Melatonin and REM sleep behavior disorder

REM sleep behavior disorder is a condition in which a person acts out dreams during his or her sleep...understandingly, it can be dangerous for that person's bed partner!

What is important to know, is that there is a link between this disorder and Parkinson's disease. So anything you can do to discourage the nervous system from progressing in this direction can be crucial.

Researchers recently reported that a variety of medications can be helpful in treating REM sleep disorder, especially clonazepam (Klonopin). Second in line was a natural hormone that is available as an over the counter supplement, melatonin.

While the researchers promoted clonazepam as their first choice, I would have to put my money on melatonin. Not only is it a sleep enhancer, it is a very powerful antioxidant, which means it can not only help with current symptoms, but do that preventive work I mentioned.

One of the biggest problems with the way medicine is practiced, in my opinion, is that we tend to focus on the current problem and what band-aid...er...drug...we can prescribe, to feel like we've fixed the problem. Rarely do we look deeper to the core issue. And that's why so many people are on so many medications today.

I can guarantee you, people with REM sleep disorder are not having problems because their bodies are deficient in clonazepam! But they could be having trouble with melatonin metabolism. Which is why this option makes so much sense to me.

Gugger JJ, Wagner ML. Rapid eye movement sleep behavior disorder. Ann Pharmacother. 2007 Nov;41(11):1833-41.

Bubenik GA, Blask DE, Brown GM, Maestroni GJ, Pang SF, Reiter RJ, ViswanathanM, Zisapel N. Prospects of the clinical utilization of melatonin. Biol Signals Recept 1998 jul-Aug;7(4):195-219.

Deigner HP, Haberkorn U, Kinscherf R. Apoptosis modulators in the therapy of neurodegenerative diseases. Expert Opin Investig Drugs 2000 Apr;9(4):747-64.

Srinivasan V, Pandi Perumal SR, Maestroni GJ, Esquifino AI, Hardeland R, Cardinali DP. Role of melatonin in neurodegenerative diseases. Neurotox Res 2005;7(4):293-318.

Antolin I, Mayo JC, Sainz RM, del Brio Mde L, Herrera F, Martin V, Rodriguez C. Protective effect of melatonin in a chronic experimental model of Parkinson's disease. Brain Res 2002 Jul 12;943(2):163-73.

Mayo JC, Sainz RM, Tan DX, Antolin I, Rodriguez C, Reiter RJ. Melatonin and Parkinson's disease. Endocrine 2005 Jul;27(2):169-78.

Rozerem and sleep apnea

Sleep apnea is a common disorder that disrupts quality sleep...and therefore function during the daytime. A group of researchers decided to try ramelteon (Rozerem), a sleep enhancer, on 26 patients with sleep apnea to see what it would do. They compared the results to what they observed in the same individuals when they were not on this medication.

In the words of the researchers, "Ramelteon had no effect on the number of central, obstructive, or mixed apnea episodes. No significant differences were observed in SaO(2) for the entire night between ramelteon and placebo (95.1 vs 94.7%; P = 0.070). Ramelteon did not meaningfully affect sleep when evaluated by polysomnography and post-sleep questionnaire. Compared with placebo, ramelteon had no significant effect on next-day residual effects."

Yet, these same researchers concluded that the medication was "well tolerated".

Isn't the obvious question here, why would you take a medication that has absolutely no effect on the problem you have...just because it is well tolerated? I tolerate a lot of medications...but they're not going to help any issues I might have. Is it just me, or aren't we supposed to be taking medications that directly address the problems we're working to heal?

Something's wrong with this picture.

Kryger M, Wang-Weigand S, Roth T. Safety of ramelteon in individuals with mild to moderate obstructive sleep apnea. Sleep Breath. 2007 Sep;11(3):159-64.

Epilepsy, medications, heart disease, and dietary strategies

In recent years, researchers have identified that elevated homocysteine levels are associated with cardiovascular risk. This compound builds up in the blood when it cannot be converted into methionine. Two important nutrients, folate, and vitamin B-12, are important in this chemical reaction; when deficient, homocysteine can accumulate and cause problems.

For people with epilepsy, this is important to know, as some common epilepsy medications can decrease folate and vitamin B-12 levels, and in turn increasing cardiovascular risk.

In a recent study, children receiving carbamazapine (Tegretol) and valproate(Depakote) had statistically lower folate and higher homocysteine levels than children without epilepsy who were not on these medications.

There are several strategies you might consider if your child needs to be on these medications:

1. Give your child a daily multivitamin supplement containing folate and vitamin B-12.
2. Know your dietary sources of folate and include them in your family's meals on a regular basis: fortified cereal, sunflower seeds, dried beans and peas, and leafy greens.
3. Know your dietary sources of vitamin B-12 and include them in your family's meals on a regular basis, namely meat and dairy products.
4. Consider using a fish oil supplement. Their omega-3 fatty acids have shown promise in helping to control seizures. Using the supplement may not eliminate the need for the medication, but it may reduce the necessary dose and therefore reduce the associated side effects.
5. Limit the use of pro-inflammatory fats and oils, as they reduce the effectiveness of omega-3 fatty acids. They're easy to remember: any oil, alone or in food, beginning with the letters "S" or "C". The only exception to this is canola oil.

Vurucu S, Demirkaya E, Kul M, Unay B, Gul D, Akin R, Gokçay E. Evaluation of the relationship between C677T variants of methylenetetrahydrofolate reductase gene and hyperhomocysteinemia in children receiving antiepileptic drug therapy.Prog Neuropsychopharmacol Biol Psychiatry. 2008 Jan 28

Zinc supplementation during lithium therapy

One of the most important things to understand about psychiatric disorders, is that they induce metabolic stress on the brain that can be significant enough to induce degeneration. An important treatment goal for any psychiatric disorder is to pursue balance and deter this process as much as possible.

Sometimes, as is the case with lithium, the treatment can be as deleterious as the disorder. In the process of stabilizing mood, lithium can also reduce the activity of several antioxidant enzymes. Antioxidants are chemicals that delay and prevent degeneration and aging. These enzymes promote chemical reactions that help to preserve brain tissue.

One very powerful tool that can slow down this process, is nutrition. Researchers in India were able to demonstrate that zinc supplementation given to rats who were also being given lithium, helped to restore antioxidant enzyme activity.

Zinc is required for many reactions occurring in the brain and nervous system so I'm not surprised at this. I also would venture to guess that other antioxidants would have been helpful as well. The message is not to load up on zinc, but to be sure that if you have bipolar disorder, that your nutritional choices include a wide variety of foods from all food groups. I'm always surprised at how little nutrition information is given to people for their psychiatric diagnoses. It's a powerful little strategy that can go such a long way!

Bhalla P, Chadha VD, Dhar R, Dhawan DK. Neuroprotective effects of zinc on antioxidant defense system in lithium treated rat brain. Indian J Exp Biol. 2007 Nov;45(11):954-8.

Caffeine and antidepressant medications

Over the short term (one day on meds), imipramine (Tofranil)and amitriptyline (Elavil) decreased, while fluoxetine (Prozac) accelerated the overall metabolism of caffeine. Nefazodone(Serzone) also stimulated metabolism, but through a more indirect pathway. To say it another way, the body more rapidly broke down and inactivated caffeine under the influence of these medications.

Fluoxetine given chronically increased an indirect pathway of caffeine metabolism. Sertraline (Zoloft) and mirtazapine (Remeron) enhanced the rates of all caffeine oxidation pathways.

I must qualify this study was done on rats, not humans, and I can't remember the last time I saw a rat in line chumming it up with the barista. Even so, it's not unreasonable to assume the same effects could be seen in humans.

So...if you're feeling like your Prozac may have reduced the effect of your double caf skinny no foam morning treat into a half caf regular cup of joe...it may not be your imagination!

Don't let that drug influence tempt you into buying a frequent flyer card at your local coffee haunt, though. Excess caffeine is associated with insulin resistance which can aggravate weight gain. Better to focus on better sleep habits (and less late night web sudoku)than on better productivity through chemical stimulation.

Kot M, Wójcikowski J, Daniel WA. Caffeine metabolism during prolonged treatment of rats with antidepressant drugs. Pharmacol Rep. 2007 Nov-Dec;59(6):727-33.

Antidepressants and risk of bone fracture

Are broken bones the price paid for a better attitude? Some researchers may think so. In a rather large study (124,655 fracture cases and 373,962 age and gender matched controls), relationships between fractures were seen with the following psychiatric medications:

Amitriptyline (Elavil), clomipramine (Anafranil), citalopram (Celexa), fluoxetine (Prozac), and sertraline (Zoloft) were all associated with an increased risk of fractures. Imipramine (Tofranil) and nortriptyline (Pamelor) did not demonstrate this association. Paroxetine (Paxil) showed a slight relationship but statistically it was insignificant.

No medication is perfect, ever. However, antidepressants are used for a wide variety of medical problems, and as you know if you read my blog, many of these uses are off-label. For anyone with a family history of osteoporosis, or in a demographic group at risk for osteoporosis, it is important to (1) weight the risks vs. benefits of your prescribed medication before taking it, and(2) consider consulting with a dietitian to enhance your diet and lifestyle choices to minimize the risk of bone-debilitating side effects.

Many of the lifestyle choices you are likely to be advised to adopt to prevent osteoporosis (more exercise, less soda, wider variety of foods) also enhance brain health. And what do you know--that may reduce your depressive symptoms as well.

(If you're getting tired of hearing that exercise, healthy food, adequate sleep, and less stress might be your answer...maybe that means you should try them...tee hee!!)

Vestergaard P, Rejnmark L, Mosekilde L. Selective Serotonin Reuptake Inhibitors and Other Antidepressants and Risk of Fracture. Calcif Tissue Int. 2008 Jan 25 [Epub ahead of print]

Topamax and kidney stones

I just ran across an abstract reporting increased uric acid and risk of uric acid stones in users of Topamax. This adds to my list--I'd already found an abstract on the increased risk of calcium phosphate stones. The uric acid research group recommends increasing fluid intake if on Topamax. I would think if you have a history of kidney stones it might be a good idea to discuss with your physician the possibility that another medication may be more appropriate.

Vega D, Maalouf NM, Sakhaee K. Increased propensity for calcium phosphate kidney stones with topiramate use. Expert Opin Drug Saf 2007 Sep;6(5):547-57.
Koçer A, Dikici S, Atakay S, Okuyucu E.Serum Uric Acid and Lipid Levels While Taking Topiramate for Migraine. Headache. 2007 Dec 27.

Anxiety disorder: medication vs. acupuncture

Chinese researchers recently investigated the effectiveness of acupuncture compared to psychotropic medications in the treatment of anxiety disorder. Eighty six patients with this diagnosis were assigned to one of three treatment groups: acupuncture only, medication only (primarily Prozac, Paxil, or Xanax), or a combination treatment. The most effective treatment appeared to be the acupuncture treatment, followed by the combination therapy, with medication having the lowest effectiveness. Acupuncture was even able to modify levels of platelet serotonin and plasma ACTH, a stress hormone.

If you are comfortable with complementary treatments for medical problems, and you have anxiety disorder, it might be worthy to engage an acupuncturist in your treatment to see if you respond as did the subjects in this study.

Yuan Q, Li JN, Liu B, Wu ZF, Jin R. Effect of Jin-3-needling therapy on plasma corticosteroid, adrenocorticotrophic hormone and platelet 5-HT levels in patients with generalized anxiety disorder. Chin J Integr Med. 2007 Dec;13(4):264-8.