Wednesday, November 07, 2007

How This Shrink Picks A Sleep Medication


I have more to say about sleep medications. But I have a lot less to say about choosing a sleep medication than I do about choosing an anti-depressant, and my thinking on this is a lot less structured.

Everyone who wants medication to help them sleep gets a talk about the obvious sleep hygiene issues. Here are the basics:
-- Choose a 7 hour period during which you'd like to sleep. Keep it the same everyday, for example, midnight to 7 am, but the exact hours aren't important. The regularity is. Set an alarm.
--Don't nap.
--Don't watch TV or do anything else interesting in bed (sleep and sex, that's it)
--No caffeine after 2 pm. And not much before that. That includes caffeinated soda and iced tea and sadly, chocolate.
--Exercise regularly, preferably 3 hours before you go to bed, but absolutely no closer to bedtime.
--Limit alcohol, and don't drink it near bedtime, it screws up your sleep architecture.
--If you have sleep apnea, use your CPAP machine. Really.

No one follows these recommendations, at least not when I make them.
Linda, the self-proclaimed sleep Nazi, would add: No Screens of any kind after 11 pm for adults and 10 pm for kids-- no computers, TV, video games. Even I'm glad I don't live at her house.

I prescribe sleep medications frequently, insomnia's a common complaint. Sometimes I feel strongly that someone should take a sleep medication-- disturbed sleep goes hand-in-hand with affective (mood) disorders and in patients subject to manic episodes, sleep is really important and I worry that poor sleep habits might either announce or precipitate an episode. Often, though, I feel like it's not the end of the world if every night's sleep is not perfect (great blogging gets done in those wee hours), and that some people are too quick to look to pills to fix problems. I'm probably going to get blasted for that one.

Sleep issues take on a life of their own. People get anxious about not sleeping and it builds on itself. They have all sorts of expectations about how much sleep they need or should have-- one patient was beside herself because she was only sleeping 6 hours a night and felt she needed 8 to 9 hours. Maybe she was right, but when I suggested that maybe she only needed 6 hours and that's why she was waking up, she felt I was dismissive and she found another doc. Another patient said he was greatly relieved when I told him his body was getting rest by just lying there quietly, he stopped worrying so much, and his sleep improved (plus, he turned on his CPAP machine).

All medications have the potential for side effects and adverse effects. Sleep medications are no exception. And many sleep medications are addictive and many patients insist they won't become addicted. And even folks who don't become addicted in an up-the-dose, abuse-the-med kind of way, they get habit-forming, whatever that means, and there are people who will end up taking a pill to sleep every night of their lives and won't hear of even trying to stop the medicine.

So my non-scientific, mostly random method of picking a sleep medication:

If the patient presents with depression, I hope that as the depression resolves, the sleep disturbance will resolve. Some anti-depressants are so sedating (TCAs, Remeron, Serzone, Trazodone) that they are effectively sleeping pills. Other times the anti-depressant, especially SSRIs, cause the sleep disturbance.

Trazodone. It works well in combination with SSRI's. It's cheap. It's not addictive. It's easy to stop. The down side: the fear of priapism and there have been case reports of patients who need surgical intervention. Ouch. The other downside: it doesn't always work, even in escalating doses. Or, it works but patients complain of feeling drugged for hours after waking up. When it's good, it's good.


If trazodone doesn't work or isn't tolerated, and there is no history of substance abuse (particularly of issues with alcohol/benzos), then I try Ambien. This usually works, and it doesn't have a hangover. At least it works for a while, some people get tolerant to it's effects. And some people never want to stop taking it. It's theoretically not very addictive, but it does hit those same benzodiazepine receptors.

If there's a history of substance abuse, I may try visteril. This works only rarely. Once someone has had extended exposure to alcohol or benzodiazepines, it's hard to knock them out.

If visteril doesn't work, I try Rozerem, even though I hate the Abe Lincoln/Beaver advertising campaign, and even though it costs a small fortune, and even though it did terribly on our survey. It does seem to work.

Sometimes I use seroquel or zyprexa. These work, though they have that same effect of leaving some people feeling groggy in the A.M. With all the concern about how these medications are linked with diabetes and lipid disorders, I use low-doses, as needed only for the short-term, and I don't prescribe it as quickly as I used to. Unlike many sleep medications, these are fairly easy to stop.

If there's no history of substance abuse, if the patient is a light social drinker with no history of abuse, then I may try ativan or valium for a short term issue. Restoril works well, though with it's long half-life, it's always a bit surprising that people don't feel groggy on this the next day.

I've never prescribed Sonata, and the first and only patient I gave Lunesta to complained of a horrible taste in her mouth.

With those thoughts, Good Night, Sleep Tight, Don't let the Bed Bugs bite.

22 comments:

Anonymous said...

Great Post..you shouldn't forget that many patients may actually be suffering from a sleep disorder that is easily treated without drugs too..hear the interview that we did here: http://www.apnea-treatment.com

Rach said...

Good morning!

I went the non-meds route in treating the sleep.. Melatonin and tryptophan. The tryptophan has been a life saver in terms of letting me get a good night sleep, without any of the side effects commonly found in most of the prescription meds. Downside: it costs mega $$$.

~Rach, who is up, posting at 6:20 am because she couldn't sleep any longer.

Anonymous said...

Hi Rach, I was up at 1:20 , you shoulda called me. The house is so clean now.

The Shrink said...
This comment has been removed by the author.
The Shrink said...

Agreed that trazodone 300mg can flatten elephants, excellent at helping folk sleep.

Quetiapine, likewise.

I'm more in favour of zopiclone, usually, or rarely a benzodiazepine.

I agree with what you said.

My issues are that :
- sleep hygiene is key. For someone with insomnia, without good sleep hygiene the only way you'll get to sleep is with an anaesthetist.
- medication should be a short term adjunct (and not the solution).
- hypnotic medication has risks (my elderly folk with nocturia then bumbling about in the dark when drowsy, having more falls).
- sleeping tablets can help with initial insomnia but often won't affect the latter half of the night.
- even if total quantity of sleep is improved, it disrupts sleep architecture (with less stage IV sleep) so it's a less satisfying and refreshing sleep.

There was a paper I read years ago, which was showing that a hot milky drink was as effective as medication . . .

DrivingMissMolly said...

My psychiatrist has never mentioned "sleep hygeine" or given me any tips. I have had sleep issues since I was a child, including insomnia, night terrors and sleepwalking. I, through my own research, pretty much know all the tips and have since I was about 14, however.

As an adult I have problems falling asleep, problems waking during the night and problems waking up too early, although usually I can go back to sleep. I am sleepy during the day. I am obsessed with sleep. I wonder why my shrink has not suggested a sleep study. I can't breathe! I have asthma and allergies and can no longer breathe through my nose. I used to see an allergist who had me all managed, but, of course, insurance is an issue and I already pay a lot out of pocket for my shrink.

I have been given Klonopin and take 1mg at bedtime when doc has me take ALL of my meds. I also take Benadryl. I am up to 6 or 7 Benadryls with my other drugs. I also put on a BreatheRight strip on my nose to help me breathe. The Benadryl in turn dries out my nose and makes everything worse.

I am overweight and wouldn't be surprised if I had sleep apnea. I am pretty sure I have restless legs syndrome and rythmic movement disorder. I feel like crap. At least I know I can look forward to an early death.

I thought about going about renting a CPAP myself, just to see if I feel better, but I bet they'll ask for an RX.

WHY DOESN'T SHRINK SUGGEST A SLEEP STUDY?!?!!!

Lily

Anonymous said...

> - sleep hygiene is key.
> For someone with insomnia,
> without good sleep hygiene
> the only way you'll get to
> sleep is with an anaesthetist.

Oh, I wouldn't mind sleeping with a cute anaesthetist! But that aside, sleep hygiene -- explained to me by a pulmonologist specialising in sleep disorders -- is what saved me from going bonkers. Two thumbs up!

Thanks,
Felix.

Midwife with a Knife said...

I got that same horrible taste in my mouth with Lunesta. I think the taste receptors have something to do with the same receptors Lunesta hits.

I find that with the sleep disturbance I get from the prednisone (have I mentioned yet how much I hate prednisone? :P only about 8000 times, I think), sleep hygeine is key, and about the only thing that helps. I take an Ambien on occaision, but my problem is more maintenence than sleep initiation. In order to get regular, good sleep, I seriously have to be my own sleep nazi. Also, a willingness to watch some tv, read, or do some other relaxing activity for 30 minutes at 3am makes the waking up not suck so much.

ladyk73 said...

"am up to 6 or 7 Benadryls with my other drugs"

Um...that's a pretty high dose of Diphenhydramine ....Benadryl should not dry up your nose in the same way other cold meds can. Are you taking a decongestion? Because the Phenylephrine or Pseudoephedrine may dry the hell out of your nose...and keep you from sleeping....as they are pretty much uppers.

Phen

NeoNurseChic said...

Ahhh sleep.... I used to be such an insomniac, but I'm really not sure what changed it all. I actually did go for a sleep study back in 2005, and it confirmed that I have insomnia and RLS/periodic limb movement, but I got no recommendations out of it because I don't have sleep apnea. Then I started a job where I rotated between day and night shift every week, and sleep hygiene went out the window. The sleep psychiatrist I saw (a very well known one who presents at a lot of conferences) said that people doing shift work are some of the most difficult to treat.

I actually felt some recognition when I read what you wrote about sleep and people who suffer with mania - that it can be a sign of a manic period or even initiate a manic period... I wrote about this once before (I'm not diagnosed with bipolar, so this is just a loose association for me), but if I have a night of insomnia and it's because my mind is a flight of various ideas, then forget it - for at least a week or more, I sleep hardly at all and am very very "up". I note that during these periods, everything seems so clear and I come up with about 100 different projects for myself. For me, the periods only last a week or so, and then I crash back into my status quo, but you can tell when I'm in that phase because I write soooooooo much more often and say a lot more than usual, plus have all these "aha!" moments and ideas. I'm not sure which comes first, the "fast" version of me or the lack of sleep, but I feel like it happens whenever I'm up late and online for a whole night and can't seem to slow my mind down...

When I was suffering from insomnia, I went from klonopin to ativan to serax. The klonopin worked very well for RLS/PLMS, but left me with this hangover exhaustion feeling the next day, and because I also was taking concerta and ritalin, my psychiatrist felt that I was in a bad pattern of taking a stimulant and then a sedative. We went to the ativan to take something with a shorter halflife, but that still made me too tired the next day, so then we went to serax. That has the same half-life as ativan from what I've read, but it doesn't leave me feeling exhausted the next day and usually it initiates sleep within 30 minutes for me. Granted, I usually wait until I've tried to sleep for a few hours before I take the serax, and I don't like to take it if I have to get up early the next day - even though those are the nights I need sleep the most so sometimes I cave. At this point, I only take serax about once every 2 months or so when I have a bad period of insomnia.

The last year or two, my problem is hypersomnia, and I've almost considered going for a sleep study because I sleep too much. When I went for the study before, I was also diagnosed with excessive daytime sleepiness, but again we didn't discuss any remedy for this due to my shift work at the time. (I don't work night shift anymore except but once in a blue moon when they ask me to do overtime at night...) Nowadays, I feel like I can fall asleep anytime, anywhere....and it leaves me feeling rather miserable. I can't get out of bed because I'm so exhausted. I don't know if I'm exhausted because of pain/illness, med side effects, mood, or a combination of all these things, but it is so draining. Today I was taking a shower before going in to work an evening shift, and I started laughing because I felt like I was fighting extreme exhaustion, and I had drank a red bull and tried everything to keep myself awake. I thought it was amusing that I was THAT tired (Know how people get giddy when tired? That was me.), and I was trying to get ready for an evening at work!

Whenever I do have problems with insomnia these days, it is mostly difficulty shutting my brain off to fall asleep. I'll have to admit that I don't hold by the "no screen" rule, and my laptop lives by my bed, plus I keep the tv on (with the volume at next to 0) while I fall asleep. If I listen to music, it stimulates my brain (go figure...) and I can't sleep at all - it does not relax me and make me tired - it really wakes me up and makes me want to study or read. Sometimes what happens is that I'm utterly exhausted, and I fall asleep for anywhere from 30-90 minutes, and then I wake up and I'm just not tired - wide awake, and it takes hours to get back to sleep. I generally wake up at 4am either from cluster attack or just my body's habit of waking up at that hour, but I always go back to sleep. I have the ability to sleep until 2pm the next day without any trouble at all....

DMM - why don't you ask your psychiatrist about going for a sleep study? I realize it would be ideal if he (she?) recommended one, but since they're not doing that, then maybe you should ask for a referral to one? My psychiatrist had worked with the great sleep psychiatrist, and he suggested that I go for the study and even called the doc for me, but otherwise I wouldn't have even thought to ask for one. I would bring it up with your doc...and if he says no, ask why. Sounds like you could use one!

Take care,
Carrie :)

NeoNurseChic said...

P.S. Your picture for this post is very relaxing! My boyfriend was over last night, and he found my teddy bear (that I've had for 26 years) in my bed and said, "What is this doing here?" I said it was cuz I was anxious the other night and needed something to hug. He laughed and said, "Well you can keep it in your bed!" I put him back on the shelf with the other stuffed animals... :)

Anonymous said...

"sleep Nazi" is an oxymoron. They didn't allow much sleep. Come to think of it they didn't allow much soup either. Funny how words lose their meaning over time.

Midwife with a Knife said...

Nazi originally meant national socialist party, and my understanding is that they weren't really socialists, either. Words are fluid.

Rach said...

I never quite understood the point of going to a lab for a sleep study - hooking me up to wires and then filming me while I'm sleeping is so not going to replicate my natural sleeping environment at home!

Assrot said...

The best sleep medicine is no sleep medicine in my point of view. I have been an insomniac all my life. I once went to a psychiatrist because I thought maybe I was nuts is why I could not sleep.

That imbecile put me on 100mg Geodon per day. He never told me of the side effects or how very physically addictive this medicine is. I was on it for about a year and decided that the cure was worse than the sickness. He told me just to stop taking it that I would lose sleep for a week and be okay after that.

I have never been through a greater hell in my life. I laid flat on my back in bed in the worst agony I have ever felt for three solid weeks. That stupid S.O.B. would not give me anything to help with the withdrawal.

The withdrawal was so bad from this medicine (poison I'd call it) that I actually had suicidal thoughts for the first time in my life. I felt it would be better to die than suffer like I was suffering. I had never felt that bad and I did not think it would ever end.

I finally told my family doctor what was going on and he helped me out with some other medications. I suffered for a total of 6 weeks before I felt normal again. The first 3 weeks were the worst.

No more sleep meds for me and I will never see another psychiatrist again as long as I live. I think they are witch doctors.

:-(

Anonymous said...

I don't doubt I have sleep issues as I'm up at 0426 on a psychiatrist's website. However, I don't understand the point of taking someone on antidepressants and signing them up for a sleep study. Basically, all you are determining is how that person sleeps while on drug X. My psychiatrist sent me off for a sleep study after putting me on antidepressants. I had muscle spasms while awake, so it makes sense that I also had muscle spasms while asleep - this apparently interfered with REM. So, now all I know is that I have PLMS while on drug X. I'm no longer on drug X. So, do I still have PLMS? Who the heck knows. I think it was a waste of $$. It seems to me that if they are going to do a sleep study then they should do it before putting the patient on a bunch antidepressants. That way if it is a sleep disturbance like PLMS that is causing the depression then you have that information in the beginning.

Sleepless in Texas

Kaliki said...

Rach--I thought the same thing about a sleep study. When I went in for the study, they hooked me to so many wires and stuff I just had to laugh and wonder how I could ever sleep when I couldn't even turn over. I felt like I never closed my eyes the whole night. They still managed to find out that I stop breathing 11 times a minute ( and called this "mild" sleep apnea.) I have CPAP now and although it took some getting used to, I love it now, and it relaxes me just to put it on.

Anonymous said...

I know what what Nazi meant. It still means the same thing whether people choose to put into their juicer or not is another story.

Catherine said...

I tried melatonin and it kept me up all night -- same with trazadone. I suppose I am just weird like that.

wearealldiseased said...

I have had two sleep studies. I have been on every benzodiazepine in the book except for oxazepam and triazolam. I have ritualistically followed every recommended sleep hygiene advice given to me by my neurologist and psychiatrist. I have tried rozerem, ambien, sonata, lunesta, hydroxyzine, cyproheptadine, and many many more. I'm too tired to list them all.

In any case, NOTHING has worked. My body sleeps when it wants to. I considered suicide for a long time because I couldn't function, or work. And I was spending half my life trying to get descent rest, only to toss and turn for 8 hours at a time.

I hate being an insomniac. On top of that I have OCD, which is under treatment, and a heart condition, and chronic migraine headaches, but they tell me that is unlikely to be part of the problem. (The headaches may be worsening it, but because of the heart condition they cannot treat the migraines, and pain killers don't work very well for vascular headaches.)

I've been an insomniac since 6 years old. I don't know what to do next.

The problem is so severe, that last time I had to be put under general anesthesia for a minor operation, they could not keep me asleep. I'm not kidding. I woke up in the middle of it, and they couldn't get me back to sleep.

The only thing that has worked so far is propafol during a cardioversion. But that only lasts an hour, and it's inpatient only.

I just wish there was something reliable to knock me out. I'm scared to death of respiratory depression, so part of the problem is that when I do take a med to sleep, I have to check my vitals (I keep a pulse oximeter, a plethsyemograph, and a BP monitor on my bed) to reassure myself that I won't die in my sleep.

Anyway, insomnia sucks.

Anonymous said...

trazodone was originally an antidepressant and like all of these meds it can cause severe side effects, especially for anxiety sufferers.
problem is that the prescribing doc often doesnt get to hear of the bad reaction to it, the patient simply never returns....

mizunogirl said...

I'm a big fan of exercise for sleep disorder....and Also a fan of Lunesta. Yes sometimes there is a bad taste in mouth...brush the teeth and it goes away.