Barry Rotman, MD

Beyond the Pill: Natural Ways to Fight Depression

Unfortunately, depression isn’t rare. Approximately 3.8% of people experience depression at any point during the year (including 5% of adults), and every individual has a 29% risk of being diagnosed with depression in their lifetime.

Although medication is a common treatment for depression, it’s not a cure-all. The response rate of a major symptom reduction is usually only 50–60%. (A placebo’s symptom reduction rate is 30–40%.)

Introduced in the 1980s, Prozac was the first selective serotonin reuptake inhibitor (SSRI). However, the difference between the drug effect and the placebo was slight, and so few studies showed efficacy that Pfizer had to cherry-pick studies to get FDA approval.

Drugs don’t cure depression. We still don’t understand the biochemistry behind depression, which is why our drugs’ efficacy is so poor.

Therapy has documented efficacy for depression. It’s harder to study than drugs, but medication and therapy combined can achieve up to an 80% reduction in symptom scores.

Because we don’t have a single depression-busting magic bullet, we treat it through stacking (also called the “everything but the kitchen sink” method). By bundling modalities, including natural ways to fight depression, we see more benefits than with any single treatment. 

So, can depression be treated without medication? Absolutely.

A Physician’s Caveat

Medical literature offers varying degrees of support for natural ways to fight depression.

The safer a treatment, the more likely I am to recommend it to a patient even if it lacks strong, supportive data. It all comes down to the risk-benefit ratio — if a treatment’s risk is low enough, I’ll try it.

These therapies are safe, and I’m not bothered by the paucity of data on their efficacy. That said, don’t consider or use them in lieu of medication or therapies prescribed by your physician. Talk to your doctor first.

12 Non-Pharmacological Treatments for Depression

The following are my top recommendations on natural ways to fight depression and other non-pharmacological treatments for depression:

Sleep Enhancement

Sleep impairment is associated with emotional illness, including bipolar disorder and depression. Any action taken to enhance sleep mitigates these conditions’ symptom burden.

Every other treatment on this list improves sleep.

Light/Chronobiology

Circadian rhythm is a large component of emotional illnesses such as bipolar disorder and depression. Re-synchronizing your circadian rhythm with light therapy can play a prominent role in these therapies.

At Banner Peak Health, we recommend the TUO light bulb to help re-sync your circadian rhythm. Get as much morning light as possible, and be cautious of using sunglasses during the first few hours of the day. Morning light is a powerful signal for your circadian rhythm.

Fish Oil

While literature supporting its effects on the heart is controversial, literature supporting fish oil’s antidepressant effects is strong. Just one to two grams daily helps manage depression (and may also improve your heart health).

Meditation

Mental health is associated with greater sympathetic discharge (cortisol, stress, and anxiety). Meditation, including breathing exercises, reduces your stress response and improves your mental health.

Exercise

Aerobic and strength training exercises reduce stress, enhance sleep, and improve mood. It’s a valuable weapon in the fight against depression.

Nature

We’ve evolved over hundreds of thousands of years to exist in nature. Our urban environment is so new that we haven’t evolutionarily adapted to it yet. Exposing yourself to nature helps you harness your evolution to your benefit.

Pet Ownership

People who own pets or even have access to visiting pets in nursing facilities have better mental health.

We live more solitary lives than ever before in our evolutionary history. Any contact with human beings or pets connects us to how we evolved to survive, both physically and mentally.

Nutrition

When our mental health declines, we crave substances like sugar, fats, and caffeine that worsen, rather than improve, our emotional state.

To improve your mental health, adopt a healthier diet.

Avoiding Substance Abuse

When we’re not feeling our best, we gravitate toward substances that hurt our mental health. We’re better off when we eliminate marijuana, alcohol, nicotine, and other counterproductive exogenous substances from our lives.

Acupuncture

Acupuncture is a proven non-pharmacological treatment for depression. Anyone who’s had it has felt its calming, centering effects. It’s worth a try if it’s available in your area.

Vitamin D

Higher vitamin D levels are associated with many better medical outcomes, including mental health. However, whether taking supplemental vitamin D improves medical outcomes remains controversial. Fortunately, taking supplemental vitamin D is safe in almost all circumstances.

Of note, please discuss this with your doctor, as there are some rare conditions in which over-the-counter vitamin D may not be helpful.

Herbal Supplements (e.g., St. John’s Wort)

St. John’s Wort is one of many substances and herbal supplements recommended for treating depression. However, the data documenting their efficacy is meager, and the side-effect ratio for some supplements is not as benign as other modalities we’ve discussed.

For example, St. John’s Wort can cause the following side effects:

• Headaches
• Dry mouth
• Confusion
• Anxiety
• Stomach upset
• Drug interactions

I’m including St. John’s Wort and other herbal supplements for completeness, but the risk-benefit ratio is not as good as the other modalities on this list. People inevitably ask about them, but I’m not bullish on them.

Today’s Takeaways

Stress and depression are ever-present in our modern world. Fortunately, there are many effective non-pharmacological treatments for depression with exceptional risk-benefit ratios.

If you’re struggling with your mental health, please reach out to a therapist or schedule an appointment with a Banner Peak Health physician. We’re here to help.

If you need immediate assistance or know someone who does, help is available 24/7 at the Suicide and Crisis Lifeline. To access it, dial 988 from any phone.

by Barry Rotman, MD

How to Keep Your Knees Healthy: Preventing Injuries and Pain

With enough wear and tear, all mechanical devices (e.g., engines, hinges, tires, etc.) degrade.

For many years, conventional wisdom said the same about our knees. They were just biological hinges that would inevitably give out over time, especially with overuse, such as running. Trying to figure out how to keep your knees healthy was a lost cause, especially for athletes.

A study that began in 1984 turned this notion on its head.

How to Keep Your Knees Healthy: The Shocking Truth

Doctors at Stanford tracked two study groups to test the hypothesis that knees are analogous to mechanical hinges that wear out over time.

The study followed 45 recreational, long-distance runners and 53 non-runner controls over 18 years. The participants were predominantly men with a mean age of 58. The runners had at least 10 years of running experience and ran an average of five hours per week.

At the beginning of the study, 6.7% of the runners and 0% of the non-runners showed X-ray evidence of arthritis. The participants had X-rays of their knees taken every few years.

At the end of the 18-year study, the results flabbergasted everyone: 20% of the runners had evidence of some form of arthritis, while 32% of the controls did. Even more startling? Only 2.2% of the runners had severe, disabling arthritis, while 9.4% of the controls did.

The non-running controls had over four times the rate of severe arthritis in their knees as the runners. The results contradicted the original hypothesis and debunked the myth that running damages knees.

Important Caveats

The study’s participants were:

• Uninjured
• Mostly men
• Over age 50
• Recreational, long-distance runners

The study definitively answered whether knees wear out over time for that population. They don’t.

Unpacking the Conventional Wisdom

Where did the notion that athletes have “bad” knees (or are destined to) come from?

Countervailing literature on high-intensity sports, including ballet, soccer, wrestling, and weightlifting, shows that athletes can have three to six times the level of degenerative arthritis as non-athletes.

When you examine the literature for sports that have increased rates of degenerative arthritis and remove injured athletes, there’s no increased risk of degenerative arthritis. The literature tells us that running makes a healthy, uninjured knee healthier.

Conversely, a sport that injures a knee causes the knee to wear out faster. The goal is to safely participate in sports that can strengthen the knee without injuring it. How can you find the right balance?

Let’s examine the knee’s anatomy to understand why this happens and how to keep your knees healthy with appropriate exercise.

The Knee’s Anatomy

The knee contains “hard stuff” and “less hard stuff.”

The “hard stuff” is bones:

• Femur
• Patella
• Tibia
• Fibula

The “less hard stuff” is cartilaginous tissue, tendons, and ligaments:

• Lateral meniscus
• Medial meniscus
• Lateral collateral ligament
• Medial collateral ligament
• Anterior cruciate ligament

The lateral and medial meniscus act like washers to cushion the areas between the bones. The ligaments connect the bones and align your knee.

When the anatomy works well, exercise perfuses the soft tissues and cartilage. Cartilage is avascular, meaning it contains few or no blood vessels. The medial meniscus, for example, gets nutrition from the synovial fluid.

Synovial fluid bathes and lubricates the entire knee joint when you move your knee. The more effectively you move your knee, the more you nourish those soft tissues.

If you injure your knee — for instance, if you tear a meniscus or ligament — you change the knee’s mechanical alignment. At that point, you’ve disturbed the anatomy of the knee and changed how the force is distributed within the joint, which increases your likelihood of generative arthritis and joint wear.

In contrast, maintaining an injury-free knee strengthens it.

How to Keep Your Knees Healthy

With this understanding of anatomy and pathophysiology, here’s how to keep your knees healthy:

1. Exercise. It strengthens the bones and enhances the knee’s surrounding musculature, protecting and aligning it. Exercise also moves the synovial fluid around, maintaining cartilage health.
2. Practice extreme caution with high-impact, injury-prone sports. Every sport, even running, can injure you. If you participate in high-risk sports, maintain your flexibility and strength, and don’t overdo it.
3. Remember that running is a double-edged sword. When done properly, it’s good for your knees, but if you injure your knees while running, your risk of arthritis increases. Practice safe running techniques:
   • Pay attention to your gait. Watch videos online or talk to a coach.
   • Wear appropriate footwear. Use insoles if you need them for proper alignment.
   • Avoid carrying extra body weight if possible, but if you must, maintain strength and flexibility. Extra weight demands more of your knees.

If you feel pain, remember that musculoskeletal pain is a message from your body. Don’t ignore it. Figure out what your body is trying to tell you.

Knee pain can be a valuable lesson if you listen to your body and decipher its message. Did you run too far? Do you have a bad gait? Do you need different shoes? Listening to your body is the best way to keep your knees healthy.

At Banner Peak Health, we’re proud to offer the resources you need to achieve optimal health through our Outperform program, including access to fitness instructors. Contact us today to take advantage.

by Barry Rotman, MD

Your Guide to Belly Breathing: Benefits, Techniques, and More

I’m 62 years old and have taken about 500 million breaths. Recently, I learned that most of these breaths were done improperly.

Why do we breathe? We take in oxygen for our metabolism to generate energy. We exhale CO₂ (metabolism’s byproduct) to expel it from our bodies.

Given the vital necessity of breathing, we’ve evolved a complicated, sometimes redundant breathing mechanism. It involves a multitude of muscles that expand the lungs (to inhale) and natural elasticity that contracts them (to exhale). The muscles involved are:

• In the neck
• In the shoulder girdle
• In the chest wall
• The diaphragm (one big muscle that lines the bottom of our lungs and depresses)

These muscles make up the redundant anatomy, which we use in different combinations.

Different Forms of Breathing

There are two types of breathing: chest breathing and belly breathing.

Chest breathing is the predominant type and involves the muscles on the sides of the rib cage, in the neck, and in the shoulder girdle.

Belly breathing, or diaphragmatic breathing, relies on the diaphragm to depress the lungs into the abdominal cavity and enlarge them.

How Breathing Develops

As newborns and young children, we default to belly or diaphragmatic breathing. It’s more efficient — bringing the diaphragm down expands the lungs more efficiently than chest breathing.

Because of the functioning of our nervous systems, most of us transition to chest breathing at some point in life. As we become more anxious, we become more sympathetically driven (i.e., the sympathetic nervous system, fight or flight) in how our autonomic nervous systems coordinate our breathing. We tend to take more shallow, rapid breaths with our chest walls.

Belly breathing is more calming. It involves a more parasympathetic (i.e., rest and digest) tone that consists of the diaphragm coming downward.

The Cycle of Stressful Breathing

Improper breathing creates a vicious cycle: We breathe improperly because we’re stressed, and our breathing mechanism becomes more stressed (sympathetically driven) because we breathe improperly.

So, how can we escape the cycle?

We can retrain our bodies to use distinctively diaphragmatic breathing like babies do. Watching a baby breathe, you’ll see the tummy move up and down. That’s the kind of breathing you want to mimic.

Retraining Your Brain to Breathe Right

The autonomic nervous system is a two-way street. It causes us to breathe a certain way; however, if we consciously breathe a certain way, we can rebalance our autonomic nervous system.

This rebalancing begins with consciously recapturing (or relearning) diaphragmatic breathing.

Benefits of Diaphragmatic (Belly) Breathing

Studies show many benefits associated with belly breathing. The most common are:

• Increased parasympathetic tone, which can lead to:
  • Increased heart rate variability
  • Reduced anxiety
  • Reduced cortisol
  • Reduced blood pressure
  • Reduced heart rate
• More effective and efficient breathing:
  • More oxygen is taken in
  • More CO₂ is expelled
  • Increased athletic performance
  • Improved cognition
• Reduction in GERD (gastroesophageal reflux disease)
• Reduced neck stress
• Improved posture

Organs below the diaphragm and muscles above it work better with belly breathing. People who belly breathe experience less stress in their neck and shoulder muscles and also have less gastroesophageal reflux.

How to Practice Belly Breathing

Although breathing is an unconscious process, we can reprogram our default (how our unconscious breathing works) through conscious training.

To apply this training, follow these instructions for five to 10 minutes, three to four times daily:

1. Lie on your back with your knees bent and a pillow under your head, or sit upright in a chair with your torso upright and your feet flat on the floor.
2. Place one hand on your upper chest and one on your abdomen, slightly below your ribcage.
3. Inhale slowly through your nose.
4. Focus on feeling your abdomen rise under your hand.
5. The hand on your chest should be still.
6. Exhale through pursed lips. You should feel your abdomen fall, and your chest should remain still.
7. Repeat for 5–10 minutes.

Let your hands guide you. If the hand on your chest moves, you’ve got it wrong. Correct your inhalation so only the hand on your abdomen moves.

You’ll have to think about every single breath. Eventually, this technique will lead to a shift in your automatic breathing.

As-Needed Breathing Techniques

We all deal with stressful situations in which focused breathing can help us relax. These techniques will help you do just that, and plenty of literature supports their efficacy.

Box Breathing

Box breathing is perfect for improving focus and marshaling your resources when you’re feeling overwhelmed. Don’t think of it as just another hippy-dippy, granola-loving new-age practice. Navy SEALs and tactical police officers use it in high-stress situations.

Here’s how to start:

1. Inhale for a count of four.
2. Hold your breath for a count of four.
3. Exhale for a count of four.
4. Hold your breath for a count of four.
5. Repeat.

4-7-8 Breathing

When you’re feeling anxious or stressed, the 4-7-8 breathing technique can help. Many people also find it useful when they have trouble falling asleep.

Here’s how to practice it:

1. Inhale through your nose into your belly (use belly breathing) for four seconds.
2. Hold your breath for seven seconds.
3. Exhale slowly through pursed lips for eight seconds.
4. Repeat.

Today’s Takeaways

After so many blogs chronicling stress’s adverse effects, I’m happy to offer practical, cheap, operational techniques to tip the scales in the other direction.

Try paying attention to how you breathe. See if making a conscious effort to revert back to belly breathing improves your life.

Identifying the latest science-backed ways to improve your health is a huge part of what we do at Banner Peak Health. If you want to learn how we can help you improve yours, we’re just a phone call or email away.

by Barry Rotman, MD

What Is Non-HDL Cholesterol? Understanding Your Heart Health

When doctors order traditional lipid panels as part of annual blood tests, patients see “non-HDL” and often ask, “What is non-HDL cholesterol?”

The question reminds me of reading Shakespeare’s “King Henry IV” in high school.

In the play, the character Prince Hal has five different names. This confused me until I realized all those names refer to the same person. Once I understood that, the play and plot became clearer.

The terminology used in medicine influences our comprehension and treatment options. Non-HDL is one of the least understood characters in the cholesterol metabolism “play.”

Blood Is Like “Oil and Water”

Our blood isn’t a homogenous liquid. It’s more like an oil and vinegar salad dressing. In this example, the water component of our blood is the “vinegar,” and the fat is analogous to the oil.

Fat doesn’t dissolve in water. Therefore, the fat forms little protein- and phospholipid-covered balls suspended in the blood.

Cholesterol’s Purpose and “Cast of Characters”

There’s no such thing as “good” cholesterol or “bad” cholesterol. A cholesterol molecule is exactly the same whether it’s contained in a “good” HDL particle or a “bad” LDL particle. We need cholesterol to build cell walls, manufacture hormones such as testosterone, and make bile acids to digest our food. Too much cholesterol in the wrong place, such as the walls of our arteries, confers its “badness.”

Understanding the “characters” that comprise the “play” of cholesterol metabolism is helpful.

“Main Characters”

HDL and LDL are the “main characters” featured in cholesterol. You’ll see them on your lipid panels.

• LDL (low-density lipoprotein):
  • It carries cholesterol from the liver to cells and the rest of the body.
  • It can carry excess cholesterol to arterial walls to create dangerous buildup.
• HDL (high-density lipoprotein):
  • It carries cholesterol from the body back to the liver for reprocessing.
  • It reduces the amount of cholesterol deposited on arterial walls, where it can cause damage.

“Supporting Characters”

The following are some “supporting characters” to help you better understand cholesterol.

• VLDL (very low-density lipoprotein):
  • It primarily contains triglycerides and very small amounts of cholesterol.
  • VLDL transports triglycerides from the liver out to the body.
    • Your body uses these triglycerides for immediate energy in muscles or energy storage in fat cells.
• IDL (intermediate density lipoprotein):
  • As a VLDL particle delivers its triglycerides, it becomes proportionally richer in cholesterol and becomes an IDL particle.
• Chylomicron (ultra-low-density lipoprotein):
  • It’s primarily a triglyceride-containing particle that transports fat from the gut to the blood.

What Is Non-HDL Cholesterol?

Non-HDL cholesterol is your total cholesterol minus HDL cholesterol. In other words, non-HDL cholesterol is the sum of LDL, VLDL, IDL, and chylomicron.

Why Measure Non-HDL?

Non-HDL cholesterol is easy, cheap, and convenient to measure. It’s a better predictor of coronary artery disease risk than LDL alone — especially when LDL isn’t elevated.

The Crucial Role of Lipoprotein B-100

Returning to the oil and water analogy, you might imagine a chaotic mix of tiny balls floating through your bloodstream. However, that’s not the case.

Each ball has a set of lipoprotein markers that identify its contents and the route it must take through the body to arrive at its designated location. Think of it like a passport.

A single lipoprotein called B-100 (“APOB”) occurs on each non-HDL particle.

Why is it important?

All non-HDL particles confer risk because they contain cholesterol, and blood vessel walls can absorb them. This means non-HDL cholesterol is potentially atherosclerotic and can contribute to cardiac disease.

Today’s Takeaways

Gaining a better understanding of lipid physiology and your lipid panel is beneficial for reading lab results and becoming more informed. This way, you won’t need to ask, “What is non-HDL cholesterol?”

Banner Peak Health employs non-HDL (or APOB) because it’s the most accurate risk assessment tool. The more accurately we can gain insight into your atherosclerotic risk, the more accurately we can target and mitigate that risk. Maintaining and improving your health is always our priority.

by Barry Rotman, MD

Normal Oxygen Saturation by Age: Measuring and Monitoring

We all want to know we’re healthy and aging well. But what does oxygen saturation tell us about our health? What is oxygen saturation? Is there a normal oxygen saturation by age? Is it a good metric to track and gauge our health against?

Pulse oximetry is a tool worth understanding, and it’s essential to only use it in conjunction with qualified healthcare.

What Is Oxygen Saturation?

Our metabolism uses oxygen, which makes up 21% of our air, to produce energy. Oxygen saturation is the percentage of oxygen bound to the hemoglobin (a protein in red blood cells) in our blood.

However, the process is complicated.

Imagine a city (the body) where various construction sites (tissues) need lumber (oxygen) to function. Trucks (hemoglobin) go to the lumberyard (lungs) to pick up their cargo. They follow this system:

1. Trucks (hemoglobin) arrive at the lumberyard (lungs) empty.
2. Workers (alveoli: tiny air sacs in the lungs) load lumber (oxygen) onto the trucks.
3. Each truck can carry four pieces of lumber (each hemoglobin binds four oxygen molecules).
4. Fully loaded trucks leave the lumberyard (lungs) and enter the highway system (bloodstream).
5. The highway has a central hub (the heart) directing traffic to different parts of the city (body).
6. Trucks (hemoglobin) travel along various roads (blood vessels) to reach construction sites (tissues).
7. The trucks (hemoglobin) turn bright red when loaded with lumber (oxygen).
8. At each site, workers unload (release) the needed lumber (oxygen) for use (absorption into cells).
9. Empty trucks return to the lumberyard (lungs) to pick up more cargo (hemoglobin returns to the lungs).
10. When empty or carrying less lumber (oxygen), the trucks (hemoglobin) appear darker, with a bluish tint.

This cycle continues, ensuring a constant lumber (oxygen) supply to all construction sites (tissues) in the city (body).

How to Measure Oxygen Saturation

We measure oxygen saturation in two ways: blood testing and pulse oximetry. While drawing arterial blood for lab tests is accurate, it’s painful and inconvenient.

Pulse oximetry is non-invasive. It measures the color change of the hemoglobin to determine oxygen saturation. Blood with ample oxygen is reddish, while blood with depleted oxygen is more purple. Additionally, it measures your pulse rate — the quantity of hemoglobin that moves through your skin every time your heart contracts.

How Accurate Are Pulse Oximeters?

Source: Mockup Graphics via Unsplash

Pulse oximeters come in medical and over-the-counter (OTC) grades.

We don’t know the accuracy of OTC-grade devices because they aren’t FDA-approved. FDA medical-grade pulse oximeters are more accurate (±2–4% for oxygen saturation in the 90–100% saturation range). However, these devices become less accurate when oxygen saturation falls below 90%.

In addition to the inherent error source from the devices themselves, common use errors include:

• Too much ambient light
• Inadequate wait time between measurements
• Insufficient perfusion
• A cold finger or poor finger placement
• Nail polish on the measured finger

A pulse oximeter’s ability to detect the color of hemoglobin can be influenced by skin color. Darker skin containing more melanin absorbs more light and can produce falsely high readings.

An example occurred during the pandemic when many relied on pulse oximeters to triage medical emergencies. Tragically, people with darker skin were less likely to have their low oxygen levels show up on pulse oximeters.

As a result, during the height of the pandemic, this demographic probably suffered during triage decisions in the Emergency Department, being sent home when their true oxygen levels were lower than displayed on a pulse oximeter. This was an inexcusable ethical lapse by the medical community.

Use Cases for Pulse Oximeters

The best use case for this device isn’t a single measurement, but looking at an individual’s changes over time.

During the pandemic, we gave anyone who tested positive for COVID an OTC pulse oximeter and instructed them to monitor their oxygen saturation. Rather than looking for “normal oxygen saturation by age,” we looked for change in individuals.

For example, if a person’s pulse oxygenation looked like this: 94, 94, 94, 89 — we knew we had a problem.

Now, we recommend these devices for a very narrow set of conditions. When a member has a lung infection or lung impairment, such as an emphysema flare, pneumonia, or severe COVID, we use a pulse oximeter to monitor the illness over time, trying to detect a worsening.

Is There a Normal Oxygen Saturation by Age?

Technically, yes, there are age-related changes to oxygen saturation. Children, young adults, and middle-aged people usually have between 97% and 100% oxygen saturation. Once a person reaches 70 or older, their number will be closer to 93–97%.

However, as mentioned, even the higher-quality FDA-approved pulse oximeters are only accurate to ±2–4%. Any difference due to aging is less than the device’s accuracy. So, you can’t accurately measure change due to aging by measuring a single person.

Today’s Takeaways

Pulse oximeters are an important technology, but they’re only helpful for monitoring individual changes over time.

They’re prone to inaccuracy and are often used incorrectly. The device can create more anxiety than it alleviates. It’s not a valuable instrument at home, independent of consulting a doctor.

If you’re concerned about your oxygen saturation compared to the normal oxygen saturation by age, visit your healthcare physician and use a pulse oximeter in conjunction with their advice.

by Barry Rotman, MD

How Long Does Melatonin Stay in Your System?

Can’t sleep? Do you finally get to sleep but can’t stay asleep? You’re not alone.

Millions of people experience sleep disruption, insomnia, or some form of sleep disorder. They take sleeping pills and supplements in the hopes of solving their sleepless nights, only to find themselves more exhausted.

What about melatonin? It’s all natural, right? It must be better than Benadryl! But how much should you take? And how long does melatonin stay in your system?

These are important questions to ask before taking any medication or supplement, and we’ve got the answers.

What Is Melatonin?

First discovered in 1958, melatonin is a hormone manufactured by a part of the brain called the pineal gland. Here’s how the process works:

1. We have special non-image receptors in the back of our retinas that perceive light and darkness.
2. As these receptors detect darkness, they send a signal to the brain region called the suprachiasmatic nucleus.
3. The suprachiasmatic nucleus triggers the pineal gland to secrete melatonin.

Melatonin is the “hormone of darkness.” It helps to synchronize our circadian rhythm (i.e., internal clock) with the light and darkness of the world around us.

Melatonin as a Supplement

Since melatonin is a crucial hormone for normal biological function, its use as a supplement has become popular in recent years for various reasons.

The global market value for melatonin supplements in 2022 was $2.15 billion, projected to increase to $8.64 billion by 2032.

The literature on the efficacy of melatonin supplements varies. Some studies show benefits, and others show none. The key component to consider is the root cause of insomnia.

For example, melatonin can be helpful for people with delayed sleep phase disorder (aka “night owls”) because it’s a circadian rhythm issue — tied to when your body makes melatonin.

If we think of your sleep as a house, we want to investigate the reasons for the cracks in the walls rather than simply painting over them.

Most prescription medications are like paint: They cover the cracks but don’t repair them. We want to find and fix the root cause of the damage.

Causes for insomnia can include medication side effects, unresolved pain, associated mental health challenges (e.g., anxiety, depression, PTSD), substances (e.g., nicotine, alcohol, caffeine), and more. A sleeping pill doesn’t address any of these.

Who Might Melatonin Be Helpful For?

Since it’s a natural hormone, melatonin naturally affects our circadian rhythm, helping to correct circadian rhythm disorders.

Here are some examples of people for whom melatonin can be helpful:

• Night owls can use melatonin to adjust their sleep habits and improve insomnia.
  • There is both individual and age-related variability among night owls. Teenagers are naturally night owls due to hormonal changes during that life stage.
• People experiencing jet lag can use melatonin to recover faster.
• Studies have shown that melatonin can improve sleep disorders associated with Parkinson’s and Alzheimer’s. Both have reduced melatonin production as a part of the disease.

What if You’re Not in One of Those Categories?

The literature supporting the use of melatonin supplements is slim. However, it’s a remarkably safe compound — much safer than prescription (e.g., Ambien or Lunesta) or OTC sleeping aids (e.g., Benadryl, aka diphenhydramine).

When we look at the risk vs. benefit ratio, the benefits far outweigh the risks. That said, there are some potential side effects to be aware of. These include:

• Daytime sleepiness
• Change of mood
• GI disturbance
• Nightmares
• Headache
• Dizziness
• Nausea

Remember that the FDA doesn’t regulate supplements. So, if you want to try melatonin as a supplement, be aware and informed.

A study from 2017 found that the content of melatonin measured in the products varied dramatically (between -83% to +478%) from the amount listed on the package labels.

How Long Does Melatonin Stay in Your System?

Like many medical questions, the answer to “How long does melatonin stay in your system?” is “It depends.”

According to one small study, melatonin remained in the subjects’ systems for an average of five hours. However, at higher doses (>50pg/ml), it took as many as 10 hours to leave the bloodstream completely. At 10 hours, the dose may extend into post-awakening hours and affect other activities.

However, as we mentioned, there are very few studies on melatonin, and this study, although controlled and randomized, had only 56 participants. We need more larger studies to learn definitive answers about melatonin and its effects and applications.

Melatonin Use Cases and Recommendations

Currently, the most common use cases for melatonin supplements are:

Delayed Phase Sleep Disorder

People with insomnia have a difficult time falling asleep. For them, we suggest an extended-release supplement four hours prior to the desired bedtime.

This mirrors the physiology of our endogenous hormone, melatonin, inducing sleep. It builds slowly over time and signals a natural bedtime.

Additionally, we recommend blue light-blocking glasses. This is because blue light signals our body to suppress melatonin. Tip: Blue light-blocking glasses must be amber-colored. If the lenses are clear, they aren’t strong enough to block all blue light.

We suggest wearing the glasses two hours before bedtime and not removing them until you close your eyes. People in this group include:

• Teens
• Night owls
• People with anxiety
• People with fibromyalgia

Preterminal Insomnia

These people wake up in the middle of the night and have trouble staying asleep. The best way to use melatonin to treat this form of insomnia is to absorb it as quickly as possible.

I recommend low-dose, 1mg lozenges — break one in half or quarters. You really only need a small fraction of the 1mg.

Keep the broken lozenges at your bedside so you can stay in darkness and relax until it kicks in. It may take up to 20 minutes, but the benefit is that it won’t cause daytime sedation. The people most often affected by preterminal insomnia are:

• People with anxiety
• People with jetlag

Melatonin Supplement Recommendations

For most people, less is more. We suggest a dose of between 600 micrograms (mcgs) and one milligram (mg) for most people taking a melatonin supplement. Patients with Parkinson’s or Alzheimer’s may benefit from a higher dosage, 5–10 mgs, to compensate for their bodies impaired ability to make melatonin.

We recommend these two brands* of melatonin supplements:

• Short-acting: Source Naturals Sleep Science® Melatonin
• Time-release: Life Extension Melatonin Six Hour Time Released Vegetarian, 300 MCG

*Not affiliated or sponsored

Since the literature on this topic comes up short, I base these recommendations on my decades of personal and professional experience.

Today’s Takeaways

• Before taking any sleep supplement or medication, determine the root cause of your sleep disorder.
• If you need a supplement to help with sleep, melatonin is safer than many alternatives.
• If you use melatonin, decide whether you need a fast-acting or slow-release formula. This depends on your use case.
• How long does melatonin stay in your system? It depends. The average is around five hours, but it can be up to 10, so tread carefully and remember that less is more.

If you have questions about melatonin or sleep medicine, reach out anytime. We’re here to help!

by Barry Rotman, MD