Sleep Apnea Links To Depression, Anxiety

I think it was in my first practice, straight out of residency, that I learned about sleep apnea.  He was a private patient, a man about 40, who had his sleep apnea treated when some enterprising ENT (Ear, Nose and Throat doctor) fried his too-large tonsils.

Within the day or two it took the surgery to heal, he came to the office to tell me that his symptoms of anxiety and depression were totally gone. Well, if I had trouble breathing, I would be anxious and depressed too.  You want to get that oxygen, continuously.

Even if the tests , which technology has simplified over the years, show that you’ve got plenty enough oxygen in your blood, the fear of losing oxygen has got to be significant.  I remember, even as a little kid, with hay fever attacks, what it felt like to gasp for air. I can only start to imagine what it is like for those who gasp for air in the middle of the night.

So at a later time, a different patient shows up, a 53 year old man, and he tells me he wants some Xanax or at least some Ativan.  I have someone count his respirations — 14 in a minute, not too bad. He is using the muscles in his neck to hike up his chest to breathe. He has recently stopped smoking, much to his credit, but still has a solid diagnosis of COPD, (chronic obstructive lung disease) and this guy got it in spades, but the question remains does he have sleep apnea?

We are lucky.  His diagnosis was confirmed by a sleep study.  This means someone had to watch and measure him all night. He is still shocked that I made the diagnosis just by asking questions.  Not that it is hard to tell what is going on.  I heard a little bit of wheezing without a stethoscope.

First things first — I was not going to prescribe anything that could depress his heart or breathing.  That meant no Xanax.  To say that he was not happy with me was — at best — a gross understatement.

Then I got up the guts to tell him the truth. “Until we treat your sleep apnea, your anxiety and depression are NOT going to get better.”

Now when I first started telling this to people, the relationship between depression and anxiety and sleep disorders may have been something someone could debate.  Not now.

Now more of the research is looking for which people with sleep apnea are likely to be nervous and/or depressed. Nobody seems to be able to get their doctors to treat the situation. The CPAP machine, which delivers enough pressure to the muscles that are a little weak is hard to sleep with.  It is kind of like sleeping with an oxygen mask, they tell me. And it screws up your sex life “pretty much forever,” they tell me. There are doctors who are telling their patients that it’s no big deal – just live with it.

“They don’t know stuff like you do,” my desperate patient cried — a compliment I didn’t need.  Nobody among the general physicians he had known would fill out the papers to get him this thing.  A psychiatrist cannot.

I suggested a mouth piece to help keep his airway open.  He actually did the research and found it.  Cost over $200 dollars, which to this patient, was like two million.  I even told him if he bought the mouthpiece on-line, I could fit it to him using in the microwave in the staff lounge at work to soften the rubber and mold it to his mouth.

Someone sent him to a dentist.  MediCal does not even pay for regular dentistry anymore, let alone a sleep apnea mouthpiece, but he has no MediCal anyway. He is what they called direct county pay.

The best I could do was get him a list of medical doctors in the county who saw patients who had no benefits. (Doubtlessly receiving some kind of county compensation.) No, I have not heard from him.  I heard from his therapist he is no better, only angrier.  I soon after left the city where I met him.

A possible new technological advance is an implant that could help people with sleep apnea.

I find myself reading this and asking myself how much it will cost. Once the knowledge is established, as I believe the importance of treating sleep apnea to be established, at least to my satisfaction, in psychiatry, the question becomes, how do we get it to the people?

There are so many barriers. The first is the doctors’ knowledge. There is indeed a lot of knowledge that goes with being a family practitioner. (Personally, I think nobody should even try it without a computer online sitting in front of them.) Then, somebody has to establish if  technology really helps.  I mean, I do not recommend people to fry their tonsils the way I did a few years ago.

Someone has to do experiments and publish papers and such.  This kind of study is usually funded by some company that makes some kind of apparatus which strongly suggests that it could be (heaven forbid) a bit biased.  Few doctors know a whole lot about how to detect bias in research.  I know a bit and sometimes even I get flummoxed.

Only then comes the money.  The insurance, the copay, the bank account — People tell me all the time they cannot afford medical care. Many of those who tell me this have more expensive clothes (or even manicures) than I would ever purchase. Money has to be put aside for devices; yes, also for what they are worth as intellectual property, too.

How do you put a cost on breathing really well?