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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.
Thanks for this overview.
In Latvia melatonin is over the counter and people sometimes buy it but generally they find it ineffective. Benzos are commonly prescribed although recently the health authorities have started to push back. Still, when someone is hospitalized, the patient is almost always given alprazolam at night. My elderly mother doesn't like benzos and she has to instruct the hospital staff every time to not give any benzos to her. She tells that she has a paradoxical reaction to them that she becomes even more agitated. You would think that by now it would mentioned in her medical records but no, she still has to actively refuse them every time. I think doctors are completely irresponsible in this regard. There was a case of one famous elderly person dying from a fall while normally walking through the city. I am 100% that was due to benzos she was prescribed.
Quetiapine gets prescribed a lot for sleep but in cases when doctors suspect that anxiety or depression is the cause. In the UK it is much more restricted. Quetiapine on prescription indicates rather serious psychiatric problems or strong anxiety that is not resolved by usual antidepressants. Tricyclic antidepresants especially mirtazapine or amitriptyline get often prescribed as sleeping pills too especially when if pain keeps a person awake at night but can also prescribed just for sleep.
Interestingly that melatonin is prescription only in the UK. Most commonly it is prescribed to autistic children. I cannot believe that it works so well for them but carers seem desperate to get the prescription filled. I wonder if a placebo effect by proxy is involved. The UK guidelines are very strict that no medication is effective for autism, so all benzos, antipsychotics, even antidepressants are out of question unless one can prove respective co-morbidity indication.
The way you write suggests to me that what I'm about to say may already be known to you, so mostly throwing out additional context for others-
Patient reported sleep issues are more about subjective experience in most cases (as opposed to objective). This is a big piece of why benzos can be popular while melatonin often isn't, since benzos effectively make you pass out more than they make you sleep but to patients that seems like a good deal.
Paradoxical agitation due to benzo administration in a hospital setting is a known quantity and dare I say it, the norm. However what to do about this becomes a complicated and long running fight. Yes, in some settings getting any sleep at all is the way to go (most classically: helping to abort a manic episode or substance induced insomnia) but more commonly we see nursing staff demanding benzo administration until the medical team or a consulting team gives up and recommends it to make nursing shut up.
Nursing isn't entirely wrong since an agitated patient takes away from others and can be dangerous in a variety of ways, but the literature suggests this is typically a bad idea.
For Quetiapine, Mirtazapine, and TCAs- for these managing the side effects is the primary problem. In the US we don't really use Quetiapine anymore because of concerns of weight gain, even in the setting of psychiatric comorbidity. Mirtazapine still has weight gain concerns but ultimately is better on that front so you see it more often. TCAs are a bit more complicated but probably the most commonly used option in settings where cost is a big factor.
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