What are your considerations when treating insomnia in perimenopausal patients with comorbid anxiety or mood disorders?  

I would choose to first try nortriptyline for such a patient. While being an older medication, I find it to be excellent. It is generally well tolerated and helps with insomnia, anxiety, and depression. It isn’t studied much, because it’s been generic for so long, and oftentimes, clinici...

I would first consider gabapentin or pregabalin in such a patient. While CBT-I is first line, I would anticipate medication therapy being necessary in this setting. Gabapentin has some data that shows positive benefits in perimenopause as well as sleep benefits. If a patient has excessive next-day s...

If the insomnia is due to vasomotor symptoms, the venlafaxine might improve sleep and treat depression/anxiety. SSRIs also have data for vasomotor symptoms.

As with all people, I would try to understand, and help the patient to understand, what she is anxious about and why, psychologically. Psychological investigation and potential psychotherapy are the first rule for people with psychological symptoms. If an antidepressant is needed later, that's fine....

Given measurable levels, titration to a known therapeutic window is a definite plus. Many years ago, I was the psychiatrist for a geriatric psychiatric unit… Having measurable levels and a known therapeutic window was a huge plus, especially in treatment-resistant patients.