Depression

Psychological causes of depression in sleep apnea patients

People with sleep apnea tend to become social isolated from their partners and children because of their fatigue and sleepiness. They will tend to stay less with their family and relationships and to spend more time sleeping. Family or friends can be more like a burden, rather than a source of support. Sleep apnea can deeply affect your quality of life. From your inactivity in family's social life to negative attitude throughout the day, all this will affect your home and social life. These problems may contribute to marital conflict and divorce.

A sign of depression can be when someone has the inability to sleep, or insomnia. People with depression either struggle with a lack of sleep, or sleep too much. An important clue that someone has depression is when they have a lack of sleep for a long period of time.

Depression is a serious disorder and can affect the way a person eats, sleeps, feels and thinks. This disorder can be effectively controlled with treatment.

Some people have depression symptoms before sleep problems, and other way around. Sleep problems and depression may react to the same treatments regimes. Sleep problems are linked to a more severe depression illness. People that suffer from insomnia, have a much higher risk of suffering from depression, when compared to those people who sleep well.

They have difficulty falling asleep, or staying asleep, unrefreshed sleep as well as daytime sleepiness. Depression is at a higher risk in people who suffer from both onset and sleep maintenance insomnia.

Sometimes these symptoms can overlap and a misdiagnosis is then common, as a depressed mood could be sign of insomnia, OSA or narcolepsy. RLS is a condition that causes a discomfort in the legs which disturbs sleep patterns. Children who suffer from depression, caused by insomnia and hypersomnia have a higher risk for long lasting depression. They also suffer from weight loss, impaired movement, and an inability to feel happy.

These treatments can be affected by sleep disorders, when treating depression. People who have both depression and insomnia should avoid using sedating antidepressants as they have a potential to suppress breathing and worsen OSA. Before someone starts doing treatment for depression, they should talk to their health care provider regarding their sleep symptoms. When effective treatment is given for sleep problems, depression symptoms can be decreased. Book a consultation with our Health Renewal doctors for Depression.

Disturbances during sleep with depression are associated with a decrease in slow wave sleep (SWS) production, and disturbed REM sleep regulation. When REM is shortened, increased REM sleep duration and increased REM density are considered as biological markers of depression, which can predict relapses and recurrences. Neurochemical and neurobiological factors play a role in the relationship between REM sleep and depression. REM sleep dysregulation in depression is linked to genetic predisposition to develop the illness. REM sleep changes in depression can contribute to the development of central symptoms of depression like cognitive distortions such as low self-esteem and consolidation of negative emotional memories.

Depression can appear when sleep apnea is successfully treated. This type of depression can start when a person experiences a big change in his life in a very short time, from sleepy and lonely to awake and active. Former sleep apnea patients may be pushed too fast into the active life, and he may feel strange about how to deal with this changes. Another common reason to be depressed after a successful sleep apnea treatment is when you realise that you have lost many good years of your life in a state of somnolence.

• pessimism
• fatigue
• decreased energy
• loss of interest
• poor sexual functioning
• poor self-esteem

Depression symptoms can disappear if you start a successful sleep apnea treatment. Depending of the severity of your sleep disorder, these depression symptoms may not vanish from the beginning of your treatment. If you have a severe case of sleep apnea, you have a lot of sleep debt to recover until you'll feel treated. The ideal case to avoid depression when you already have sleep apnea is to start the treatment in the early stage of development.

The mainstream view on the cause of depression relies largely on the monoamine hypothesis - a theory proposing that deregulation in neurotransmitter signalling is the sole cause of depression. This has been the ground for the primary utilisation of antidepressant drugs in the management of depression for decades. However, this theory fails to take into account various other well-studied causes, and partly explains the poor success rate of antidepressant medications in some cases. Conventional medicine overlooks several important biological factors that influence depression, thereby undermining the likelihood that a holistic strategy will be employed to thoroughly manage a patient’s depression. If left unchecked, aberrations among these under-appreciated factors may work together to create metabolic and neurochemical imbalances that provoke mood changes and initiate depression.

Critical omissions from conventional assessment of depression include:

• Hormonal imbalances
• Nutritional Deficiencies
• Oxidative stress and mitochondrial dysfunction
• Insulin resistance and chronic inflammation
• Hormonal influences

Balanced and youthful concentrations of hormones can help control depression, and astute clinicians often find hormonal imbalances in patients with depression. Because a wide range of hormones can influence depression, it is important to discern which hormone(s) may be an underlying factor when considering depression. For example, thyroid function directly affects metabolism and brain function, and low thyroid activity can contribute to depression.

Conventional medicine relies on overly broad thyroid lab ranges, failing to recognize many cases of sub-optimal thyroid function. Overt hypothyroidism has been shown to perturb serotonin signalling in the brain, which can contribute to depression. Furthermore, because the brain requires sufficient thyroid hormones to function optimally, a low thyroid hormone status can contribute to overall loss of function and degeneration in the brain, including the areas of the brain that govern mood. Hashimoto’s thyroiditis, an autoimmune thyroid disease, can cause a person’s metabolism to swing between overly active to overly depressed. These swings can mimic the symptoms of bipolar disorder and cause misdiagnosis and inappropriate treatment.

Sex hormones also influence mood and depression. Women are more susceptible to anxiety than men and also experience more depression when they are pregnant, postpartum, premenstrual and menopausal than at other times in life. These general observations have piqued the interest of scientists and given rise to an expanding body of research linking depression with sex hormone imbalances.

By now, it is well known that most steroid hormones (e.g., pregnenolone, estrogen, progesterone, testosterone, and DHEA) are neurologically active. In fact, the brain contains large numbers of receptors for DHEA, estrogen, and progesterone. These hormones affect many functions in the brain, including the regulation of mood. In the follicular phase of menses, when estrogen levels are high, women produce more serotonin and experience an improved mood. When estrogen decreases during the premenstrual period, serotonin levels drop, contributing to the negative mood and personality shifts associated with PMS. Likewise, the drop in estrogen during menopause is associated with reduced serotonin production and a negative impact on mood and cognition. This is evidenced by the fact that SSRIs have been shown to improve mood and cognitive function in menopausal women.

In addition, testosterone deficiency has been linked with depression in men, which is not surprising since testosterone plays an important role in brain function, including mood regulation. In studies, select populations of men were more likely to be depressed if their total and/or free testosterone levels are low; these included those with heart disease, HIV/AIDS, and the elderly.

Medical research acknowledges the link between hormonal imbalances and depression; however, conventional doctors rarely evaluate and address hormone status when treating depression. Instead, they frequently dismiss such imbalances as a normal part of aging, while in truth, restoring youthful hormonal status may effectively combat multiple health deficits associated with aging, including mood imbalances.

Medical research acknowledges the link between hormonal imbalances and depression; however, conventional doctors rarely evaluate and address hormone status when treating depression. Instead, they frequently dismiss such imbalances as a normal part of aging, while in truth, restoring youthful hormonal status may effectively combat multiple health deficits associated with aging, including mood imbalances. 

Nutritional deficiency or insufficiency

Nutrition plays an essential role in brain function, and poor nutrition significantly increases one’s risk for depression. Dietary nutrients influence nervous system function in multiple ways. Important dietary nutrients include:

B-complex vitamins: B-complex vitamins serve as cofactors for the production of neurotransmitters. Inadequate levels of B vitamins, especially folate, vitamin B12, niacin, and vitamin B6, can disrupt neurotransmitter synthesis. This not only may lead to mood alterations, but also can impact overall brain function, memory, and cognition.

An Optimal balance of omega-3 and omega-6 fatty acids: Fatty acids are critical components of nerve cell membranes and play an important role in neuronal communication. Fatty acid imbalances can impair the transmission of messages between nerve cells, leading to cognitive deficits and mood alterations, including depression.

A Vitamin D activity: A vitamin-D insufficiency, which is very common even among dedicated supplement users, is linked with seasonal depression. Recent evidence suggests that it also may contribute to general depression through its considerable influence on genetic activity, its ability to control inflammation, and other mechanisms. It is important to remember that optimal brain function necessitates all of these nutritional aspects be addressed simultaneously.

Oxidative Stress and Mitochondrial Dysfunction

Brain tissue is particularly susceptible to oxidative damage due to its high concentrations of phospholipids and the exhaustive metabolic rate among neurons.

A growing body of research suggests that oxidative stress contributes to depression and other brain-related disorders. This is thought to result from either an increase in damaging reactive oxygen species (ROS), a decrease in antioxidant defence mechanisms, or a combination of the two. These mechanisms become especially important with advancing age. Newer research sheds light on the critical role of mitochondria and neurotransmission and mood regulation. Mitochondria are the “powerhouses” in each cell that generate energy. In an intriguing study, researchers measured the content of mitochondrial DNA within white blood cells in aging patients who were depressed, and in an age-matched group who were not depressed. The subjects with depression had significantly fewer mitochondria than non-depressed controls, leading researchers to suggest, “Mitochondrial dysfunction could be a mechanism of geriatric depression”. In a similar study, greater numbers of mitochondria in peripheral cells were associated with improved cognitive function in healthy elderly women. Preliminary research suggests that two nutrients, coenzyme Q10 and acetyl-L-carnitine, which support mitochondrial function, may influence depression. A small study of 35 depressed patients in comparison to 22 healthy volunteer controls showed that plasma CoQ10 levels were significantly lower in the depressed patients. Levels were also lower in treatment-resistant patients, as well as those with chronic fatigue. Several studies of geriatric depression have investigated acetyl-L-carnitine. Acetyl-L-carnitine also has been found to relieve depression and improve quality of life in patients with liver disease and to ease depressive symptoms significantly in patients with fibromyalgia.

Insulin Resistance

Recent data suggest a direct link between insulin resistance and depression. Evidence suggests that a popular glucose control agent, Metformin, may influence psychiatric health. Individuals who are overweight, have suboptimal glucose control, or have diabetes with concurrent depression may find that losing weight and gaining control over their glucose levels eases their depressive symptoms. Scientific literature indicates that for optimal health, fasting glucose levels should fall between 4.0 and 5.0 mmol/l and 2-hour postprandial (2 hours after a meal) glucose levels should not exceed 6.7 mmol/l.

Chronic Inflammation

Several studies support the role of inflammation and immune system deregulation in depression. Studies have found elevated levels of inflammatory cytokines (signalling molecules with which immune cells communicate) in patients suffering from major depression, late-life depression, and in patients who do not respond to SSRIs. These cytokines include the interleukins IL-1beta and IL-6, as well as the cytokines INF-gamma and TNFalpha. Studies show an association between the systemic inflammation marker C-reactive protein (C-RP) and major depression. Moreover, elevated CRP levels are associated with a number of other significant health problems such as cardiovascular disease. Health Renewal suggests that women target a CRP blood level of less than 1.0 mg/L and men target a level of less than 0.55 mg/L. In prospective studies involving patients being treated with recombinant cytokines for immune-related conditions, depression is observed to develop after inflammation initiates several other undesirable metabolic cascades. This has led some researchers to identify depression as a late-stage consequence of chronic inflammation. Research innovations even suggest that future antidepressant medications may be anti-inflammatory in nature. 

Depression is a multifactorial condition, and efficient relief requires addressing multiple neurochemical and metabolic imbalances that may underlie mood disturbances. The nutrients listed below are categorised according to their evidence-based mechanisms of action in brain health and mood regulation.

Broad-Range Nervous System Effects

Omega-3 fatty acids are long-chain polyunsaturated fatty acids found in fish and various oils, such as flaxseed oil. The brain has a high concentration of polyunsaturated fatty acids, which are found mostly in cell membranes. They affect adaptability of the nervous system, nerve cell conduction and function, and neurotransmitter synthesis. Several research models exhibit the influence of omega-3 fatty acids in depression including: (a) dietary studies; (b) nutritional status studies showing positive effects associated with higher omega-3 to omega-6 fatty acid ratios; and (c) intervention studies that look at both eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) taken as a stand-alone treatment and as an adjunct to medication. One investigation showed that adding the omega-3 fatty acid EPA to conventional antidepressant treatment may help to relieve depressive symptoms. Among children with depression, supplementation with omega-3 fatty acids demonstrated “highly significant” effects on symptom scores. In a review article, researchers analysed results from six published studies and found that omega-3 fatty acids may reduce symptoms of depression among adults as well. Because they are anti-inflammatory, omega-3 fatty acids also reduce the risk of cardiovascular disease, which is highly associated with depression. In fact, the American Heart Association recommends fish oil for both preventing an initial heart attack and for preventing a second attack when one has already occurred. Omega-3 fatty acids are counterbalanced with the inflammatory omega-6 fatty acids. Typically, South Africans consume far too many omega-6's and not nearly enough omega-3's. The ratio of omega-6 to omega-3 fatty acids is very important and a ratio of Omega 6 to omega-3 of less than 4:1 is recommended. Unfortunately with our current diet so high in Omega 6 fatty acids our ratio is more in the line of 10-20:1, which in turn causes more inflammation in our bodies.

Magnesium

Magnesium is a cofactor for more than 300 enzymes in the body; it is important for blood-sugar regulation, and has a calming effect on the nervous system. Some evidence shows a link between magnesium deficiency and depression, and a recent, comprehensive review suggests that magnesium supplementation might be a viable approach for depressive symptoms. A major hurdle for supplemental magnesium historically has been delivery into the brain. This is a barrier that has limited the ability of typical magnesium supplements to target conditions that arise from within the central nervous system such as depression and anxiety. However, in a recent scientific breakthrough, researchers collaborating from Beijing, Ontario, the University of Texas, and the Massachusetts Institute of Technology have developed a highly advanced form of supplemental magnesium called magnesium-L-threonate.

Magnesium-L-threonate was shown in multiple animal models to not only effectively penetrate deep into the brain, but also to trigger enhancements in learning and memory by optimizing neuronal communication and reinforcing brain structure in key areas of the cortex, the most advanced aspect of the human brain. Since magnesium-L-threonate is readily able to diffuse across the blood brain barrier, while other forms of magnesium are not, it appears to be the ideal form of supplemental magnesium for those with depression of other mood disorders.

Supporting Neurotransmitter Synthesis

• L-tryptophan and 5-hydroxytryptophan (5-HTP) are immediate precursors to serotonin. L-tryptohan is essential for the brain to synthesize serotonin, and several studies have shown that acute tryptophan depletion can cause depression in humans. In fact, some foreign countries license L-tryptophan as an antidepressant.
• Methylation (a biochemical building block process for producing neurotransmitters):

Methylation is a process in which a molecule passes a methyl group to another molecule. Methylation is essential to multiple functions in the body, including the production of neurotransmitters.

One can supply raw materials to support methylation reactions by supplementing with S-adenosyl-methionine (SAMe) or by providing metabolic cofactors such as folate, vitamin B12, and vitamin B6. These nutrients are necessary for neurotransmitter production and have other regulating effects.

S-Adenosylmethionine (SAMe)

SAMe, which can be found in almost every tissue in the body, assists with production of creatine, glutathione, taurine, L-carnitine, and melatonin. Research not only showed that SAMe can benefit depressed patients who do not respond to SSRIs, but also suggested that it might improve memory function.

Folate

Research shows that low blood levels of folate are associated with depression, and may also be predictive of poor response to antidepressant medication. Because relapse is associated with low serum folate, it is important to maintain folate supplementation for a year following a depressive episode. The form of supplemental folate is important since a considerable portion of South Africans may have a genetic polymorphism that impairs folate metabolism. In fact, mutations in the gene (MTHFR) that convert’s folic acid into the active 5-methyltetrahydrofolate (5-MTHF) are associated with depression. Therefore, taking supplemental 5-MTHF directly, which can cross the blood-brain barrier, may be more effective in supporting healthy neurotransmission and decreasing potentially neurotoxic homocysteine levels.

Vitamin B12

Vitamin B12 should always be measured in the event of depression (or any other psychological problems), as a vitamin B12 deficiency can be a reversible cause of various neuropsychiatric disorders. One should also consider whether a vegetarian diet or malabsorption due to celiac disease or gluten enteropathy is a factor in B12 deficiency. Weaker digestion, reduced absorption of nutrients, and hypochlorhydria (inadequate stomach acid needed to break down proteins that contain vitamin B12) are common in the aging population and associated with a B12 deficiency; B12 levels should be tested in an older person with symptoms of depression. Evidence suggests that the methylcobalamin form of B12 may have more beneficial metabolic effects than cyanocobalamin.

Vitamin B6

Vitamin B6 is a cofactor for the production of most neurotransmitters, but it is particularly important for serotonin synthesis. B6 levels are often low in women taking oral contraceptives and research has shown that B6 supplementation in these women can improve mood. For example, one study showed 22 women who had depression associated with oral contraceptive use and a B6 deficiency saw significant improvement in their symptoms with B6 supplementation. A more recent study examined blood levels of pyridoxal-5-phosphate (P5P), a metabolically active form of B6, in the blood of 251 elderly individuals. The investigators found that deficient levels of P5P doubled the likelihood of depression in this population. Accordingly, when dietary composition was assessed, those with higher daily B6 intakes were less likely to be depressed.

Blood sugar regulation and insulin resistance

Green Coffee Extract- clorogenic acid

• Recent data linked increasing consumption of coffee with a possible decreased risk of depression. In fact, this relationship proved to be dose-dependent, meaning that the more coffee study participants drank, the less likely depression would strike them.
• Conventional coffee preparation, which involves roasting the green coffee beans at high temperatures to attain the desired flavour profile, dramatically lowers levels of health-promoting coffee constituents called chlorogenic acids.
• Chlorogenic acids have been shown in several studies to aid in controlling blood sugar levels; especially those glucose spikes which occur after a high-carbohydrate meal. In a 12-week study, consumption of chlorogenic acid-fortified instant coffee lead to a considerable reduction in body weight when compared to regular instant coffee. As elevated glucose levels and excess body weight are common among depressives, chlorogenic acids may help combat some symptoms of depression tied to insulin resistance and irregularities in glucose metabolism. Green coffee, the primary source of chlorogenic acids, cannot be consumed as a beverage due to its extremely bitter taste. Consuming a green coffee extract standardized to chlorogenic acids is an effective means of obtaining biologically active concentrations of chlorogenic acids. The potential role of chlorogenic acids in mediating the mood boost associated with coffee consumption, and their thoroughly studied antihyperglycemic properties give rise to promising multimodal depression protection.

Chromium

Chromium has been studied for its role in regulating blood sugar by facilitating the uptake of glucose into cells, and some research indicates that it may be beneficial in depression as well. Chromium may also help regulate blood sugar and cravings for sugar and carbohydrates in relation to seasonal depression.

Antioxidant Effects

• N-Acetyl-cyseine (NAC) One of the best-researched antioxidants for depression is NAC. NAC is a precursor to glutathione, one of the body's most powerful antioxidants. Research has found glutathione depletion and oxidative stress in people with depression. Two recent studies showed NAC is a safe and effective adjunctive treatment that improves depression in patients with depressive disorders.
• Alpha Lipoic acid, Vitamins C & E, and Selenium Although Alpha lipoic acid has not been well studied for depression, it is one of the most effective supplemental antioxidants, since it helps recycle other antioxidants, such as Vitamin C. It also may benefit blood sugar regulation and neurological function, as evidence shows it can help diabetic neuropathy. In general, antioxidants may help buffer nerve cell damage in cases of chronic or recurrent depression, although they also serve other roles in brain health. For example, the antioxidant vitamin C is an important cofactor in the synthesis of serotonin, norepinephrine, and adrenal hormones that mediate stress. Vitamin E can help protect nerve cell membranes, and low selenium levels are associated with depression.

Additional nutrients

• Vitamin D3 Growing evidence suggests that vitamin D significantly effects depression. This is not surprising in seasonal depression, since the skin synthesizes vitamin D in response to sunlight, which is less available in the winter. However, vitamin D has been found to play other roles in depression. Studies found that vitamin D3 (cholecalciferol) supplementation can improve symptoms of depression. High dose vitamin D supplementation, for one year showed an improvement in mood. Vitamin D's effectiveness may be related to the high prevalence of vitamin-D deficiency in the general population, its importance in blood-sugar regulation, and its importance in overall regulation of genetic activity.

Zinc 

Zinc is a trace element known to help regulate the nervous system and may be specifically related to depression.

Inositol

Increasing evidence shows that decreased blood levels of zinc are associated with depression, and, in depressed subjects, lower levels of zinc are associated with worse depression.

Inositol levels in the brain and cerebrospinal fluid were found to be lower in subjects with depression. One well-controlled trial showed that taking inositol daily helped relieve symptoms associated with depression. Further research on bipolar depression suggests beneficial influences of inositol. Inositol, a second-messenger precursor, has important cellular communication functions in the nervous system. It therefore may have more of an effect on overweight or obese individuals, as well as those who are insulin resistant, such as those with metabolic syndrome or women with polycystic ovarian syndrome (PCOS). These findings require further research and replication. 

The importance of early management of any condition cannot be overstated. Once certain conditions set in and damage to organs occurs, complete recovery may be difficult to attain. Best results for prevention and longevity is early detection of a possible problem combined with conventional treatments, nutritional supplements and a healthy diet and lifestyle.

• Exercise – If you have depression, or even if you just feel down from time to time, exercise is a MUST. The research is overwhelmingly positive in this area, with studies confirming that physical exercise is at least as good as antidepressants for helping people who are depressed. One of the primary ways it does this is by increasing the level of endorphins, the "feel good" hormones, in your brain.
• Get enough Sleep.
• Address your stress - Depression is a very serious condition. It's a sign that your body and your life are out of balance. In reality, one of the most important things you need to do is to return balance to your life, and one of the key ways to doing this is by addressing stress.
• Meditation or yoga can help. Sometimes all you need to do is get outside for a walk.
• Eat a healthy diet - Another factor that cannot be overlooked is your diet. Foods have an immense impact on your mood and ability to cope and be happy, and eating whole foods will best support your mental health. Avoiding sugar & grains will help normalize your insulin and leptin levels, which is another powerful tool in addressing depression.
• Spend enough time with family and friends, who have a positive influence on your life.
• Support optimal brain functioning with essential fats - We also strongly recommend supplementing your diet with a high-quality, animal-based omega-3 oil, like salmon or krill oil. This may be the single most important nutrient to battle depression.
• Get plenty of sunshine – Making sure you're getting enough sunlight exposure to have healthy vitamin D levels is also a crucial factor in treating depression or keeping it at bay. One previous study found that people with the lowest levels of vitamin D were 11 times more prone to be depressed than those who had normal levels. Vitamin D deficiency is actually more the norm than the exception, and has previously been implicated in both psychiatric and neurological disorders