Even with the best sleep habits everyone has trouble sleeping on occasion. Almost everyone would benefit by having medication available that safely provides good quality sleep.

Our internal clock (circadian rhythm) is regulated by bright sunlight. Even on cloudy days, it is at least ten times brighter outside than indoors. Bright light suppresses melatonin, (the body?s natural sleep inducing hormone). As evening approaches and light diminishes, melatonin increases. Under these conditions, melatonin peaks around 9:00p.m. Ideally, this would make going to bed at 10:00p.m. and waking at 5:00 or 6:00a.m. a healthy sleep schedule. Going outside for the first time at noon will set your sleep clock for 16 hours later, or 4a.m. This makes it very difficult to fall asleep even at normal bedtime.

Some individuals, especially the elderly are ?phase advanced?. This means melatonin peaks in the late afternoon, causing sleepiness. Even if going to bed is delayed, they often wake up in the middle of the night. They usually fall asleep in the early evening and then wake up 7 hours later at 3:00-4:00 a.m. They complain of not sleeping through the night, but are actually getting plenty of sleep.

This is helped by:

? Getting late afternoon sunlight

? Melatonin (see below) intake in the morning

? Minimizing morning bright sunlight

Others, especially teens and young adults tend to be ?phase delayed?. Phase delay may be due to lack of morning bright light, lack of any exposure to outside bright light, and excessive evening artificial light. They also tend to stay up late, even when they must get up early the next morning. Their melatonin peak is delayed to midnight or later.

This is helped by:

? Getting bright morning sunlight

? Melatonin (see below) intake in the evening

? Minimizing afternoon bright sunlight

Melatonin comes in 3mg tablets.

Starting dose-1/4 tablet sublingually 3 hours before bedtime if phase delayed. If phase advanced, take in the morning.

Increase the dose to 1/2-1 if needed.

This does not help sleep associated with hyper arousal. However it can help with jet lag, shift work, or changing the internal clock.

Another option is to use an artificial full spectrum, bright light. These can be purchased by companies such as Sunbox Corp (www.sunbox.com.)

Can you sleep too much? Yes! Since after 7 1/2 hours sleep you are getting almost all REM sleep, which uses MENTAL energy, you end up more sluggish.

What?s the difference between sleep and fatigue?
Sleepiness is improved by either a nap or vigorous physical activity, fatigue is not.

People who live long, healthy lives have good sleep habits. It is like regular car maintenance. ?Pay me now, or pay me later.? You can ?make up? 6-10 hours of sleep loss, but each day after inadequate sleep you will have higher levels of stress hormones and potential detrimental affects to your health. Make the time to sleep 7 hours every night, or subject your body and brain to increased wear and tear.”

Depression in women is more likely to be associated with anxiety. This is related to imbalances in the serotonin system, or hypersensitivity to changes in serotonin. In general, women do better on SSRI’s, Lexapro, Zoloft, Prozac, Celexa, Paxil and lower doses of Effexor XR. Women with pain, fatigue, or severe melancholic depression do better on antidepressants that also enhance norepinephrine. These include Effexor XR in higher doses, Cymbalta, and Remeron.
Premenstrual depression responds quicker than other forms of depression to medication. For PMDD, there are many advantages to using medication just for the last few days of the menstrual cycle and not during the entire month. The advantages include protection against long term weight gain, sluggishness, and decreased libido.
Rate of onset of medication effect is partly related to how much it gets tied to protein. Only the part not tied to protein crosses into the brain.
Protein binding of antidepressant medications:
Effexor XR-26%
Lexapro-56%
Celexa, Wellbutrin XL, Remeron-80%
Prozac, Paxil, Cymbalta-96%
Zoloft-98%
Since Effexor XR and Lexapro have much lower protein binding, they can be used in lower doses and closer to the time symptoms begin. In women with premenstrual exacerbation(PME), medication is usually taken every day but the dose may be increased premenstrually. Adding estrogen can frequently be helpful. Since oral forms of estradiol significantly increase protein binding this can cause problems with decrease in estradiol, thyroid, and testosterone activity. Non oral forms of estrogen and conjugated forms of estrogen (Premarin, Cenestin) are less likely to increase protein binding.
Alprazolam, by enhancing GABA, helps premenstrual anxiety that is partly due to dropping progesterone. Progesterone increases GABA activity and this effect is lost premenstrually.
Side effects associated with SSRI’s that are short term include:
• Nausea
• Jitteriness
• Headache
• Sluggishness
• Dizziness
• Delayed orgasm

The short-term side effects usually go away in a few days, but if bothersome can be managed by changing the time medication is taken, taking after sex if delayed orgasm, splitting dose to lower peak levels, or decreasing the dose. Some side effects can be blocked with Trazodone. Wellbutrin XL can help with sexual side effects. Ginger is used to help alleviate nausea.
Long term side effects include “poop out,” sluggishness, loss of libido, and weight gain.

? Depression is twice as common in women as in men
• Lifetime prevalence of depression in women is 21.3% and 12.7% in men
• 75% of depressed women that stop taking antidepressants during pregnancy relapse
• 50-80% of women experience some psychological or physical symptoms premenstrually
• Postpartum depression is more likely to happen in women who lack the support of a partner
• During perimenopause the risk of depression triples
• Depression is the main cause of disability in women
• Women are 3x’s more likely then men to become depressed in response to a stressful event
• 10-15% of mothers become depressed after the birth of a child
• In an unhappy marriage, the woman is 3x’s more likely to be depressed than the man
• Women tend to subordinate their own needs which can lead to depression
• Menopause is a time of decreased depression in women

Although medication can be very helpful in treatment of depression in women, it can’t make up for poor health habits. It is important to get 7 hours of good sleep each night, and 30 minutes of vigorous physical activity (preferably on a daily basis). It doesn’t have to be “exercise” it can be work or play. A good sex life has physical as well as emotional benefits.
Family/relationship problems that are not improving may benefit from counseling. Unresolved grief, feelings of helplessness, inability to control addictive behavior, sexual dysfunction, and suicidal thoughts that persist are some of the problems that can benefit from cognitive/behavioral treatment.
Cognitive therapy identifies negative thought patterns and teaches techniques to improve “self-talk.” Behavior therapy helps find better options for counterproductive behavior.

MOOD IN WOMEN IS EQUAL TO:
THYROID
X
ESTROGEN, TESTOSTERONE
X
SEROTONIN, DOPAMINE, NOREPINEPHRINE

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Thyroid - hormone that regulates activity level of every cell in the body. If thyroid is low, brain cell activity is low.

Estrogen - hormone that increases serotonin activity in the brain. If estrogen drops, serotonin activity drops, which can cause depression. Estrogen increases brain cell growth in areas that control mood and memory.

Testosterone - increases libido, and in the brain is converted to estrogen

Serotonin, norepinephrine, GABA and dopamine - brain cell transmitters. They are released by some cells to activate or inhibit adjacent cells. Serotonin regulates temperature, appetite, and sleep. Low serotonin can cause depressed mood and irritability. Norepinephrine increases arousal and activates muscles for fight or flight in an emergency. GABA is the brain’s natural tranquilizer. Dopamine increases to enable the pursuit of pleasure and well being.

SSRI medications approved for PMDD:
Sarafem (Prozac)
Zoloft
However, all of the other SSRI’s, (Paxil, Celexa, Lexapro) and Effexor XR are beneficial. They work by raising serotonin levels in the brain.

Judith Reichman quotes a patient in her book as saying: “so am I perimenopausal, or has an alien taken over my body?” Perimenopause is a roller coaster ride of hormones. The hormone levels fluctuate erratically because of intermittent ovulation. Estrogen continues to decrease,
Perimenopause occurs in the 40’s to 50’s. The symptoms include changes in periods, hot flashes, night sweats, vaginal dryness, sleep disturbances, concentration problems, libido changes, and mood swings. Perimenopause is the period of transition from regular menstrual cycles to amenorrhea. Therefore, the symptoms which are experienced during the perimenopausal years have a relationship to the changing of the reproductive functioning. Perimenopausal women have a much higher incidence of depression.

10-15% of women experience depression following childbirth. PPD occurs during the first four weeks after delivery, but can emerge as much as 2 years after giving birth. The hormone fluctuations (especially the drop of estrogen and progesterone) is greater than any other time in the life cycle. This causes vulnerability to mood disorders.

Other factors that can lead to PPD are:
• Lack of social and partner support
• Stressful life events
• Previous depression
In addition to the normal symptoms of depression such as sadness, depressed mood, and lost of interest and pleasure, the following symptoms may be present:
• Overconcern for the baby
• Guilt, inadequacy, worthlessness, feeling like a failure as a mother
• Fear of losing control or “going crazy”
• Lack of interest in the baby
• Diminished libido
• Anxiety
• Obsessionality

During the childbearing years, 3-5% of women experience physical and psychological symptoms that impair functioning. This is caused primarily by changes in hormone concentrations.
Symptoms of PMDD include the following:
• Depressed mood
• Anxiety
• Lability (sensitive, out of control)
• Irritability
• Decreased interest in usual activities
• Difficulty concentrating
• Marked lack of energy
• Marked change in appetite, or overeating/cravings
• Hypersomnia or insomnia
• Sense of being overwhelmed
• Breast tenderness, headaches
Symptoms must occur during the week before menses and remit a few days after the onset of the menses. Using a symptom tracking chart can aid as a guide for when medication would be beneficial in the cycle. Best meds for PMDD

? Hormonal - menses, pregnancy, menopause
• Victimization - sexual abuse, assault, harassment in the workplace
• Unresolved loss issues-past abortions, miscarriages, or infertility
• More sensitive to stress and seasonal changes
• Demands of multiple roles
• More likely to have atypical symptoms such as appetite and sleep increases
• Internalizing coping skills