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We should tell our patients to sleep well, eat well and exercise more. A surprising prescription, or perhaps simply common sense – backed by impressive evidence. A cross-disciplinary approach was on the agenda at the ECNP 2019 Expert Science Exchange on reducing the burden of non-communicable diseases. It was also an invigorating work-out, and not at all conducive to sleep.
Globally, 71% of deaths are now from non-communicable diseases, notably cardiovascular conditions, cancer, diabetes and chronic lung disorders.1 Affective disorders, anxiety and schizophrenia are major risk factors and linked to the increased overall morbidity and mortality.
“Sleep is the golden chain that binds health and our bodies together”, wrote the English dramatist Thomas Dekker four hundred years ago. And perhaps he was right.
“Sleep is the golden chain that binds health and our bodies together” – Thomas Dekker, 1572-1632
Insomnia – defined as difficulty in initiating or maintaining sleep that has persisted for three months or longer – seems to have a causal role in many illnesses, increasing the risk of disorders that extend from hypertension and diabetes to depression.2
Indeed, there is a case for considering sleep a vital sign in psychiatry -- as important as blood pressure in cardiology. The appearance of sleep problems can be a precursor of relapse, and may be one of the last symptoms to remit.
Tackling insomnia and sleep apnea
In people with depression and insomnia, treating the sleep problem also benefits the mood disorder.3 And this is an important consideration, since we have an effective, evidence-based and inexpensive intervention in cognitive behavior therapy for insomnia (CBTI). Participants take the course online, but are given individual guidance by a therapist.
Use continuous positive airway pressure (CPAP) ventilation to treat sleep apnea in people with schizophrenia who are also obese
In people with schizophrenia who are also obese, obstructive sleep apnea can be troublesome. Screening for the problem involves a simple questionnaire, followed if necessary by oximetry at home and a night in the sleep laboratory.
The apnea is eminently treatable using continuous positive airway pressure (CPAP) ventilation. A pilot study from Australia has found that CPAP in people who have schizophrenia and obstructive apnea improves not only sleep but also cognition and hypertension.4
In optimizing sleep quality in people with mental health problems, it might also be helpful to refer on any bladder and prostate problems that lead to night-time waking.
A focus on nutrition
The implications of adverse early life experience for adult mental health are well known, as is the possibility that an initial vulnerability may require a “second hit” before it is expressed.
Micronutrients are not only building blocks but also signaling molecules
The Expert Science Exchange heard of preclinical studies suggesting that nutrition may modulate the effects of early life events, perhaps through epigenetic mechanisms. The possible role of vitamins B6, B12 and folate, and of omega-3 and omega-6 fatty acids is being investigated in animal models of stress.
Micronutrients are not only building blocks but also signaling molecules. Their effects might be mediated through inflammatory pathways, and there is now great focus on obesity as a pro-inflammatory state. We know that connectivity in the brains of children born to obese mothers differs from that in neonates with normal-weight mothers.5
There is now increasing evidence that obesity in adults relates to brain pathology, including that is seen in dementias and depression.6 Obesity, especially visceral obesity, “metastasizes” to the brain in the sense that the insulin resistance and inflammation associated with overweight is linked to loss of brain volume and connectivity.
Obesity is hazardous for the brain
Indeed, if depression is a disorder of drive and the experiencing of pleasure, so too is obesity. Both involve abnormal cognitive control, and obesity can be viewed as brain disorder.
Exercise versus obesity
Obesity can be hazardous for the brain, and its adverse effects increase with duration. The other side of the coin is exercise, which seems capable of inducing brain trophic factors that benefit both brain volume and function – although probably only if undertaken with an intensity that leads to breathlessness. In those who have already developed depression, a meta-analysis adjusting for publication bias now shows that exercise has antidepressant effects.
The content of this article was derived from an Expert Science Exchange session sponsored by Upjohn.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
2. Garg H. J Family Med Prim Care 2018;7: 876–883
3. Blom K et al. Sleep 2017;1:40(8)
4. Myles H et al. Schizophr Res Cogn 2019; 15: 14–20.
5. Li X. Int J Obes (Lond) 2016;40:1931-1934
6. Bischof GN, Park DC. Pychosom Med 2015; 77(6): 697