More Trouble Sleeping than Your Spouse?

Anxiety or Depression May Be the Problem

Thomas C. Neylan, MD

October, 2004

When it comes to sleep disorders, men and women aren't created equal. Women are more likely to have insomnia, beginning at midlife^1-3 and insomnia is among the most common complaints of menopause women.⁴ Researchers are now trying to find out why.

Investigators at the University Hospital of Freiberg, Germany, recently measured slow wave and REM stages of rest for both women and men and found higher rates of insomnia among women dealing with mood disorders and psychological stress.⁵ They suggests that low-level anxiety and depression may be the underlying cause of women's wakefulness.

The take-home message is this: In women insomnia may be driven by a strong emotional component. These patients may sleep more soundly and have a better quality of life if they are treated with low-dose antidepressants.

What is healthy sleep?

Healthy adults fall asleep about 10-15 minutes after they turn the lights out. Then they enter "slow-wave sleep," which is associated with restoration of the body and tissue repair.

They then alternate between slow wave and REM sleep, with each cycle lasting between 80 and 125 minutes.

The first REM cycle is short, lasting one to five minutes, but REM sleep increases throughout the night. In the second half of the sleep period, it is predominant.

Depressed adults have a harder time falling asleep, wake up more often, and get less restorative, or slow-wave, sleep.^6-9

In depressed women, sleep rhythms are more severely impaired than in men.^10-11 They are also more likely to feel low or emotionally vulnerable without a good night's sleep. So this cycle perpetuates itself.

Depressed women are also more likely to complain of weight gain, sensitivity to rejection, and irritability. They also worry about the effect of their moodiness on friends and family members, and they tend to get help sooner.

In contrast, depressed men tend to worry about their behavior on the job and only ask for help once that depression has become severe.^12-14

Trauma vs. the usual life challenges

Rosalind Cartwright has studied the sleep patterns of women who were in the process of divorce (http://www.4woman.gov/editor/jan00/jan00.htm). She found changes in REM sleep that were similar to patients undergoing a major depression. Their sleep patterns normalized after the situation was resolved.

Insomnia may be linked to garden-variety depression and be caused by divorce, family losses, empty nest, or job stress. Women in this situation often respond to SSRI antidepressants. SSRIs (Selective serotonin reuptake inhibitors) make more serotonin available in the brain, resulting in improved mood and better sleep.

SSRIs can also be effective for women with low-level anxiety.

Women who have suffered traumas resulting in nightmares or profoundly disturbed sleep, however, are more likely to need antidepressant medication combined with psychotherapy.

One of our patients whom I'll call Claudia was sexually assaulted when serving in the military. Her sleep was grossly affected; she had trouble both falling asleep and staying asleep. She often dreamt about her attacker. She was hyperaroused, and any sudden noise from traffic or the heating system would leave her sitting up in bed, her heart pounding.

Since Claudia was assaulted in her sleeping quarters, the bedroom was now linked with feelings of anxiety and threat. (This problem is not uncommon for sexually abused women.) We used intensive Cognitive Behavioral Therapy to help Claudia reduce her fear response. This involved relaxation exercises, deep breathing, and distraction techniques. The goals were both to take her mind away from the assault as she was trying to fall asleep and also to gradually reduce her sensitivity to traumatic memories.

Claudia's sleep was so severely disrupted that we prescribed a sedating antidepressant called mirtazepine.

We are currently initiating a study at the San Francisco Veterans Affairs Medical Center on gender differences in sleep, related to post-traumatic stress disorder (PTSD) Preliminary data indicate that women complain of sleep disorders more frequently than do men.

The physical consequences of insomnia

Disturbed sleep can elevate glucose levels and make a woman more resistant to insulin.

It is also associated with elevated blood pressure and increases in the hormone cortisol, which has been linked to depression.

One of the first lines of defense for women with insomnia is exercise. A number of studies show that exercise has robust and positive effects on mood, anxiety, and sleep quality. A half hour of aerobic exercise four times week often produces excellent results.

If you are working out regularly and still have trouble sleeping, you should inform your primary care physician.

The second line of defense consists of drugs - antidepressants, with or without sedative effects - and, in some cases, psychotherapy.

No matter what the cause, long-term sleep deprivation can have serious consequences, and symptoms should not be neglected.

Ethnic variations

Researchers have also found ethnic variation with regard to sleep disorders. Non-European women, for example, are more likely to have breathing disorders that interfere with a good night's rest.¹⁵ According to the National Sleep Foundation, sleep apnea may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke.

In general, premenopausal women are protected from sleep apnea by the hormone progesterone, which is a respiratory stimulant. When progesterone declines, postmenopause, women are almost as likely to start snoring and develop sleep apnea as men.

HRT (hormone replacement therapy), however, is not the answer. The Women's Health Initiative Study found that HRT had little impact on sleep and was not much better than a placebo. Certain forms of apnea can be addressed with dental appliances that change the position of the jaw. A sleep specialist may also prescribe a sleeping mask that forces air through the nasal passages. Some patients require surgery to increase the size of their airways.

Sleep disturbances have been linked to decreased exposure to light in certain ethnic groups.¹⁶ One study found that African-American, Native American and Hispanic women spent fewer hours in the sun. Light exposure is important for strengthening and consolidating circadian rhythms. These are responsible for our overall pattern of sleeping and waking.

These individuals often respond to bright-light therapy. SSRI antidepressant and light therapy are also prescribed for those suffering from Seasonal Affective Disorder (SAD), mood swings that occur in dark winter months.

For more information on the link between insomnia and depression and the effectiveness of antidepressants, contact The National Sleep Foundation http://www.sleepfoundation.org/ask/sleepanddepression.cfm

Notes

1. Ohayon, 1996
2. Partinin, 2000
3. Mitchell, 1996
4. Voderholzer, 2003
5. Armitage, 1997
6. Reynolds, 1987
7. Knowles, 1990
8. Berger, 1993
9. Armitage, 1997
10. Armitage, 2000
11. Thase, 2000
12. Nolen-Hoeksema, 1995
13. Shaw, 1995
14. Kripke, 2004
15. Kripke, 2004

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Kripke DF, Jean-Louis G, Elliott JA, Klauber MR, Rex KM, Tuunainen A, Langer RD. Ethnicity, sleep, mood, and illumination in postmenopausal women. BMC Psychiatry. 2004 Apr 7;4(1):8. [Full text]
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