Psychopharmacology: Expert Tips for Insomnia

Introduction

Insomnia is one of the most common symptoms patients report to their doctors. Up to fifty percent of patients in a general medical practice complain of insomnia. Treating insomnia improves patient satisfaction, compliance, and medical care. Insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven’t found relief from their insomnia from previous treatment.

Insomnia’s Impact

Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person’s life including:

– Decreased job performance

– Impaired focus and concentration

– More frequent car accidents

– Increased risk of suicide

– Worsening health condition

– Poor medication compliance

Causes of Insomnia

Addressing and treating a person’s insomnia can make a great impact on an individual’s overall quality of life. A thorough assessment is essential in determining the potential underlying causes.

Some of the most frequent causes of insomnia include:

– Depression, anxiety, and work stress

– Medical illnesses including reflux and asthma

– Restless leg syndrome

– Substance abuse including alcohol abuse

– Medication side effects e.g. antidepressants, stimulants, or steroids

– Primary insomnia, insomnia without a known underlying cause

Insomnia Assessment

During an assessment of insomnia, it is critical to obtain a thorough medical and psychiatric history to discover potential underlying causes.

Here are ten essential questions:

When did your sleeping problems start?

Have you had any changes at work or at home?

Are you taking any new medications or supplements?

How late do you exercise?

Do you snore or kick your partner?

Have you struggled with insomnia in the past?

What treatments or solutions have you tried?

What medical problems do you have?

Do you have a history of depression, anxiety or ADHD?

Do you have a family history of insomnia, depression, or anxiety?

How much do you drink and how often? Do you use marijuana or any other drugs? How much caffeine do you get and how late in the day?

Insomnia Treatment

Many times, the underlying cause of the insomnia is discovered and treated; however, more often than not, a specific root cause of the insomnia is unclear. At this point, it is imperative to explore various treatment plans that include addressing any underlying medical or psychiatric causes of insomnia, non-medication treatments such as evidenced-based cognitive behavioral therapy for insomnia (CBT-I), behavioral modifications, practicing good sleep hygiene, and the possible short-term use of medications.

There are numerous treatments available for insomnia. Here are some of the major medical treatments for insomnia:

Benzodiazepines

One of the most commonly prescribed medications for sleep includes benzodiazepines, e.g. Ativan, Klonopin, and Temazepam. These medications

It is important for these medications to be monitored by the physician and therapist due to their abuse potential. In addition, these medications are typically recommended for only short term use due to the risk of dependence. However, in certain situations, a doctor or psychiatrist may determine a patient requires the medication for longer periods of time because the risk of chronic insomnia outweighs the risk of dependence. In these situations, the dosing, monitoring, and side effects should be closely monitored.

Nonbenzodiazepines

The three main sleeping medications in the “nonbenzodiazepine” class include Ambien, Sonata, and Lunesta. When these medications were introduced to the market, many felt that they were different than the benzodiazepines and thus would not have the risk of dependence. However, they work in a similar fashion and can be habit-forming.

Ambien is an intermediate-acting sleeping medication. Its effect lasts for 6-8 hours, and it should be taken on an empty stomach. Many patients are not aware of this fact, and thus may report that the medication is ineffective. It is recommended to use for only two weeks, but often patients may require longer periods of use.

Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake too early and need an additional 2-3 hours of sleep without a drug-induced hangover. This medication also should be taken on an empty stomach.

Lunesta is another medication in this class. Many doctors find this medication to be less useful because of the high risk of side effects including a metallic taste that occurs in forty percent of patients.

Antidepressants

Often, non-serotonin antidepressants have sedating properties. They are used “off-label” for insomnia, meaning they are being prescribed for reasons other than originally approved by the FDA. The doses for these medications when they are used for insomnia are typically lower than used for depression.

One of these medications is Trazodone. There is a risk of hypotension and thus a risk of falls; thus, patients should be cautious of this side effect when they start the treatment. Also, in men, there is a risk of priapism, a prolonged erection.

Atypical Antipsychotics

Many atypical antipsychotics such as Zyprexa and Seroquel have sedating properties and can assist with sleep, especially if there is a co-occurring psychiatric disorder such as schizophrenia, bipolar disorder, or depression. There is significant concern about the side effects of these medications including diabetes, metabolic syndrome and other serious side effects. Thus, it is important for the doctor and patient to collaboratively discuss different treatment options, risks, and benefits in order to make an informed, collaborative decision.

Melatonin Medications

Melatonin is a hormone that occurs naturally in the body and signals the body to sleep. It peaks around four to six hours prior to sleep and is influenced by many factors, including exposure to light.

Melatonin is an over-the-counter medication that has been shown to be helpful for jet lag and insomnia. Some studies have shown that smaller doses are more effective than larger doses. In addition, some psychiatrists recommended taking the medication when the natural melatonin level peaks in the early evening, rather than at bedtime.

Rozerem is a prescription medication that increases the body’s melatonin and has been shown to help treat insomnia.

Other Sedating Medications

Clonidine, originally an anti-hypertensive medication, can be an effective off-label, treatment for insomnia. Adult ADHD, may address impulsivity and in PTSD it can help with nightmares.

Neurontin is a seizure medication that can be sedating. In small doses, it is prescribed off-label for insomnia. Some sleep specialists feel that it helps with a syndrome called delayed sleep phase, a body clock disorder that makes it difficult to go to sleep prior to 2 or 3 am and challenging to wake for work or school.

Conclusion

Insomnia is a very common symptom. Insomnia can create significant impairment in functioning and quality of life. A comprehensive and thorough assessment including an evaluation for medical causes of insomnia. Along with the assessment,  a consideration of effective and evidence-based interventions can help people have a better quality of life.

If you have any questions about insomnia, please feel free to contact me at 212-631-8010 or scott@scottshapiromd.com.

 

Bibliography

Weich S, Pearce HL, Croft P, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: a retrospective cohort study. BMJ 2014

Schatzberg, Alan, et al. Manual of Clinical Psychopharmacology. 7th ed. American Psychiatric Association. Arlington, Virginia. 2010.
Disclaimer: The author of the material has consulted sources believed to be reliable in his efforts to provide information that is in accord with the standards accepted at the time of posting. However, in view of the possibility of error by the author contained in this newsletter, the author does not guarantee that the information contained is in every respect accurate or complete, and the author is not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers reading articles posted in this newsletter and/or website should review the information carefully with their professional healthcare provider. The information is not intended to replace medical advice offered by the physicians.

About Scott Shapiro, MD
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Scott Shapiro, MD is a psychiatrist in private practice who specializes in helping people with insomnia, adult ADHD, depression and anxiety.