often achieved by moving your lower jaw, jaw muscles, uvula, soft palate, tongue or a combination of several of these parts.

The most common type of oral appliance is a mandibular repositioning device, which uses the upper jaw as an anchor to bring the lower jaw forward. In this position the walls of the pharynx and the tongue are also corrected. There are other oral appliances for sleep apnea available too, such as the tongue retaining device, which uses a suction mechanism to keep the tongue from falling backward and blocking the throat while you lie down.

In general, oral appliances have a higher compliance rate than CPAP in treating obstructive sleep apnea. Less than half of patients that are put on a CPAP treatment plan are actually able to continue the use of their machines and masks as recommended. And even these patients sometimes prefer oral appliances over CPAP because the oral devices are supposedly easier to use during travel and feel less distracting in shared bedrooms. Some oral devices, such as the Thornton Adjustable Positioner (TAP), have volume knobs that allow the patient to be more in control of sleep apnea treatment. Others, such as the Somnomed appliance, feature a straw through which you can drink water at night. In the end, the specific brand of oral appliance you use is not as important as keeping the upper airway unobstructed.


This is a guest blog post:



Sleepdisorders.com is designed to link sleep disorder sufferers to local sleep doctors and sleep centers. In addition to our directory of sleep doctors, you can find informational articles related to your unique sleep disorder.

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My thoughts:  Oral appliances are a reasonable treatment option for mild to moderate OSA.  CPAP remains the gold standard, especially  for more severe forms of OSA.   Oral appliances can be difficult to tolerate for some patients.  In order to have success with an oral appliance, the involvement of a well-trained dental sleep specialist, working with a board-certified sleep doctor, is necessary.  I do NOT recommend mail-order dental appliances.

Study Links Sleep Apnea to Increased Cancer Risk

A recent study, presented at the European Respiratory Society’s Annual Congress in Vienna, suggests that sleep apnea is linked to an increased risk of developing and dying from cancer. First, an overview of this condition: sleep apnea is a condition in which sleeping individuals experience abnormal pauses while breathing and the frequency of their breathing is abnormally low. Associating sleep apnea, an unpleasant sleeping condition, to an increased risk of developing cancer, not to mention dying from cancer, is surely the stuff of nightmares.

At the ERS Annual Congress experts presented two studies that provided substantial evidence in drawing an association between sleep apnea and cancer. The first study consisted of 5,600 patients from a total of seven sleep study facilities in Spain. In the study these medical experts utilized a hypoxaemia (which is the deficiency of oxygen in arterial blood) index in order to measure how severe sleep apnea was in each of the patients. The hypoxaemia index functions to record how long patients have had low oxygen levels (less than 90 percent oxygen saturation) in their blood while sleeping. Medical scientists discovered that individuals who had low oxygen levels in their blood during 14 percent of their sleeping, for instance 14 percent of an eight hour sleeping period, were 50 percent more likely of developing and dying from cancer. Of course, the patients who did not suffer from sleep apnea were not subject to these unfortunate odds. These medical experts also found a correlation between the sex of the patient and the likelihood of developing cancer. Male patients and young patients, in general, with sleep apnea are significantly more susceptible to developing life threatening cancer due to low levels of oxygen in arterial blood. Similar to the first study, the second study produced similar results. The evidence produced by the second study suggested that individuals with sleep apnea are more likely to develop cancer than those without the sleeping condition; the study suggested that there was a high prevalence of cancer in those with sleep apnea.

Now, the current focus of the study is to figure out the role of CPAP devices in the link between sleep apnea and cancer. CPAP (continuous positive airway pressure) treatment utilizes air pressure to keep a person’s airways open, making it an ideal method in treating patients with sleep apnea. CPAP treatment is often described as unpleasant since a patient must wear the mask over their nose and mouth while sleeping. The mask connects to a machine via tube which provides the patient with mild pressure air flow. Since CPAP uses air pressure to keep airways open, then patients ideally should not suffer from oxygen deficiency in their arterial blood. If there is no sign of oxygen deficiency in the patients’ arterial blood while they are sleeping, then the risk of developing life threatening cancer should be significantly reduced, if not avoided completely. CPAP treatment can be considered the light at the end of the tunnel for patients with sleep apnea.

This is a guest blog post:

Sleepdisorders.com is designed to link sleep disorder sufferers to local sleep doctors and sleep centers. In addition to our directory of sleep doctors, you can find informational articles related to your unique sleep disorder.

EKG During Sleep Study

EKG during sleep study

http://rebeldoctor.blogspot.com/2012/05/eng-during-sleep-study.html

Mobitz type 2 vs blocked PAC?  I think it's Mobitz II, what do you think?  (I gave this to the IT chief at Reggie White Medical Enterprises with poor instructions about which of my blogs to post it on, that's how it ended up on my old blog).

Do Sleeping Pills Kill?

A recent study published in BMJ Open found that the prescription of sleeping pills (hypnotics) was associated with a greater than threefold increase in the risk of death. The abstract and full article are available (free) here:

http://bmjopen.bmj.com/content/2/1/e000850.full

There are a number of problems with this study, as mentioned by Dr. Nancy Collop, President of the American Academy of Sleep Medicine:

"Although the study found that the use of hypnotic medication, or sleeping pills, was associated with an increased risk of mortality, a cause-and-effect relationship could not be established because the study only analyzed an insurance database... it was impossible for them to control for psychiatric conditions and anxiety, which is an area of significant concern to this study population..." http://www.medscape.com/viewarticle/759336?src=mpnews&spon=17

The major problem that I have with the study is that, as I far as I can see looking at the full article, the presence of insomnia was not controlled for (most of the comparison group did not have insomnia). Insomnia itself is associated with increased mortality (in some but not all studies) and morbidity (illness). To further illustrate why this is a problem, consider a hypothetical study in which the use of insulin was associated with an increased death rate. It is well known that dibetes itself increases the risk of death. If the comparison group in this hypothetical study did not have diabetes, I don't think much if anything could be learned from the study.

This new sleeping pill study doesn't add much new information to the field of sleep medicine, although it does add to the literature suggesting that insomnia is a serious problem. I did find this earlier editorial by Dr. Kripke (primary author of the current study) which sums up the problem with this current study:
"Numerous previous studies have shown an association of hypnotic use to mortality, which can become confounded with insomnia. Was mortality controlled for hypnotic usage in examining the association with insomnia?" http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079930/?tool=pubmed
To fully apply to the current study, that last statement can be changed to: Was mortality controlled for insomnia in examining the association with hypnotic usage?

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Edit: The association between insomnia and death is a complex issue. It is clearly associated with illness/morbidity. This abstract sums up the issues: http://www.ncbi.nlm.nih.gov/pubmed/15600216

Some studies have found that while a subjective complaint of insomnia is not associated with an increased risk of death, short sleep time is.

CDC Issues Warning About Nasal Washes

Nasal rinses can be very helpful for allergies, but can also be deadly:

http://denver.cbslocal.com/2012/02/28/cdc-issues-warning-about-nasal-washes/

" It’s because of a brain-eating amoeba called Naegleria fowleri" that can be present in tap water.

Many patients with sleep apnea use nasal rinses.... these are safe as long as boiled or distilled water are used. Similarly, tap water should not be used in CPAP humidifiers (distilled water is recommended).

Reggie White Medical Enterprises.....New Commercial

Heavy NFL players are at increased risk of Death

"The heaviest athletes are more than twice as likely to die before their 50th birthday than their teammates, according to a Scripps Howard News Service study of 3,850 professional-football players who have died in the last century."

http://www.sleepdt.com/heavy-nfl-players-twice-as-likely-to-die-before-50/

Many of these athletes likely had untreated or inadequately treated obstructive sleep apnea (OSA). The heavier NFL players tend to have large necks. Increased neck size (greater than 16 inches in men) is a risk factor for OSA, whether the increased neck size is due to fat or muscle. Obstructive sleep apnea increases the risk of various types of heart disease, including coronary artery disease, heart attack, and congestive heart failure.

An earlier 1994 study found that "offensive and defensive linemen had a 52 percent greater risk of dying from heart disease than the general population."

Sleep Disorders are High in the South

A recent study found that "Oklahoma, Arkansas, Mississippi, Alabama and West Virginia had the highest rates of sleep disturbance and daytime fatigue"

I suspect that the high rate of sleep disturbance and fatigue in the south is due to obesity, a major risk factor for obstructive sleep apnea

Read more: http://www.foxnews.com/health/2012/02/24/southerners-sleepiest-in-us-study-says/#ixzz1nOmzb4lX

I will try to post a link to the actual research study later. As a southern sleep doctor (currently licensed in Mississippi and Alabama, formerly licensed in West Virginia), this topic is of concern to me.