Between puberty and menopause women are twice as likely as men to be anxious or clinically depressed. This vulnerability has been found in multiple countries and ethnic groups and is not just due to socio cultural factors.
Differences in men and women are:
• Frequency of depression and anxiety
• Types of depression and anxiety
• Associated conditions
• Responses to stress
• Types of stress
• Duration and severity of symptoms
• Preferred medications
• Dosages of medications
• Role of hormones
Symptoms in women are especially prominent premenstrually, during pregnancy, post partum and perimenopausal. Dropping levels of estrogen cause symptoms in susceptible women. Menopause has not been found to be a period of increased risk for depression.
The role of hormones (estrogen, progesterone, DHEA, and testosterone)and brain transmitters (serotonin and GABA) have been extensively studied. All of these factors guide the treatment.
More than half of all adults will experience a significant stress disorder in their lifetime. Clinically depressed men and women are very likely to have other concurrent stress disorders. Women most commonly have anxiety and eating disorders. Men are more likely to have alcohol or substance abuse.
Women are three times as likely as men to have seasonal affective disorder. This is a common form of depression referred to as “atypical” because instead of the normal symptoms of depression, loss of appetite, weight decrease, inability to sleep and blunting of normal feelings, in atypical depression they tend to overeat, gain weight, sleep excessively, overreact emotionally, feel rejected, and may have a feeling of “leaden paralysis.” It is as though they have gone into a hibernation state. Since seasonal depression most likely occurs in the winter, there is probably an underlying adaptive mechanism that gets activated.
In general, women are more reactive to stress and are more stressed by problems associated with family and home. Men are more stressed by issues with work and finances. Men are also more likely to respond to stress by taking action, or increasing physical activity. Women tend to seek social support and are more likely to internalize conflict. This can cause women to develop physical symptoms of illness. These include low thyroid, chronic fatigue, irritable bowel, migraine, pain, interstitial cystitis, and fibromyalgia.
Women are more likely than men to seek help for their symptoms, but men are becoming more aware of the effects of stress on functioning and quality of life. There is an old TV ad where a mechanic holds up a can of engine additive for cars and says, “you can pay me now or you can pay me later.” In women as well as men the earlier the recognition of symptoms and the better the patient education and treatment, the less the suffering, long term complications and the higher the quality of life. The goal of complete remission of symptoms and return to full functioning can usually be achieved through collaboration between the patient and the PCP and/or psychiatrist.

“Insomnia phobia” is a phrase I use to describe the fear of not being able to fall asleep.
Fear has an alerting effect and wakes you up! Telling yourself, “don’t worry about it!”, won’t help if you don’t have the confidence that you will get enough sleep. Cognitive therapy can help. Having a sleeping pill nearby to take if needed is also a way to help eliminate the fear. Even if you don’t use the medication, it allays anxiety, allowing you to lightly focus on something else as you drift off.

• MOOD is affected more by sleep deprivation than are cognitive skills or physical performance
• A 45 minute nap can improve alertness for the next 6 hours … a 1 hour nap can improve alertness for 10 hours
• Healthy sleep prepares the brain for the next day and renews mental balance
• Laboratory rats deprived of sleep died in only 16 days
• Inadequate sleep is probably the most common cause of irritability
• Untreated insomnia can lead to a worsening of a sleep disorder and the onset of depression
• Alcohol and OTC sleep aids DO NOT result in normal sleep
• 33% of traffic accidents are caused by sleepiness
• The invention of the light bulb by Thomas Edison marked the beginning of sleep loss and abnormal sleep rhythms
• Negative effects on sleep can be measured even 16 hours after ingestion of 200mg of caffeine (which is 2 cups of coffee)

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SLEEP AND ALCOHOL An individual that can drink one glass of alcohol and show no impairment when rested can become … An individual that creates “fatal fatigue” with only one glass of alcohol when sleep deprived

Sonata - 10mg is probably the mildest sleep med. Since it totally wears off in 5 hours, there is no a.m. grogginess. If there is ever an emergency during the night you should be able to function normally and have full recall (memory) in the a.m.
Ambien - 10mg is 2 1/2 times stronger than Sonata 10mg and lasts 7-8 hours. The main advantages are duration, depth of sleep, and lower cost. Disadvantages (mainly at full dose of 10mg) include possible a.m. hangover, and if an emergency occurs during the night, there may be some lack of awareness and memory for the events in the a.m.
Gabitril - Is not indicated for insomnia, but
works well to increase stage 4 sleep and allow normal dream sleep.
Provigil - This is a mild stimulant used to
treat daytime sleepiness associated with narcolepsy, shift work sleep disorder, and obstructive sleep apnea/hyponea syndrome.
Neurontin and Xyrem - both of these medications also allow normal sleep to occur with normal dream sleep and increased Stage 4 sleep.

Breathing Technique Steps:
Close your eyes and focus on breathing
Reduce tension by breathing out FIRST
Slowly, exhale by saying ‘s H H H H?
Next inhale and count “1 2 3 4”
Hold and count “1 2 3 4”
Slowly, exhale again, “1 2 3 4”
FEEL THE TENSION LEAVING THE BODY

Since you can’t “do sleep,” trying to force its onset will only cause the opposite to occur. Instead, try to shift focus away from sleep. Read, watch TV, focus on breathing, thumb through a magazine or book, or listen to soothing music. Shifting focus to activities that are non’stimulating to you, will relax the mind and body, and allow sleep.
Sleep Restriction - Limit time in bed to match actual time needed for sleep. Start with 5-6 hours only and increase by 30 minutes at a time only if sleeping most of the time when in bed.

There are two basic types of sleep:
Non-REM (NREM) sleep - This includes stages 1-4 of sleep.
Stage 1 is very light sleep, and stage 2 is transitional sleep.
Stages 3 and 4 are deep sleep. They occur in the first 3 hours of sleep. Stage 4 is the only restorative sleep phase. It increases energy in the brain cells, releases growth hormone, and builds the immune system.
Dream, REM sleep - mainly starts after 3 hours of sleep. Each 90 minute cycle has a higher percentage of REM sleep. Although the brain only weighs 3 pounds, it uses 25% of our O2. More O2 is used during REM than during waking hours. That is why sleeping 9 or more hours can make you feel mentally drained.
Studies show that learning takes place during sleep. We show more benefit of study/practice in the morning after good sleep.

DEPRESSION - Sleep disorders are both a risk factor for and a symptom of depressive disorders. A study of 373 adults showed that 60% of people being treated for depression also had insomnia. Depression causes delayed sleep onset and awakenings, especially early morning awakenings. REM occurs earlier and is more intense. Dreams are usually negative.
Stage 4 sleep is usually decreased the most by depression. This can inhibit the body’s ability to promote growth hormones and boost the immune system. Early morning awakenings, possibly caused by cortisol are common. Cortisol (stress hormone) is higher than normal during serious depression. Cortisol releasing hormone causes a decrease in stage 4 and increase in REM sleep.

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BIPOLAR-MANIA - Mania usually creates a feeling of high energy and reduced need for sleep. Severe insomnia can result. Sleep is essential for the bipolar individual. It helps reduce the risk of a manic episode.

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ANXIETY - Most anxiety disorders have related insomnia. Anxiety causes vigilance and an inability to “turn off the mind.” This results in problems going to sleep and also produces shallow sleep.

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PANIC ATTACKS - Sleep related panic attacks can be found in up to 30% of those with the disorder. Night time panic attacks occur three hours after going to sleep. This is during stage 4 deep sleep when breathing becomes shallow and CO2 levels peak. Individuals with panic disorder are extremely sensitive to CO2.

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MEDICATIONS AND INSOMNIA

Most of the antidepressants which are used to treat depression can initially cause insomnia (especially if taken at night). This is due to the stimulating or activating effect they have on the system. Antidepressants include the SSRI’s-Zoloft, Paxil, Prozac, Celexa, Lexapro and also Wellbutrin XL, Effexor XR, most Tricyclics, and MAOI’s.
Antidepressants that increase stage 4 sleep include Remeron, Serzone, Trazodone, and Elavil. They decrease REM. Most antidepressants should be started in the morning and switched to bedtime later, (dinner time with Effexor XR) if sluggishness begins to occur.
The Benzodiazepines (Xanax, Klonopin, Ativan) improve sleep continuity by promoting quick sleep onset and reducing night awakenings. However, they don’t give normal sleep because they decrease stage four sleep.

Everyone has a range of stimulation within which they function. They are excited at the higher end and relaxed at the lower end. But everyone also has a level of stimulation below which they are bored and above which they are overstressed.
ADD/ADHD people tend to have a problem at both ends. They need higher stimulation than normal people, and are bored with routine levels. This causes an inability to concentrate. But they are also overloaded or stressed too easily. It is hard for them to focus on one thing at a time when there are multiple stimuli.
Stimulants help both problems. They turn on the brain to enable concentration on the lower level stimuli. Stimulants also allow focus on one thing at a time when there are multiple stimuli, which helps the ADD person to be less hyper and more relaxed.

? 3-6% of elementary children meet the criteria for ADD, but only 25% of those receive treatment
• The primary cause for ADD is genetic:

92% of identical twins are both ADD

33% of fraternal twins are both ADD
• As many females as males are ADD
• 40-60% of ADD children remain so as adults and only 15% are symptom free
• ADD causes problems with social skills:

fewer friends

more likely to divorce
• 3 X more job changes
• 2 x more likely to run away from home
• 2 1/2 times more serious auto accidents
• 10 x more teen pregnancies