As many of you know I travel abroad 3 or 4 times a year, mostly to visit family or go to conferences.  So many of us have gone global… there are 30 million travelers who fly from the US for destinations that are at least 5 or more time zones away from their home. Most suffer from jet lag upon arrival at their destination and then, alas, upon return. A recent review of jet lag appeared in the New England Journal of Medicine. I thought it appropriate (as I prepare to fly 7,000 miles in early April,) to share this pertinent information with you.

Jet lag is due to a temporary misalignment between your internal clock (termed the circadian clock) and local time. Your brain’s time and function follows a light-dark cycle set by the sun. And this internal clock does not readjust at the speed of jet travel. As a result, many travelers experience insomnia, daytime sleepiness, mood changes (I get grumpy) and fatigue. Fatigue may also be due to the fact that you are immobile, don’t eat right, become dehydrated and stressed with log-distant air travel. (And I am not even considering the stress that must have accompanied that recent “delayed flight” on Virgin Atlantic lasting 17 hours from LAX to JFK!)

There are a number of factors that contribute to jet lag:

• The number of time zones crossed: Obviously, the more the worse it gets, and if the trip is long, even if the number of crossed time zones are not great (i.e. the same latitude), travel fatigue can cause symptoms.
• Direction of travel: It is usually more difficult traveling east then west .Most people find it is easier to lengthen the day than to shorten it. (Unless like me you are a “morning type”, in which case the reverse can happen.) It’s estimated that the circadian clock resets an average of 92 minutes each day on a westward flight and 57 minutes earlier each day after an eastward flight.
• Sleep loss during travel: Chances are if you are in coach you will not be able to stretch out and go to sleep.
• Loss of light cues (exposure to natural light at your destination): If it’s the “wrong” time or if you arrive in non sunny weather, you don’t get the sun light that helps your brain adjust.
• Ability to tolerate circadian misalignment: Some people just can….hope it’s our politicians! Tolerance seems to decrease with age. Oi!

There are a few strategies that seem to somewhat mitigate jet lag:

• Optimize light exposure: Try to get  bright sun light in the evening if traveling Westward, not the early morning  and seek exposure to bright light in the morning if traveling Eastward (you get up much earlier so try to take a morning walk.)
• Take melatonin: Melatonin is the hormone that is secreted for about 10 to 12 hours at night and is a darkness signal. You can purchase melatonin without prescription. To promote shifting of the body clock to a later time when you travel westward take 0.5 mg during the second half of the night until you become adapted to local time. If you are traveling eastward take 0.5 to 3mgs at local bedtime nightly until becoming adapted.
• Schedule sleep changes ahead of time: Try to go to sleep 1-2 hours later than usual for a few days before your westbound trip and go to sleep 1-2 hours earlier for a few days before your trip east.
• Sleep medications. They help; you might try taking medications such as Ambien or Lunesta at bedtime for a few nights until you have adjusted to local time.
• Agents that promote alertness: Caffeine works, but avoid it after midday so it won’t adversely affect your sleep. Armodafi (Nuvigil)l and Modafinil (Provigil) which are drugs approved for narcolepsy and for shift workers (to improve alertness) have been show to reduce symptoms of jet lag if taken in the morning. They are not yet FDA approved for jet lag. Side effects include headache and nausea.
• On the plane: If possibly fly after you have had a good night’s sleep. Travel in business or first class (but know your health insurance won’t pay for this, even if your doctor recommends it). Drink lots of water, don’t consume caffeine if you expect to sleep on the flight, and don’t imbibe alcohol if you take a sleeping pill. You can try taking a short acting sleep medication such as Sonata. If the flight is more than 10 hours you can consider taking a longer acting sleeping pill such as Ambien or Lunesta.  (Make sure the flight takes off and is OK before taking any of these.)
• Exercise when you are at your destination…it can have an impact on your circadian rhythms.

So here’s hoping you have a safe and uneventful trip and that a few of these tips will help you enjoy the first few days of your arrival and return. I will be off trying all these jet lag preventions during the first 2 weeks of April. I’ll be back in the office and seeing patients after the 15th. I intend to be alert!

Most of us can point to depressing episodes in our lives….woes befall all of us: the economy, personal loss, worries about errant spouses, children (remember, we are only as happy as our most unhappy child) and aging parents. And I haven’t even begun to list the enormity of the global energy problems, international conflicts and consequences of disease. (If I keep going, I’m bound to find something that depresses you!) There is, of course, a difference between having to deal with either personal or large scale social issues that lead to sadness and worry and the occurrence of true clinical depression. The best way to define the latter, without going into treatises put out by the American Psychiatric Association, is that nothing gives you pleasure; nor can you function in your everyday mode of life. If you feel that you are in a dark tunnel with no light at the other end, day after day; you are clinically depressed. And a huge number of us are… up to 25% of women develop clinical depression at some point in their lives (more then twice the prevalence of clinical depression in men, which may be a reflection of our genetic capacity for concern and sensitivity).

Clinical depression peaks in our reproductive years. Nine percent of women will have an episode during or within 3 months of pregnancy. The consequences can be harmful to both mother and child. There are entire medical journals dealing with “the safest way” to deliver a baby, the pros and cons of Cesarean vs. natural delivery, the concerns about vacuums, forceps, routine episiotomy, not to mention tables to ascertain desired weight gain, concerns about preterm deliveries and of course tests to ensure the genetic integrity of our offspring. But few Ob Gyns are trained to either recognize or treat clinical depression in pregnancy. When asked by a patient whether it is safe to start or continue antidepressant medication during pregnancy….we hem and haw. Here is what I now tell my patients:

Women are more apt to develop depression during pregnancy if they:

• Have a history of depression at any time including a previous pregnancy or postpartum.
• Have been diagnosed with clinical depression in the past.
• Have a family history of depression, especially during pregnancy or postpartum.
• Have other psychiatric illnesses (panic disorder, obsessive-compulsive disorder, bipolar disorder, substance abuse).
• Marital instability…this cover a lot of issues, I translate it as a non supportive, or worse yet, abusive spouse.
• Unplanned pregnancies …unfortunately as many as 50% of pregnancies are not planned).

Depression can harm a pregnancy:

Studies have shown that women who are depressed during pregnancy have twice the risk of cesarean section, premature delivery and neonatal intensive care admissions of the newborn as well as four times the risk of delivering a low birth weight infant when compared to women who were not depressed. Depression and severe stress can cause changes in the hormonal environment in which the fetus is developing (This includes steroids such as cortisol, maternal brain hormones, estrogen, progesterone, insulin and growth hormones to name a few). The theory is that this “upset” hormonal milieu can impact fetal growth and fetal programming so that the infants, especially those born at lower than expected birth weights to women who were significantly depressed or stressed during their pregnancy are at future increased risk for schizophrenia, cardiovascular disease, type 2 diabetes osteoporosis and depression.

Treatment: Is it Safe in Pregnancy?

All psychiatric medications cross the placenta. If a pregnant woman is mildly or even moderately depressed (a brief definition: she has no thoughts of suicide, has not needed medication for depression in the past and is able to continue her usual functions) then traditional psychotherapy may be all she needs to successfully deal with her depression. (And we have all become more familiar with therapy sessions after watching Gabriel Byrne). But if her depression is moderate to severe and medication has helped in the past, her best option would be pharmacologic….i.e. antidepressant medication. And the current recommendation is to use the drug that previously worked. Clinical depression is a medical disorder that, like diabetes or hypertension can adversely affect the outcome of pregnancy…not treating it will create a greater risk for a woman and her unborn child than treating it. There has been a reluctance to include pregnant women in many pharmaceutical studies conducted in the past, but as the need to address depression in all women becomes apparent, antidepressants are now being investigated for use during pregnancy.

SSRI’s (Selective Serotonin Reuptake Inhibitors)
There are many….each with a slight change in chemistry, indication and side effects. Medications in this category include Zoloft, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, and Serazone. As I write this, more are being introduced. Multiple studies have shown there is a very low absolute risk of congenital anomalies when these medications are used during pregnancy. But the pharmaceutical companies and prescribing physicians must include appropriate reports of adverse effects….sort of like the list of everything that can go wrong at the end of those direct-to- consumer ads you see on television (usually stated in a hurried, breathless manner by a male voice) or read in the patient information provided with the prescriptions.

So here are some: There have been studies that describe an increased risk of abdominal and skull defects with first trimester use of SSRI’s and a rare cardiac defect with Paxil. (Although a Canadian study contradicted the latter.) There has been no evidence of fetal malformations due to use of Prozac in pregnancy…this is indeed the most studied (and oldest) SSRI.

There maybe a sight increase in miscarriage rates among women who take antidepressants compared to nondepressed women: 12.5% v. 8.7%. (It’s difficult to establish if this is due to the meds or their underlying depression). There are also reports that third trimester exposure to SSRI’s can cause tremor, breathing, sleeping and feeding problems in newborns, but this is usually mild and disappears after 2 weeks. The long term good news is that these medications appear to have no effect on exposed children’s IQ, language development or temperament.

Benzodiazepines (such as Valium, Xanex, Dalmane, Ativan, Klonipen. Restoril)
There have been studies that may have shown an increase in cleft palate in infants exposed to benzodiazepines but other studies have not… quite frankly the literature is not definitive.

Lithium
This is considered relatively safe during pregnancy: but it may increase an exposed infant’s risk of a rare cardiac valve problem. The recommendation is to stop lithium 24 hours before delivery.

To Summarize: If you are on a medication for depression that works, especially an SSRI and you conceive….keep taking it. If you stop, chances are you will have a relapse and this can harm you and your pregnancy. Know that you may need higher doses as the pregnancy develops. (There are a lot of changes in the metabolism and dilution of any medication as you and your pregnancy grow.) After 4 to 6 weeks you and your doctor may decide you need to increase the dose every 2 to 3 weeks until your symptoms are in remission.

Every time the media reports on a new adverse effect from an antidepressant….remember that bad news makes news. If you suffer from clinical depression before or during pregnancy, treatment can make a very positive difference in your pregnancy outcome and the future health of your child.