Sleep, Medical Privacy, Seasonal Affective Disorder

• Doctor's Mail Box
• Sleep - Why We Need It and How to Get It
• Rant O' The Month - The Medical Privacy Act
• Seasonal Affective Disorder
• Monroe Street Clinic News - Holiday Schedule

Doctor's Mail Box -- Lions, Not Tigers

Dear Doctor:
Great information (in the article about the evolution of anxiety and depression (in our November 2003 Newsletter) but, just because it is my pet peeve, may I point out that there are no tigers on the African savannah. Lions, perhaps, but tigers live in Asia. Your nit-picking friend,
J.D.

Sleep -- Why We Need It and How to Get It

The Evolution of Sleep

There's nothing quite as blissful as waking up from a night of profoundly relaxing sleep. Can you imagine a world whose creatures do not sleep? According to some scientists, that's exactly the world that existed long ago in the prehistory of our planet, when none of the life forms slept. As evidence, they point to the fact that even today many creatures, as diverse as starfish and snakes, do not sleep.

Our evolution into creatures that sleep probably went something like this: Some animals that foraged by day found places to hide and rest quietly by night. The repair mechanisms in their bodies still functioned around the clock, but because some of those mechanisms were more efficient when the creature was resting, those animals that carried out these repair mechanisms during the night survived better that their siblings. Passing such genes on to their progeny, these creatures evolved to be more quiescent at night, more efficient at repairing and maintaining their physiology at night, and freer during the day to forage, find mates, and reproduce. Nocturnal animals, on the other hand, repaired their physiology while they slept during the day.

While You Were Sleeping

In modern humans, so many necessary repairs occur during sleep that we cannot function without our forty winks. While we sleep, our bodies are busy repairing damaged cells. Certain immune processes, such as cancer surveillance and infection control, occur more efficiently during sleep. Our bones are strengthened during the night. Our bodies produce melatonin, a hormone that helps keep cancers at bay. Just as the cook prepares the sauces and raw materials before the restaurant opens, during sleep our bodies create many essential proteins, such as those that carry oxygen and enable blood to clot. During the day, as we deal with the stimuli of our lives, the brain uses up neurotransmitters more rapidly than it can produce them. It depends on dreamless sleep to catch up.

All these build-and-repair processes take place at a much lower level while we are awake, but they do their major work while we snooze. Sleep is an evolutionary advance that allows more efficient functioning during the day. To help achieve this, we have not just one but several internal "clocks," regulating over a hundred physiologic processes.

Insomnia - a Modern Disorder

Fast forward to the twenty-first century with electric lights and television to keep us up at night and jet lag to foul up our sleep-wake schedules. Even people who aren't jetting around the world can have difficulty sleeping. Why? Insomnia can be due to many perturbations in the system. Common disturbances include cigarette smoking, menopause, depression, and too much alcohol or caffeine. Less commonly, sleep can be impaired by restless leg syndrome, gastro esophageal reflux, fibromyalgia, panic disorder, habitual insomnia, and many other problems.

Everyone has a pet remedy for sleep, but because the causes of insomnia vary widely, one remedy does not work for everyone! Possible cures to this annoying disorder include herbs, nutrients, and lifestyle changes. Each individual needs to experiment to discover the cause of his or her insomnia and divine which remedies help the problem.

Herbs and Nutrients May Help

You can go to the Food Coop or health food store and purchase a whole pharmacopoeia of herbs that promise to help you sleep. Commonly used soothing herbs include hops, lemon balm, passiflora, lavender and valerian. These are often combined. If you want to try some of these out, remember that just as all corn does not taste sweet, so not all valerian is going to have a sedative effect.

Another herb, Withania somnifera (does the word "somnifera" sound suggestive, you Latin fans?) not only has a sedative effective but is prized by Ayurvedic medicine as a rasayana, or general system strengthener - for good reason. It appears to slow the height loss that comes with age, retard graying of the hair, strengthen the immune system, and even restore lost manhood! According to a 1980 article in the Journal of Research in Ayurveda, Withania improves erectile function, but I think I am wandering off the subject here...

You have probably heard of the herb kava, which has been in the news. Kava is often made into a strong extract that can, on rare occasions, harm the liver. Some people find this herb useful. Others wake up depressed, even though it helps them sleep. While kava may turn out to be safe when we understand more about it, for now I am going to have to advise you to avoid it.

Some people have metabolic idiosyncrasies that prevent sleep, and they benefit from pantothenic acid, methylcobalamin, or L-tryptophan. It's difficult to self diagnose, so it is best to consult your health care provider before taking these nutrients.

The hormone melatonin is effective on its own account. Just don't take too much. Usually a lower dose, such as 0.3 to 0.5 milligram works better than the higher doses.

There is no one remedy that works for everybody. I have a patient who found that valerian actually disturbed his sleep. For all these agents, you need to go by your experience and not by the books.

The Doctor's Advice

1. Exercise during the day.
2. Don't take any caffeine after noon. As we age, we metabolize caffeine more slowly, and that noontime cup of coffee may still be around at bedtime. Some people find even a morning cup of coffee interferes with sleep.
3. Avoid alcohol in the evening. Alcohol certainly helps people fall asleep, but it tends to make people wake up during dreaming, then have trouble returning to sleep.
4. Dim the lights in the house before bedtime, and turn the lights out by ten p.m. This may seem draconian to some, but remember evolution. We have over a hundred physiologic processes optimized for sleep. These processes set to work shortly after dark and slow down just before dawn. My experience is that Benjamin Franklin was right. I suggest you try it.
5. If you are cold, use a hot water bottle in the bed to warm up your feet.
6. Get up early and take an early morning walk outside in the light.
7. If you have trouble getting up, use an artificial dawn device. See our note below on Seasonal Affective Disorder.
8. If you find yourself awake in the dark, don't get out of bed, whatever you do. Or as my teacher said, sleep may come, and you won't be there. If you find yourself lying there worrying about not getting to sleep, I suggest you just chill out! Pray for your loved ones; recall the events of the day just passed; review the activities you've recently enjoyed; be glad you're in a warm bed and not out on the street. Take it easy. Tomorrow will be here soon enough! Dr William C. Dement of Stanford, one of the pioneers of the new specialty of sleep medicine, has written a very readable book The Promise of Sleep. Sleep specialists determine the cause of sleep disorders in laboratories, in which people are wired up to monitors and observed overnight while they sleep. Dement has found that most often the person who claims "never to sleep a wink" actually spends a good deal of the night dozing. This is another reason I suggest that you stay in bed at night, even if you are not sleeping well.

Rant 'O The Month

What do you call a law that allows people to read your medical records without your consent? The Medical Privacy Act. We have written about this insidious law in two previous newsletters, June 2003 and August 2002. Here's the latest. I have received a letter from our Seattle laboratory, Labcorp, saying that for them to bill a patient's insurance, they will need more information than previously required. Specifically, they will need to know your birthday, the name and address of the insured party, your relationship to that party, and your diagnosis. This requirement is true for every single cotton-picking, specimen-centrifuging, arm phlebotomizing lab in the good ol' U.S. of A. This information was not required before; now it is. Why? HIPAA, the so-called Medical Privacy Act.

This disclosure of information is not required, however, if the lab does not have to bill your insurance, so our cash-paying patients will not have their privacy invaded. In truth, any insurance contract you enter into gives the insurance company the right to look at your medical records to be sure that they are spending your premium dollars wisely. I think that is reasonable. Physicians, patients, hospitals, and many others have frequently over billed insurance companies. As an example, an older physician told me at a conference last week that in his early days, a person would frequently have insurance coverage from both their employer and their spouse's employer. So, if this physician removed their gallbladder, he would bill both insurance companies, keeping one payment and returning the other to the patient. I have heard similar stories on many occasions.

To give the devil his due, the federal government may feel that it needs access to everyone's medical records for purposes of health planning. Does it say this? Is there any honest argument about these issues at all? Darn little, and I offer into evidence this so-called Medical Privacy Act, which actually reduces your privacy.

Seasonal Affective Disorder

The best treatment for the depression of Seasonal Affective Disorder is light therapy. This comes in two forms.

1. Exposure to 10,000 lux lights for half an hour a day.
2. An artificial dawn device you set like an alarm clock that turns on a dim light 20 minutes or so before you wake, then gradually brightens.

I'm hearing a fair amount of local hype about light boxes, some of it misleading and expensive. Try learning more at the Circadian Lighting Association. On a couple of occasions I've quizzed the technical person at Northern Light Technologies and can find no more cost-effective or technically competent product. They carry an artificial dawn device for $120 including shipping. They are sending us a sample for office display that you can come in and see. We have no business relationship with this company.

For more information about Seasonal Affective Disorder, come into the office and ask our receptionist for our handout.