The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:
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Can someone recommend sleeping pills (I assume pills are the conventional form) that work with a minimum of side effects and/or long-term damage?
Lately I've been alternating between nights of 12 hours of sleep, and others with pretty much none. Right now I'm at two all-nighters in a row. This is a little unusual for me, but I can't afford to be groggy all day long, so I'd like to get back on a solid schedule by any means necessary. Any advice appreciated.
The following is an abbreviated version of the talk I give students on this topic.
For a resource that is reasonably easy to parse (and free) you can check out this link. It has a chart at the end that is very helpful.
https://www.aafp.org/pubs/afp/issues/2017/0701/p29.html
TLDR: Pharmacologic intervention is not first line. Proper assessment, lifestyle modification, therapy, and treatment of underlying conditions are first line treatment. Neglecting this can render medications ineffective or outright dangerous. Talk to a doctor.
Okay so occasionally a student comes up to me and goes: "Um, what do we do for patient's with insomnia? It seems to have a ton of different causes and the AAFP, ABPN, and AASM all have different guidelines.
And then I go "GLAD YOU ASKED!!!! If you look closely the guidelines are actually quite similar, but now that you have activated my trap card (students are starting to no longer get this reference sadly) you have to listen to me ramble for an hour instead of going to get lunch.
I will organize this into clinical pearls since it is in written format.
A very large amount of insomnia is not primary insomnia. In essence that means that most insomnia has a cause that should be targeted as your first goal. If you have sleep apnea... medication will not help you. Your problem is that you are not breathing while you are asleep and your body is very concerned. Medication can be counterproductive or dangerous. Treat the sleep apnea and magically you will sleep much better. Americans are fat, it is common and people do not want to treat it. If I had a dollar for every family member or coworker who had sleep apnea and knew about it and didn't treat it I would retire. Other medical problems can also cause insomnia. Nearly every psychiatric condition has insomnia as a symptom. People who might not otherwise notice they are depressed will notice sleep quality changes.
Patient's feel very strongly about insomnia (as they should! That shit is miserable). Therefore is a lot of lore and STRONG OPINION some of which has insufficient high quality evidence. Some of which is clearly bullshit but you will never convince people. For the former - one of the best evidence based physicians I know uses magnesium and is insistent it helps. Whether it shows up on treatment algorithms is a bit complicated but it certainly seems to do something helpful for some people. Many, many people use Weed and Alcohol. They will swear by them. Don't.
What type of insomnia you have is very important. Different treatment interventions (including lifestyle but also meds) will vary depending on what type of insomnia you have.
Meds don't work part 1: they don't work.
Lifestyle change and therapy work. CBT-I is one of the most effective treatment modalities in medicine. People hate the sleep restriction portion but that shit works. However it's kinda similar to recommending exercise to a pre diabetic. Will it fix the problem? Sure! Will they do it? No.
Some of the CBT-I components actually work great and are easy to do (like sleep hygiene). It can sounds stupid but screen time changes, reading war and peace, and so on are actually extremely effective when you can implement them. Google sleep hygiene for more or talk to a competent physician.
Meds don't work part 2: Patients want meds instead of treating underlying conditions. If you are anxious that is the problem and you need to fix it. If you have OSA meds won't work.
Meds don't work part 3: Okay meds do work. The situations in which they do work are complicated and beyond the scope of this lecture. Snowing someone with Seroquel to help them sleep because they are manic is not unreasonable. Same thing with aggressive grandma who is awake at night and hitting the nurses (or wait - no, you aren't supposed to do that, except sometimes you are...complicated).
Okay, the effect sizes of meds are pretty small. Some seem to work better but are more expensive. Some are extremely dangerous for one reason or another. BZDs cause dementia, IQ loss and all cause death. Ambien causes sleep driving. If you are actually sleeping on these is a complicated question.
Getting treatment for insomnia is super fucking important, so we will prescribe and recommend even when on paper things don't work or are dangerous or otherwise problematic. Often this is harm reduction. Patient won't get a CPAP but at least they will sleep this way...
Because of all the above it is EXTREMELY easy to get VERY poor quality care for insomnia. Insomnia is miserable, patients have preconceptions about works, they are very demanding. Even if YOU aren't very demanding many doctors will be like "fine, whatever" because they don't want to have "one of those" conversations. Be careful.
Sorry. I know this is not what people want to hear.
What's the evidence in support of this? I'm looking at this: https://www.ncbi.nlm.nih.gov/books/NBK343508/#results.s3
Saying most effective in medicine is probably overstating my case, although if asked to justify that I could easily point to adherence issues being the primary point of failure for CBT-I and say something like "if only the patients actually followed the treatment it would work!" which is absolutely true but is a bit dickish.
If you look at your link in the key points section it says things like "CBT-I across several delivery modes improves global and sleep outcomes compared with passive control in the general adult population (moderate strength evidence). Evidence was insufficient to assess adverse effects of CBT-I."
Keep in mind that that the quotes you pulled out are looking at individual sleep metrics as opposed to global sleep outcomes. It is not unreasonable for a treatment method to have more impact on say sleep onset than sleep maintenance.
The AAFP guidelines note:
"Psychological interventions included stimulus control, sleep restriction, relaxation techniques, sleep hygiene education, and CBT for insomnia. CBT for insomnia is a combination of cognitive therapy, behavioral interventions (i.e., sleep restriction and stimulus control), and education (i.e., sleep hygiene). There were insufficient data to draw conclusions on the effectiveness of specific interventions alone (e.g., stimulus control, sleep restriction, relaxation techniques), but based on a meta-analysis of 20 trials, CBT for insomnia improved global and sleep outcomes in the general adult population."
Which is fair and measured.
That said if you change my quoted statement to "CBT-I is the most effective treatment modality for sleep" it becomes significantly more relevant and strictly speaking more accurate. All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management.
But why aren't the results positive in a clear majority of trials, and why are trials with sham controls less likely to have positive results? If an intervention is effective, shouldn't it be consistently effective, including when compared to sham controls? The evidence for global outcomes wasn't very good, either.
"CBT-I is the most effective treatment modality for sleep" comes across as something of a bailey to the motte of "All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management," given that the former is a statement about effectiveness and the latter is a statement about safety - in a like-for-like "per-protocol" or "intention-to-treat" comparison, to account for "adherence issues" and safety/abuse potential, is there a clear difference in QALYs?
Thanks!
If you are expecting a wide body of clear and convincing evidence you just aren't going to find it often in medicine, especially when something drifts more into psychiatry, nutrition, and the other more complicated domains.
CBT-I seems to have a good number of sources saying it does something helpful. That's enormously more efficacious than most of the medications which research often suggests do nothing or are counter productive.
Mechanistically this makes sense in the same sense that exercise is better for weight loss than medication. Yes implementation is hard, but working out actually works and medications of various kinds are significantly more variable.
Additionally some of the other sources (like the AAFP) are more positive.
Ultimately medical research is hard and is hampered by ethics and expense. The evidence base for ANYTHING is pretty poor but if it seems to work and makes biological sense, we run with it.
Most medications do not or run into clear issues which just doesn't apply to CBT-I.
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