About the Episode
Poor sleep can affect more than just energy. It can shape mood, focus, and mental health in surprising ways.
In this episode, Dr. Julie Lopez sits down with psychiatrist Dr. Andres Barkil-Oteo to explore the hidden connection between sleep apnea and mental health. They discuss why sleep apnea often goes unnoticed, how it can mimic depression or ADHD, and what steps you can take to uncover and treat it.
This episode is an empowering discussion on the hidden impact of sleep apnea and why it is essential to take action so that you can restore your mental and physical vitality.
Episode Guest
As an Associate Professor of Psychiatry at Georgetown University School of Medicine, Dr. Barkil-Oteo brings a wealth of knowledge and experience to our clinic. At Georgetown, he supervises the Mood and Anxiety Consultation Clinic (MACC), which specializes in the evaluation and treatment of complex and hard-to-treat anxiety and mood disorders.
Dr. Barkil-Oteo treats people who are experiencing a range of mental health challenges, such as anxiety, depression, job burnout, or trauma, and are seeking a comprehensive, holistic approach to their well-being. They are open-minded and motivated to explore conventional and complementary therapies to achieve a deeper level of healing. They recognize the importance of addressing their symptoms and the underlying causes and contributing factors, including lifestyle, nutrition, and emotional health. They aim to achieve a balanced, resilient mind, body, and spirit.
Dr. Barkil-Oteo’s impact extends globally through his work with NGOs in conflict zones, providing vital mental health services. He has coordinated mental health responses for refugee crises with Doctors Without Borders (MSF), conducted evaluations and training missions with the International Committee of the Red Cross (ICRC). He regularly collaborates with international organizations such as the IMF, World Bank, and UNICEF, advising on staff well-being and mental health policies. Dr.Barkil-Oteo completed his psychiatry residency at Yale University School of Medicine, pursued further training in public mental health at Columbia University, and honed his skills in psychodynamic psychotherapy at the prestigious Anna Freud Center in London, UK.
Connect with Dr. Andres Barkil-Oteo:
Watch the episode:
Episode Transcript
Introduction: Dr. Andres Barkil-Oteo
Julie: Hi, everyone.
My name is Dr. Julie Lopez, and I’m your host for Whole by Design. On this week’s episode, we will be diving into the silent, invisible, hidden topic related to mental health. You should stay until the end, where our guest is going to share the three primary ways that you can improve your sleep health today.
I’d like to welcome Dr. Andres Barquil-Oteo of Washington Interventional Psychiatry, who is a trauma-informed psychiatrist who gets great results for his patients on improving their mental health and overall improving their lives. Before we jump in, don’t forget to check out our website, www.vivapartnership.com for free and low-cost resources that can change your life.
Thank you so much for joining us, Andres.
Dr. Barkil-Oteo: Thanks for having me. I’m always excited to talk about sleep and sleep apnea and the importance of that for mental health.
Why Sleep Matters for Mental Health
Julie: I love that you picked this topic because, obviously, we all know that sleep is kind of a foundational element of well-being, but specifically how sleep apnea can be related to mental health, which has a lot of different facets to it, I think that’s something that the average person isn’t fully aware of.
Dr. Barkil-Oteo: Yes, and I’ve seen this a lot in my practice, so a few things. The idea that sleep relates to mental health it tends to be kind of common knowledge. Everyone knows that if they don’t sleep well, they don’t feel well.
The problem is, it seems like people don’t want to do anything about it, or they take it for granted that, okay, I’m not going to sleep because I have things to do, and that they feel not good. And then you try to kind of help them to improve their sleep, and that’s when kind of the problems start. So I started trying to advise people about sleep and how they sleep, till with more questions that I realized, oh, some people I see have sleep apnea.
And this is a close topic to me because I had sleep apnea 12 or 15 years ago, and I went through the stages of how I feel when people have sleep apnea, and then I got it treated, and it’s gone. And that made me much more attuned to the importance of sleep and sleep apnea regarding mental health. So I stumbled over this based on a personal experience.
Julie: So let me jump in really quick, because I think this is important. You said, like, you’ll tell people and they’ll realize, oh, yeah, sleep’s important. It’s important for all elements of health, including mental health, but they may not realize that they actually have sleep apnea, that while they think they’re sleeping and rejuvenating and recovering and resting from their day and setting themselves up for a great next day, they’re actually not, right? They’re sleeping, but they’re not getting restorative sleep.
What is Sleep Apnea?
Julie: Can you tell us a little bit about kind of that journey of discovering that, how someone could find out that they have sleep apnea, and then also what to do about it? Cause it’s like during an unconscious time, right?
Dr. Barkil-Oteo: Okay. Yes. So, um, usually people don’t know that they have sleep apnea.
Um, they will, uh, just feel that they are tired during the day. Um, now for just the basics of sleep apnea, basically, um, sleep apnea is what we are saying that people are stopping breathing during the night, uh, briefly. Uh, so they don’t wake up, but their brain wakes up because the drop of oxygen, their brain is very sensitive to when you don’t have oxygen because it consumes a lot of the oxygen to breathe.
So when there’s a drop in the oxygen, the brain wakes up, but it doesn’t wake you up. So you are in the state where your brain is up, but your body is down. You sleep six hours nonstop, but likely your brain is up more than half of the time.
So your body is rested. Your brain is not rested. And, um, and this happens just like the technicality of it.
We have something called obstructive sleep apnea. You have central and peripheral. The one more common is the one, um, that is the peripheral.
And basically, it’s the soft tissue around the throat, uh, collapses. So it closes the airflow. And that’s when the people, um, uh, wake up.
We see this a lot with, um, uh, classically, people who snore. Sometimes if you know, if you know someone who snore or you snore, the, uh, sometimes there is the experience where all of a sudden you can’t breathe and you wake up, which tend to be kind of the more dramatic fashion, but people don’t need to snore to have sleep apnea, which is, it’s one of the, kind of the main misconception because people say, well, I don’t snore. That doesn’t matter.
You could still have a brief moment of apnea, uh, during the night. The other misconception is, um, people think that only like people above BMI of 26 or 27 have sleep apnea. So I would see people who are, you know, largely fit or thin and like, there is no way I have sleep apnea, but there will, because, uh, only one category is obstructive sleep apnea because there is a lot of, uh, say like fat around the neck, the tissues are issue.
Some people have sleep apnea because of just how anatomically their, um, their palate relates to their jaw. So it’s not something that they acquire. There’s just something by design.
They have a narrow angle where the air hits the, hurts the throat and that could create sleep apnea. So because of that, a lot of people don’t think that they have sleep apnea. Now, uh, some of the, the clear signs when people know if there’s a problem is you ask them, okay, so you slept seven, eight hours.
Do you feel refreshed? Do you feel like you slept six hours, or do you feel like you haven’t slept the whole night? And this tends to be a good indication. Now, some people will have insomnia because of anxiety and that tend to, um, it’s normal and, uh, it tends to manifest in, um, difficulty falling to sleep and then waking up around 3 a.m. And 3 a.m. is a pretty common time to wake up because usually that’s when we are switching between sleep cycles. Um, so, and then they are able to go back to sleep.
With the sleep apnea, you don’t have to wake up, but your brain is up the whole night. So you wake up in the morning feeling very tired, not motivated, like you haven’t slept. And then you go about your day, um, there is the brain and the body manages, because you have a cortisol, um, peak happens around 4 or 5 a.m. to get you going.
So the brain manages to go about another like four or five hours. That’s when you start the day, you are tired, but you are functioning. And then we get to the, um, we get to the lunchtime and usually people after that, they have a, they have a sharp decline in their energy.
And this tends to be pretty typical for people with sleep apnea. If you, if you only have regular insomnia, just like you didn’t sleep well, usually you are tired throughout the day. You just, you know, don’t feel like you have a lot of energy.
The ones who their energy dips after lunch and they feel like they can almost have a nap if they can, sometimes there’s an indication of a sleep apnea. Um, so, so that’s, that’s from that part. Now, why this is important? Because first, um, if you can’t sleep, you feel tired.
Everyone experiences that. But with sleep apnea, because your brain didn’t sleep, um, you feel all the symptoms that we think usually are depression symptoms. So you feel slow, you feel sluggish, you feel not motivated because your brain at that point is running on a very little reserve energy.
So it only focuses on the main essential things to function and everything else is out of the window. So you are tired, not motivated. And then because also like is disturbed sleep physically, you don’t feel well, you feel, you feel fatigued.
Now there’s something interesting about the brain, um, with the relationship between the brain and the mind, like how the brain functions and how we feel, and also with the body. So when the body is tired, fatigued, that usually brings the mood down with it. Now we know this relationship from depression.
When people have depression, they have the mood component and the body kind of follows. In this case, it’s the opposite. So they are tired and then they are, they get depressed because everything just feels so heavy.
And sometimes one of the, one of the signs is, um, if people will say, people with depression usually will say, I’m depressed, clearly depressed, but also tired. People with sleep apnea will say, I’m tired. I’m maybe not as depressed or maybe not very depressed, but like I’m primarily tired.
But because it’s, we understand feeling tired, not motivated, not enjoying things as depression, they will come up as depression patients versus everyone versus thinking that they have sleep apnea. So the relationship between the body, the physical energy and the way we feel is intricate. And you know, if one is not doing well, it will pull the one with it.
How Sleep Apnea Mimics Depression and ADHD
Julie: Can I jump in just for a second? So this is really interesting, right? Because you’re a psychiatrist. So they come into your office, and you probably have a questionnaire asking them all kinds of things about how they’re doing on all these different levels.
Have you had patients where they themselves have identified as having depression and you’ve seen their symptoms go away when you, when you have really honed in on the potential that they have sleep apnea and that part is treated first?
Dr. Barkil-Oteo: So, uh, yes. If I tell you like, uh, if I got a dollar for every patient who was like this, I would have maybe a hundred dollars.
Julie: But I mean, words are powerful.
Labels are powerful. People, you know, read something. Oh my gosh.
Now we’re in the world of AI, right? People. Did you know this? This is just an interesting sidebar. Getting advisement for mental health is the fastest-growing area of AI usage.
So they’re asking questions like it used to be, Hey, I’m just going to consult Dr. Google. Right. And they might be like, all right, I’ve concluded I’m depressed.
Right. And then, and then you go down a path, like here are the top five treatments and here’s the way you do this. And here are the statistics about it.
And in fact, our human system is pretty complicated, right? It’s very easy for someone to go down the wrong path and then present in a certain way, if they’re not looking for the right thing.
Dr. Barkil-Oteo: Yeah. No, I’ve seen it.
I mean, not to go on a tangent, but like I see it with my family and friends and patients. People are talking to AI for like advice. And because it’s good, you know, we know the CBT, online CBT, a lot of it could be like a CBT-oriented.
Now, on the downside of things, there was actually an interview with Sam Altman, and he was talking about how they had, I need to get the numbers right, but like they had, like 70 cases of talking to AI, and then they end up committing suicide. Yeah. It’s a big lawsuit right now.
Yes. So, like, there is a downside to it because the AI in the end is trained to optimize the interaction. So it will lead you through different pathways.
Maybe it will make your symptoms worse if you are, unless it has some guardrails about like what to feed information, whatnot. It’s almost like the algorithm of Instagram, of YouTube, where they have this thing where teenagers with eating disorders will get more videos about trying to be thin, because it’s just an algorithm that will optimize what you are watching, and they know what you like, and they feed you more of it. So, like technology could empower our good side or our bad side, depending on how we use it.
Treatment-Resistant Depression and Sleep Apnea
Julie: Well, so I’m thinking about this very nuanced topic that you’re sharing about, and it sounds like many people actually go down a very logical path that’s actually incorrect because they’re not asking the right questions or they’re not looking for the right things. And especially because you’re saying sleep apnea is a very hidden thing. I mean, you just shared a few myths that were debunked that I’ve heard many times, people thinking, you know, if you’re overweight, that can cause sleep apnea, or if you snore, that’s what causes sleep apnea.
And, you know, you can just go down a path thinking, Oh, that has nothing to do with me, or I wouldn’t even think about that. I’m tired, and I must be depressed, or I feel so heavy, and I’m depressed.
Dr. Barkil-Oteo: Correct.
And to be clear, so we have two groups. We have a larger group who tend to have sleep apnea and depression. So two separate entities.
And we have a smaller group who tend to have largely sleep apnea. Now I’ve seen many in each group, but of course, I’ve seen more people who had actual depression and sleep apnea. I’ve seen a few who had just sleep apnea, and we treated them, and then all of a sudden it’s like, oh my God, they still have maybe a little bit of symptoms, but they don’t qualify for a clinical threshold anymore.
Now, to focus on the more common case, which tends to be people presenting with depression, they have a separate depression diagnosis, and they have sleep apnea, which they didn’t know about. And these tend to be the treatment-resistant depression cases. We are at Washington Dementia and Psychiatry.
We are kind of a tertiary outpatient care. We get a lot of consultation on patients whose depression is not getting better because we also do ketamine and TMS. So sometimes I see these cases and I’m like, okay, well, let’s talk about your sleep.
That’d be important. And then you realize they actually have sleep apnea, and then you treat the sleep apnea. Then they feel much better.
They are still on the same meds. It’s not like you’re going to take them. Maybe like you do use some of the meds, but I’m not saying that we can cure your depression with the, with the, with curing the sleep apnea, but it will make it much more manageable.
Julie: Well, let’s say treatable, right? Cause you’re saying it was treatment-resistant depression. It’s a question.
Dr. Barkil-Oteo: It will make it treatable.
It will become depression that you could treat.
Julie: Yeah. It’s huge, actually.
Dr. Barkil-Oteo: Yes. And I tell people like you, it doesn’t matter what I give you. Like you cannot outrun sleep apnea because basically your brain is, your brain is not getting enough oxygen.
So it’s up. And then if it’s up, then there is nothing we could do during the day to be more productive or, or like to be less depressed. The other presentation people come in a lot, is they think they have ADHD, and then you talk to them.
Many of them will have depression, and a subset will have depression because they have sleep apnea, and they can’t sleep because one of the more common sleep apnea symptoms during the day is brain fog. They can’t focus. And yeah, of course, you can’t focus if you are tired.
So then you help them with their sleep apnea, and all of a sudden it’s not like they become super performer, but they just become, you know, like me and you, where we are tired sometimes, but you know, we still function in a non-optimized way, but that’s fine. So that tends to be also like another presentation for sleep apnea.
Julie: Yeah.
It becomes so important to be, to have this on the radar before you start going down another area. And I think it’s actually a pretty huge shift to go from treatment-resistant depression, recognizing there’s some sleep apnea, to depression that is treatable, right?
Treatment-resistant depression feels just as hopeless as depression itself might feel right. There’s no, what’s the point? I can’t even do anything about this.
It’s kind of a similar.
Dr. Barkil-Oteo: Correct. You know, it’s like a, like a terminal illness where you cannot get over it versus, I’m not saying to be clear, every treatment resistant depression case is sleep apnea, but screening for sleep apnea is so easy and the treatment is so straightforward that even like nowadays, even on a suspicion that there is sleep apnea, just the people get the test and if it’s, if it’s negative, then, you know, move on with your life.
But if there is something here, then we actually hit something very important that we need to address.
Julie: Yes. And just to review, you said if someone might be curious whether or not they have sleep apnea, one of the signs is that they’d get really tired after lunch.
Is that right?
Dr. Barkil-Oteo: So it’s a, it’s a combination of waking up in the morning, feeling already tired, feeling like they haven’t slept then, you know, fatigue, brain fog, just down during the day. And then they do crash in the afternoon. Now, not, not many people have the luxury of being able to take a nap, but it’s like, it’s almost, if you are able to, you will take 20 minute nap.
Yeah. And that usually, you know, that doesn’t have to be after lunch, but anytime in the afternoon, because your brain is already like running out of, out of steam. Right.
Testing for Sleep Apnea
Julie: And then, well, this is super empowering, I think, is just being more sophisticated around our understanding of mood and what we might be experiencing and especially the sleep apnea piece.
So let’s say, you know, someone’s like, oh my gosh, I do wake up tired and my mood feels low. And then I definitely want a nap after lunch.
And maybe I related to you what you said about the brain fog. Like I noticed that I have that. Where would they go to get a test for sleep apnea? Could they ask any doctor to do it? Do you recommend a particular place?
Dr. Barkil-Oteo: Okay.
So, so this is really, this has been, honestly, I think the issue why sleep apnea has been so under, underappreciated because the, so the way to see if you have sleep apnea is to do a sleep study. And a sleep study traditionally would be done in the hospital. And then they came up with this device that you take home, and you sleep while having the device on you, and that will record it and you have to return it to the hospital.
Now, because these devices are expensive, they didn’t have many of them. So we always had a chronic problem with getting people access to sleep, sleep studies. The wait, three to four months, unless you are lucky, you have access to a sleep center that’s more efficient.
But my personal experience, and then many people whom I used to send for sleep studies that it just takes time. And because it takes time and people are not convinced that I need to do it, then people don’t do it. Unless you are the ones who can’t, we can’t stay up during the day, and then they crash when they are driving home, then, you know, it becomes a priority.
But a lot of people are like, you know, I’m just not going to bother. So recently, one company created a basically disposable device. It’s all from, you know, like it’s a pretty cheap plastic kind of thing that you use only once.
And the idea is, instead of having to have an expensive device that you then have to rent, basically, because you sent with the patients, we have a disposable device that they just give to anyone who wants to do the sleep study. So there is only one device in the market now. It’s sold by different websites.
But the device is called WatchPAT1.
Julie: Watch at one?
Dr. Barkil-Oteo: WatchPAT.
Julie: WatchPAT.
Dr. Barkil-Oteo: Yes.
WatchPAT1. Okay. So that’s a new device.
No financial affiliation. I have nothing to do with the company. But I haven’t seen any other device.
So this is why that’s the one. And it seems many websites now sell this exact device. So it doesn’t matter who the vendor is, they’re always going to sell you the same thing.
So basically, you sign up with the model of the business model of like how great sleep apnea is. They sell you the device because, for the device, you need a medical order to get the sleep study. So then that’s a problem because then you have to find a sleep specialist.
So basically, these companies sell you the device and the sleep consultation at the same time. Got it. So you go to the website, and you basically buy the device.
And with that, you get a sleep consultation. So you speak with a sleep specialist who asks you the questions of like tired, motivated, and all that. And then they will recommend the sleep study for you.
And then they send the device by mail, which arrives a couple of days later. It’s pretty self-explanatory. It’s like a smartwatch with an oxygen sensor and then a heart monitor rhythm that you put here.
And then you connect it to an app, you sleep one night, and this is it.
Julie: That’s it? That’s amazing.
Dr. Barkil-Oteo: The information goes through the app, through the company.
And the device is basically one-time used, recyclable. So basically, you throw it away or you send it back to them. And the whole thing can be done in a week versus it used to be…
Julie: Months, right?
Dr. Barkil-Oteo: Yes.
And then the co-pays, and then insurers won’t pay for the study, and all this nonsense. Now, the device, they run sometimes promotions, but I think it’s like around $160. And that includes the device, the sleep consultation, and the report.
Treatment Options for Sleep Apnea
Julie: That’s amazing. Gosh, such a difference. So what a great thing to roll out, right? If you suspect, and you gave us some ideas of how to test for that and really change the trajectory of how you might be looking at your depression or looking at your brain fog or looking at your ADHD or whatever it’s been classified as, because there’s so much that gets missed if you’re not checking for the sleep apnea piece, if I’m understanding you correctly.
Dr. Barkil-Oteo: Oh, correct. And of course, we don’t test everyone. We only test the ones who have high yield for the sleep apnea, which tend to be feeling tired, not motivated, then crashing in the afternoon.
But the ones, once they have the positive signs, it tends to be high probability that they will have sleep apnea. Now, for that, we have degrees with the sleep apnea. So we have the mild, moderate, and severe.
There’s an index that reflects how many times you stop breathing per hour and also how low your blood oxygen level goes down. Based on that, there’s a number. Now, the problem is, and it used to be the problem, and it’s still the problem, the money is really not from the device.
The money tends to be from the CPAP machines. So there is a tendency sometimes, not with everyone, but the moment you have some kind of sleep apnea, they serve you a CPAP machine. And of course, it works, but it’s an overkill, and it’s annoying, and people have to wear it.
So not everyone should be on a CPAP machine, only the ones who are more like moderate. The mild to moderate the mild could not be treated, and it’s fine. Many of us have mild sleep apnea and it doesn’t bother us that much.
But usually I tell people if it’s mild, then you already have the symptoms. So if your numbers are mild, but you have the fatigue and you have the inability to sleep, then you need treatment. And the main treatment is, if it’s not CPAP, something called a jaw advancement device.
So it’s basically, it’s a night guard, top and bottom, and the night guard basically pushes your jaw out. So it creates some space in the back, because we say the apnea is when your throat tissue collapses. So you can’t sleep.
So that pushes your jaw out, so it creates a space in the back, where you’ll be able to sleep.
3 Ways to Improve Sleep Tonight
Julie: Oh my gosh, I’m learning so much. I want to do it all.
And I could talk to you forever, but you know, we’re at that time where we have to shift gears. So I’m going to prompt you for what we promised at the beginning, which is the three ways to improve sleep right now that you recommend.
Dr. Barkil-Oteo: So prioritize sleep, it’s very important for health, mental health.
Second, and this is the common thing that’s a problem. People work till they drop, basically. So try not to do any work two hours before going to bed.
You’re going to feel tired and you’re going to be unproductive the next day. So it’s going to be a cycle. So you’d rather just get some break before you go to sleep.
Julie: So off the screens, stopping work two hours ahead of sleep time.
Dr. Barkil-Oteo: Correct. Now, if you want to see your phone, it’s fine, but try not to Zoom scroll before going to sleep.
This is not good for your sleep or anxiety. Third, there are a lot of supplements that could be helpful for sleep for people who are having mild issues with sleep. Magnesium is a big one.
Melatonin, we know a combination of these. There are plenty of supplements on the market. Just try something that helps.
But sleep is important. If you have constant issues with sleep, combined with what we talked about, the fatigue, then consult with your doctor to see if you could have sleep apnea.
Julie: Thank you so much, Andres, for all your wisdom with us today. Those three things, again, are number one, prioritizing sleep. Just as you already know intellectually, sleep is super important.
Take the actions to actually make it a priority. Number two, stopping work and screens two hours before bedtime. And number three was, let’s just see.
Dr. Barkil-Oteo: Supplements.
Julie: Supplements.
Dr. Barkil-Oteo: You should start getting medication.
Because some people end up supplementing with a glass of wine or two, which is not very wise. But I tell people, if you want to drink wine for enjoyment, it’s fine, but don’t drink it because you want to go to sleep. There is a safe supplement, like magnesium and melatonin, that could be very effective.
Julie: So great. Thank you so much for joining us on this episode of Whole by Design.
And thank you to our audience as well.
I hope it left you feeling inspired to toss out the labels, embrace new perspectives, and take one step closer to the joy and clarity you deserve. As always, visit www.vivapartnership.com to access our free and low-cost resources that will empower you and your loved ones on health and healing. Let’s spread the message, subscribe, review, or share this episode with someone who could benefit from a stigma-dropping approach to mental health today.
