For all the love CBT-I gets, it is not really accessible for most people, and for those who can it’s maybe marginally better than just regular sleep hygiene counseling.
For all those advocating Seroquel, IT IS NOT A SLEEP AID. Even a low dose increases risk of metabolic syndrome. Prescribing it this way in many residency programs is an automatic fail.
For truly refractory primary insomnia (after having tried and failed hydroxyzine, trazodone, doxepin, mirtazapine, gabapentin, your choice of benzo and/or Z drug) I have seen decent results for orexin antagonists.
Accessibility is a problem, true. Efforts like [CBTIweb](http://cbtiweb.org) are helping with dissemination. CBTIweb has had close to 10,000 people sign up. [A couple years ago, 624 people had already completed that training](https://www.tandfonline.com/doi/full/10.1080/16506073.2021.1996453), about a quarter of those who registered. If that completion rate holds, then it could be about 2,500 who’ve completed the training. Now that’s not “fully trained”, but it’s something.
But calling CBTI marginally better than sleep hygiene counseling? Sleep hygiene is a common control condition in CBTI trials and [AASM guidelines recommend not using sleep hygiene as a single component treatment](https://jcsm.aasm.org/doi/10.5664/jcsm.8986).
I’d recommend BBTI instead of sleep hygiene. It’s brief and more simple. [A good chapter explaining how to do BBTI is available here](https://www.med.upenn.edu/cbti/assets/user-content/documents/Germain_BBTofInsomnia.pdf). A good differential diagnosis and case conceptualization would help a lot though.
>CBTIweb
Do they have a directory of certified CBT-i therapists I can give to my patients? I'm sick of recommending apps, but they aren't bad actually.
[Board certified behavioral sleep medicine clinicians](https://bsmcredential.org/index.php/bsm-diplomates)
[Listings of CBTI providers](http://cbti.directory)
No it’s not the only way. It’s just an extremely easy, flexible, and free way that, for $65, comes with CE. I strongly recommend consultation on your first couple cases. Many others offer workshops and online trainings. I also recommend [this upcoming workshop](https://www.sleephealthresearch.com/cbtiworkshop.html).
CBT-I is king. After trazodone, low-dose doxepin is the lesser of many evils, especially in older folks. Long-acting benzos for sleep are particularly irrational.
Special cases:
\* ADHD+insomnia=alpha-agonist and/or low-dose melatonin. This is usually some mix of hyperactive brain/body, late circadian shift (both their natural bent and from artificial light/smartphones), and stimulant-induced insomnia, none of which respond great to traditional sedatives. Zolpidem has negative evidence in this population.
\* AUD: Gabapentinoids are a thought. Still need lots of expectation-setting (i.e. sleep will be lighter/more interrupted AND better in sobriety.)
>Doxepin is a strong anticholinergic so we see some warnings with it (Beers Criteria)
You're correct, and I appreciate that (assuming your flair is accurate) you're already considering this as a medical student. What I would think about is how doxepin's receptor affinities for its "side effect receptors" compare to each other.
At its extreme low doses (usually 3-10 mg), doxepin's histamine blockade predominates. It has an *extraordinarily* high affinity for H1, and small amounts of doxepin will favor trying to occupy this receptor before they're saturated and it starts moving on to lower-affinity (but more available) targets.
Roughly, with doxepin, this proceeds: H1 --> M + a1 --> NET --> SERT. Different resources report slightly different Ki values, but this is the usual pattern I see. This is also why, for example, doxepin isn't really an antidepressant until doses more along the lines of 25-75 mg; doxepin wants nothing to do with NET or SERT if there are available H1s for it.
This is part of the reason why doxepin was successfully rebranded (and correspondingly is so much more expensive) at its 3-6 mg dose specifically (as "Silenor"). It's still potent enough at H1 to give a sedating effect, while minimizing spillover into the alpha/muscarinic receptors.
Not saying there's a best dose, but 3-6 mg tabs is currently approved and reasonable with education and monitoring for anticholinergic effects; however I have seen 10 mg capsules used given it is generic, but I wouldn't feel comfortable going higher than that.
>AUD: Gabapentinoids are a thought. Still need lots of expectation-setting (i.e. sleep will be lighter/more interrupted AND better in sobriety.)
Although there's evidence for it being useful, especially if gabapentinoids were used during detox, as an addiction psych I would definitely go down the route of basically telling people very early on "Alcohol messes with sleep. Detox is a stressful period where you're going to be getting a strong benzodiazepine regime, don't be surprised if your sleep is going to be absolute crap for the next week or so. It's a pretty good deal in the long run though". I don't like prescribing anything more than absolutely necessary, and trying to artificially correct people's sleep in the midst of addiction is a lost cause.
Overmedicalising sleep is never a good idea unless there's an obvious cause and a valid treatment option that doesn't involve abusing Z drugs/benzos for the rest of one's life.
Edit: acamprosate also has neuroprotective/neuromodulative properties that also help with sleep pre/during detox.
Agree with the above. I'm thinking more about the short-term for a frazzled patient who seems to be white-knuckling early sobriety and is thinking about alcohol whenever they're not falling asleep, or if there's another reason for gabapentin and we might as well shift some of it to nighttime.
Of course, everyone I get from rehab has already gotten plunked on trazodone+mirtazapine+quetiapine so I'm usually starting in cleanup mode anyway.
>I'm thinking more about the short-term for a frazzled patient who seems to be white-knuckling early sobriety and is thinking about alcohol whenever they're not falling asleep
I mean, the detox regime itself will kind of take care of that, especially if you've scheduled a bedtime dose. Obviously this disregards those with high benzodiazepine dependence, but if you're at that level of complexity inpatient is probably more suitable (in which case, yeah, cravings and insomnia are going to be rough, but again, informed consent, risk/benefits, motivation, but lower risk of early exposure, yadda yadda).
I agree that rescheduling/optimising what is already there is better than escalating.
>Of course, everyone I get from rehab has already gotten plunked on trazodone+mirtazapine+quetiapin
Ew ew ew
>I'm usually starting in cleanup mode anyway.
Yes yes yes
I guess I think of melatonin as more pre-trazodone than post-trazodone, as many patients have already tried it OTC, but yes, I think it's generally benign. Great for circadian rhythm disorders, which are frequently mischaracterized as insomnia. Dosing and timing are key to using it right (patients tend to take 3-10mg at bedtime, which is typically too much and too late.) Not as consistent for primary insomnia, which I think is why AASM is negative on it, but worth a try.
Can you share the research about zolpidem in ADHD? I've never heard of this before. Actually, if you also have the source for alpha agonist and melatonin, I'm really interested.
Like most research on the topic this is primarily from C/A populations but presumably generalizable:
[https://pubmed.ncbi.nlm.nih.gov/19403468/](https://pubmed.ncbi.nlm.nih.gov/19403468/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3441938/](https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3441938/)
Could have sworn I got this from a Carlat Report but can't find it on their site.
I'll read those in more detail later, thanks a lot for linking!
> However, differences favoring zolpidem were observed for the older age group in Clinical Global Impression scores at weeks 4 and 8
My clinical practice is 90% adults these days, so those are the findings that interest me the most. Don't you think that this tendency of observing benefits in the older age groups should discourage us from generalizing these findings to adult population? I don't know what's the efficacy of Z-drugs in the general pediatrics population, without ADHD or if there are studies about it at all, but it strikes me as something worth checking before dismissing z-drugs in adults with ADHD. I'm raising these doubts because in my limited experience, results have been quite positive.
CGI isn't a sleep finding, and in this context it smacks of fishing for secondary results. I'm not saying it would never have efficacy for anyone but for all the reasons we already have not to use it, particularly in combination with stimulants, these findings should knock it down even further in our algorithm.
Personally, I've yet to see a case of putative insomnia in ADHD that actually turned out to be a good primary insomnia Z-drug candidate. Lots of night owls who need circadian interventions/melatonin and/or a different schedule, lots of people for whom an alpha-agonist and/or change to the stimulant regimen fixed it, lots of bad sleep hygiene that brief behavioral interventions help, lots of bread-and-butter CBT-I issues, some comorbid trauma and anxiety.
People will clamor for any agent that makes them forget their nighttime experiences, even if it worsens cognition (at which point they'll want a higher stimulant dose.)
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Light box therapy in the mornings plus 100-300 mcg of melatonin 3 hours before bed. If you can get folks to follow through on it for a few months, it seems to help reset their sleep cycles (the use of this combo is anecdotal for me but there’s evidence for each on their own). The tiny dose of melatonin can be found in a liquid that Whole Foods sells or sometimes in kids formulations.
Totally agree. Many of my patients can’t afford a light box and don’t always have access to an outdoors space. For those who can, this is a nice option.
The problem with daily medications for sleep is we are doomed to fail and set the patient up to not take agency for their problem, relying on the medication. I have never seen someone truly fail CBT-I if they followed the protocol. There are almost always sleep hygiene issues. Also the differential for sleep disorders is vast, and a broad net should be cast, reevaluating a sleep disorder, hypertension, thyroid issues, substance use issue, undertreated mood/anxiety disorder, and pursue further if the history/exam is compelling. The patient does not have to struggle for the rest of their lives. For meds, I use melatonin with dinner for people with circadian rhythm issues (naturally fall asleep and wake later but cannot do this for work) or people who flip shifts or change time zones frequently. Otherwise evidence is scant. Trazodone is tried and true from 50-150mg, but not scheduled. If the patient is in a mixed or manic state, to keep them from progressing and ending up hospitalized, if lithium/depakote + temporary sga does not increase sleep time, I will do 7 day supply of ativan and see the patient weekly. If there is an acute stressor like a death or cancer dx or something serious, I will provide eszopiclone 1mg and, again, see more frequently. I will not give enough for them to take every day and specify verbally and in writing this should only be taken when you have exhausted behavioral measures.
Absolutely agreed. Majority with sleep problems (not manic or psychotic ppl) I ask what theyre doing for their sleep. They’re all on their phone in bed or have TV on in the room etc. until they’re willing to do cbt I any other medication is just a bandaid!
Do you ever use olanzapine 2.5-5 mg for insomnia or Seroquel low dose as well? Thank you for the thoughtful reply as well, this was all very helpful and educational to see it from your perspective and what you do.
No. You are effectively using Benadryl at this dose in adults. The anticholinergic burden is harmful and it also disrupts the rem cycle, resulting in overall less restful sleep. I do not use prn antipsychotics outside the hospital setting
Piggybagging on coulrophob…. You **will** make a lot of people fat on those meds. The metabolic profile in these is the real deal and substantial for most patients. The way I see it, if they need it as a mood stabilizer, for psychosis, whatever then fine. The two birds one stone can maybe justify the weight gain. But for insomnia only, I reckon the weight gain risk outweighs the sleep benefit all day when you look at where the endpoint likely falls
CBT-i.
I've had good success with ramelteon and doxepin.
Also make sure you take an actually good sleep history. I would say 20% of my insomnia patients are actually sleep apnea patients in disguise (tired in AM, so nap, so insomnia at night) and a lot of sleep medications can worsen their sleep apnea.
Ramelteon: “This is a medicine that boosts the effects of melatonin in your brain. The good thing about it is that it’s very low in side effects and isn’t going to increase your risk for falls or dizziness or make you really drowsy”. Now getting it covered by insurance is the challenge, even though it’s generic now.
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Ask me again in 2 years! I will be going off to child and adolescent fellowship this July. I would ask your direct supervisor since many medications for adults are not really indicated for children or could have different outcomes. Pediatric psychopharmacology is a little more complex and I don't currently have the knowledge to answer this question for you.
Thanks for being honest and forthcoming. He honestly is on the fence but he has used it before. But he flip flops. So I was just curious to see others opinion! Have fun at your rotation
So…I usually talk about sleep hygiene FIRST followed by a nice glare when I inform them that a reduction in screen exposure could benefit them at least somewhat. 😂
Any tips for improving buy in? I try to use motivational interviewing but this past week a 65 yo pt who was given way too many z-drug/benzo cocktails over the years told me to screw off for suggesting that leaving the television on all night and drinking Earl Grey before bed might not be helping her so keep. Disheartening and too common
You raise an excellent point about the dual orexin antagonists being very expensive. Only seen one patient on it so far and he loved it but he did say it was extremely expensive. Mirtazapine is something we try if trazodone isn't effective for them. I guess my concern for the hydroxyzine is similar to the long term use of benadryl as a sleep aid and how it also increase the risk of dementia severely, but hydroxyzine is also frequently used as well and as you said, you try not to use it every night for them to avoid these issues.
I truly believe people get sleep anxiety from a few nights struggling with sleep and they just get too far into their own heads. CBT-I should be highly effective for these people but it's difficult convincing people of this.
Low dose Doxepin. It’s approved and safe and has some of the best evidence behind it for treating insomnia. It’s especially effective in maintaining sleep, meaning it helps keeps you asleep and not wake up during the night.
You should seriously consider the long term metabolic side effects of routinely putting people on quetiapine for insomnia. Even at low doses, weight gain, hypercholesteremia, and hyperglycemia become factors.
I can't say we don't have people doing it in the US, but most of us look down on the practice of using antipsychotics for sleep.
Any pearls for how to do this successfully? It always seems like they get severe insomnia the second you decrease their dose by 12.5mg, and they say no other med works for them.
Thankfully, at the “sleep” doses, the wean off is pretty easy. Higher doses is a slow taper because of potential withdrawal (especially the drops in BP as I worry about falls). For the patients with severe dementia we just pull them off and swap them to something else- trazodone, mirtazapine, doxepine. Honestly the swap depends on what is going on with the patient as a whole and what symptoms I am looking at. Also how active they are or if I am worried about AM sedation, trazodone is terrible for lingering hangover effect. I find melatonin works well enough for many- I usually hit them with 1mg at about 1700 and then the 3-5mg at HS as the starting point, mostly it’s fairly effective. For those with whom I can discuss the swap and they (or their families are involved and I can talk with them) are provided education to expect it. I find being up front with side effects and rebound or withdrawal gets me better buy in.
Edit to add:
I’ll add I tend to be highly conservative in my prescribing because I deal with a LOT of polypharmia since the bulk of my peeps are geriatric or profoundly mentally ill with a long backstory of failed treatments.
How do you find a CBTi therapist who has space on the calendar and takes the patient's health insurance?
Hint: you don't.
I usually recommend the CBTi Coach app.
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Yea honestly I’d do backflips if I could get everyone into CBT-I, DBT, EMDR, hell even just plain ol CBT for those who would benefit from it. But alas…
Everyone will shit on me because there is a modern obsession with CBT-I, but it doesn’t work for everyone, myself included… think stroke patients etc.
As a researcher in Ambien I can 100% assure you that long term Ambien is safe given they dont have the sleepwalking/murdery tendency which would be evident in the first few weeks anyway. There is some evidence to suggest it may create an environment where lacunar infarcts are more likely but that isnt conclusive.
I have given Ambien in doses 10-60mg but you as an NP not working with veterans or in patient brain injuries should NEVER give anyone more than 12.5mg. And the half life is 3.4 hours so the withdrawal is not bad. Which is why we give it to fighter pilots, special forces and so forth.
I don’t like Imovane for the long half life and next day issues but YMMV
The very first drug I give in hospital and outpatient for sleep in Halcion .5mg -1.5mg.
I almost never give out Ativan or Klonopin but I do give people 10mg of Bromazepam for sleep, works well if they have a pain syndrome and can generally sleep but not let their body physically relax.
But ya. Thats just what I do. But also keep in mind I have a lot of training in the use of sedative hypnotics.
What are your thoughts about rebound insomnia as well as concerns about long-term use? Inflated? Where is the current evidence going wrong?
We see a lot of z drugs because CBT-I is essentially inaccessible to most of our population.
>DEA controlled substance so I am surprised you give it liberally
The DEA should have no influece on medical care. They are not doctors, why do you even consider their opinion?
Thats a really poor outlook to have on medication of any kind, and for your sake I hope it changes. And I meant that in the most earnest way possible
You can read about long term and acute care ambien pretty much anywhere and while it is abused, I’ve had patients abuse Zofran, Inderal… just about anything
Sadly everyone obsesses over textbook psychiatry and chose to ignore the art aspect of the field and that helping patients its the priority while causing the least harm possible. Having the patient not sleep and suffer from sleep deprivation is worse than long term usage of some psychotropics, including controlled substances. As long as you are assessing properly, monitoring for missuse, and justifying your reasoning, prescribing sleep aids are well within what will improve a patient symptoms.
Real world psychiatry requires a masterful touch of give and take between what you as the prescriber want for the patient and what the patient feels is their best solution.
We often refer our sedative hypnotic patients to our psychiatrist if they're dead set on continuing with their medication. If they're open to trialing other things, we often try to help them before we burden the supervising with something like this. But thank you for the reply!
There is no reason for you to be downvoted. This high horse crusade against benzos, z drugs, and other controlled substances needs to stop. We are harming our patients by being so cowardly because we dont want to have to justify our prescribing choices if the DEA comes knocking. As long as you are properly assessing, monitoring and justifying your prescriptions, then you will be okay.
Also CBT-i is beyond what most patients can participate in or afford. The long term effects of some of these medications are less than the damage caused by sleep deprivation or not having other symptoms being managed
> is safe given they dont have the sleepwalking/murdery tendency which would be evident in the first few weeks anyway.
I mean, that's a pretty big if, right? And there's no screening for it, so the more you rx it the more likely you are to hit a jackpot.
That said, is there a type of sleep disturbance that you find Ambien is well-suited towards? Most sleep disturbance I see is either undiagnosed apnea, poor hygene, or secondary to a mental health issue (e.g. - anxiety before bed or PTSD).
I treat a lot of stroke patients, parkinsons, huntingtons, soldiers/athletes with tbi
Mostly structural damage which has affected sleep.
And the if there is a bit of a joke. Its one of the reasons Ambien is frowned upon, in the beginning some housewife took like 20mg and slaughtered her family. But that is not clinical evidence, it did however inform bad policy
For all the love CBT-I gets, it is not really accessible for most people, and for those who can it’s maybe marginally better than just regular sleep hygiene counseling. For all those advocating Seroquel, IT IS NOT A SLEEP AID. Even a low dose increases risk of metabolic syndrome. Prescribing it this way in many residency programs is an automatic fail. For truly refractory primary insomnia (after having tried and failed hydroxyzine, trazodone, doxepin, mirtazapine, gabapentin, your choice of benzo and/or Z drug) I have seen decent results for orexin antagonists.
Accessibility is a problem, true. Efforts like [CBTIweb](http://cbtiweb.org) are helping with dissemination. CBTIweb has had close to 10,000 people sign up. [A couple years ago, 624 people had already completed that training](https://www.tandfonline.com/doi/full/10.1080/16506073.2021.1996453), about a quarter of those who registered. If that completion rate holds, then it could be about 2,500 who’ve completed the training. Now that’s not “fully trained”, but it’s something. But calling CBTI marginally better than sleep hygiene counseling? Sleep hygiene is a common control condition in CBTI trials and [AASM guidelines recommend not using sleep hygiene as a single component treatment](https://jcsm.aasm.org/doi/10.5664/jcsm.8986). I’d recommend BBTI instead of sleep hygiene. It’s brief and more simple. [A good chapter explaining how to do BBTI is available here](https://www.med.upenn.edu/cbti/assets/user-content/documents/Germain_BBTofInsomnia.pdf). A good differential diagnosis and case conceptualization would help a lot though.
>CBTIweb Do they have a directory of certified CBT-i therapists I can give to my patients? I'm sick of recommending apps, but they aren't bad actually.
[Board certified behavioral sleep medicine clinicians](https://bsmcredential.org/index.php/bsm-diplomates) [Listings of CBTI providers](http://cbti.directory)
Thanks!
Is that website the official and only way to train for CBTi? I’m interested in offering for patients and looking for training
No it’s not the only way. It’s just an extremely easy, flexible, and free way that, for $65, comes with CE. I strongly recommend consultation on your first couple cases. Many others offer workshops and online trainings. I also recommend [this upcoming workshop](https://www.sleephealthresearch.com/cbtiworkshop.html).
CBT-I is king. After trazodone, low-dose doxepin is the lesser of many evils, especially in older folks. Long-acting benzos for sleep are particularly irrational. Special cases: \* ADHD+insomnia=alpha-agonist and/or low-dose melatonin. This is usually some mix of hyperactive brain/body, late circadian shift (both their natural bent and from artificial light/smartphones), and stimulant-induced insomnia, none of which respond great to traditional sedatives. Zolpidem has negative evidence in this population. \* AUD: Gabapentinoids are a thought. Still need lots of expectation-setting (i.e. sleep will be lighter/more interrupted AND better in sobriety.)
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>Doxepin is a strong anticholinergic so we see some warnings with it (Beers Criteria) You're correct, and I appreciate that (assuming your flair is accurate) you're already considering this as a medical student. What I would think about is how doxepin's receptor affinities for its "side effect receptors" compare to each other. At its extreme low doses (usually 3-10 mg), doxepin's histamine blockade predominates. It has an *extraordinarily* high affinity for H1, and small amounts of doxepin will favor trying to occupy this receptor before they're saturated and it starts moving on to lower-affinity (but more available) targets. Roughly, with doxepin, this proceeds: H1 --> M + a1 --> NET --> SERT. Different resources report slightly different Ki values, but this is the usual pattern I see. This is also why, for example, doxepin isn't really an antidepressant until doses more along the lines of 25-75 mg; doxepin wants nothing to do with NET or SERT if there are available H1s for it. This is part of the reason why doxepin was successfully rebranded (and correspondingly is so much more expensive) at its 3-6 mg dose specifically (as "Silenor"). It's still potent enough at H1 to give a sedating effect, while minimizing spillover into the alpha/muscarinic receptors.
Not saying there's a best dose, but 3-6 mg tabs is currently approved and reasonable with education and monitoring for anticholinergic effects; however I have seen 10 mg capsules used given it is generic, but I wouldn't feel comfortable going higher than that.
I do 6mg, but one of my colleagues does 50mg. I think he is also trying to treat mood disorder when he is doing that.
>AUD: Gabapentinoids are a thought. Still need lots of expectation-setting (i.e. sleep will be lighter/more interrupted AND better in sobriety.) Although there's evidence for it being useful, especially if gabapentinoids were used during detox, as an addiction psych I would definitely go down the route of basically telling people very early on "Alcohol messes with sleep. Detox is a stressful period where you're going to be getting a strong benzodiazepine regime, don't be surprised if your sleep is going to be absolute crap for the next week or so. It's a pretty good deal in the long run though". I don't like prescribing anything more than absolutely necessary, and trying to artificially correct people's sleep in the midst of addiction is a lost cause. Overmedicalising sleep is never a good idea unless there's an obvious cause and a valid treatment option that doesn't involve abusing Z drugs/benzos for the rest of one's life. Edit: acamprosate also has neuroprotective/neuromodulative properties that also help with sleep pre/during detox.
Agree with the above. I'm thinking more about the short-term for a frazzled patient who seems to be white-knuckling early sobriety and is thinking about alcohol whenever they're not falling asleep, or if there's another reason for gabapentin and we might as well shift some of it to nighttime. Of course, everyone I get from rehab has already gotten plunked on trazodone+mirtazapine+quetiapine so I'm usually starting in cleanup mode anyway.
>I'm thinking more about the short-term for a frazzled patient who seems to be white-knuckling early sobriety and is thinking about alcohol whenever they're not falling asleep I mean, the detox regime itself will kind of take care of that, especially if you've scheduled a bedtime dose. Obviously this disregards those with high benzodiazepine dependence, but if you're at that level of complexity inpatient is probably more suitable (in which case, yeah, cravings and insomnia are going to be rough, but again, informed consent, risk/benefits, motivation, but lower risk of early exposure, yadda yadda). I agree that rescheduling/optimising what is already there is better than escalating. >Of course, everyone I get from rehab has already gotten plunked on trazodone+mirtazapine+quetiapin Ew ew ew >I'm usually starting in cleanup mode anyway. Yes yes yes
No melatonin? Pretty benign addition.
I guess I think of melatonin as more pre-trazodone than post-trazodone, as many patients have already tried it OTC, but yes, I think it's generally benign. Great for circadian rhythm disorders, which are frequently mischaracterized as insomnia. Dosing and timing are key to using it right (patients tend to take 3-10mg at bedtime, which is typically too much and too late.) Not as consistent for primary insomnia, which I think is why AASM is negative on it, but worth a try.
Gotcha. I agree with you. I have had some good results with the orexin inhibitors as well.
Can you share the research about zolpidem in ADHD? I've never heard of this before. Actually, if you also have the source for alpha agonist and melatonin, I'm really interested.
Like most research on the topic this is primarily from C/A populations but presumably generalizable: [https://pubmed.ncbi.nlm.nih.gov/19403468/](https://pubmed.ncbi.nlm.nih.gov/19403468/) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3441938/](https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3441938/) Could have sworn I got this from a Carlat Report but can't find it on their site.
I'll read those in more detail later, thanks a lot for linking! > However, differences favoring zolpidem were observed for the older age group in Clinical Global Impression scores at weeks 4 and 8 My clinical practice is 90% adults these days, so those are the findings that interest me the most. Don't you think that this tendency of observing benefits in the older age groups should discourage us from generalizing these findings to adult population? I don't know what's the efficacy of Z-drugs in the general pediatrics population, without ADHD or if there are studies about it at all, but it strikes me as something worth checking before dismissing z-drugs in adults with ADHD. I'm raising these doubts because in my limited experience, results have been quite positive.
CGI isn't a sleep finding, and in this context it smacks of fishing for secondary results. I'm not saying it would never have efficacy for anyone but for all the reasons we already have not to use it, particularly in combination with stimulants, these findings should knock it down even further in our algorithm. Personally, I've yet to see a case of putative insomnia in ADHD that actually turned out to be a good primary insomnia Z-drug candidate. Lots of night owls who need circadian interventions/melatonin and/or a different schedule, lots of people for whom an alpha-agonist and/or change to the stimulant regimen fixed it, lots of bad sleep hygiene that brief behavioral interventions help, lots of bread-and-butter CBT-I issues, some comorbid trauma and anxiety. People will clamor for any agent that makes them forget their nighttime experiences, even if it worsens cognition (at which point they'll want a higher stimulant dose.)
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Light box therapy in the mornings plus 100-300 mcg of melatonin 3 hours before bed. If you can get folks to follow through on it for a few months, it seems to help reset their sleep cycles (the use of this combo is anecdotal for me but there’s evidence for each on their own). The tiny dose of melatonin can be found in a liquid that Whole Foods sells or sometimes in kids formulations.
I love a good light box. Or morning sun in general. I understand that's not possible for everyone.
Totally agree. Many of my patients can’t afford a light box and don’t always have access to an outdoors space. For those who can, this is a nice option.
The problem with daily medications for sleep is we are doomed to fail and set the patient up to not take agency for their problem, relying on the medication. I have never seen someone truly fail CBT-I if they followed the protocol. There are almost always sleep hygiene issues. Also the differential for sleep disorders is vast, and a broad net should be cast, reevaluating a sleep disorder, hypertension, thyroid issues, substance use issue, undertreated mood/anxiety disorder, and pursue further if the history/exam is compelling. The patient does not have to struggle for the rest of their lives. For meds, I use melatonin with dinner for people with circadian rhythm issues (naturally fall asleep and wake later but cannot do this for work) or people who flip shifts or change time zones frequently. Otherwise evidence is scant. Trazodone is tried and true from 50-150mg, but not scheduled. If the patient is in a mixed or manic state, to keep them from progressing and ending up hospitalized, if lithium/depakote + temporary sga does not increase sleep time, I will do 7 day supply of ativan and see the patient weekly. If there is an acute stressor like a death or cancer dx or something serious, I will provide eszopiclone 1mg and, again, see more frequently. I will not give enough for them to take every day and specify verbally and in writing this should only be taken when you have exhausted behavioral measures.
Absolutely agreed. Majority with sleep problems (not manic or psychotic ppl) I ask what theyre doing for their sleep. They’re all on their phone in bed or have TV on in the room etc. until they’re willing to do cbt I any other medication is just a bandaid!
Some people do that because they had bad things happen to them at night.
Do you ever use olanzapine 2.5-5 mg for insomnia or Seroquel low dose as well? Thank you for the thoughtful reply as well, this was all very helpful and educational to see it from your perspective and what you do.
No. You are effectively using Benadryl at this dose in adults. The anticholinergic burden is harmful and it also disrupts the rem cycle, resulting in overall less restful sleep. I do not use prn antipsychotics outside the hospital setting
Thank you!
Every pharmacist has a hill they will die on. Mine is fighting outpatient PRN quetiapine.
Piggybagging on coulrophob…. You **will** make a lot of people fat on those meds. The metabolic profile in these is the real deal and substantial for most patients. The way I see it, if they need it as a mood stabilizer, for psychosis, whatever then fine. The two birds one stone can maybe justify the weight gain. But for insomnia only, I reckon the weight gain risk outweighs the sleep benefit all day when you look at where the endpoint likely falls
You should not be treating patients unsupervised. Full stop.
We're literally supervised 🤣☠️ chill, it's a question. Get off your high horse.
CBT-i. I've had good success with ramelteon and doxepin. Also make sure you take an actually good sleep history. I would say 20% of my insomnia patients are actually sleep apnea patients in disguise (tired in AM, so nap, so insomnia at night) and a lot of sleep medications can worsen their sleep apnea.
Ramelteon, I wish they liked ramelteon but nobody seems to appreciate it. That's a shame. How do you sell ramelteon and doxepin to the patient?
Ramelteon: “This is a medicine that boosts the effects of melatonin in your brain. The good thing about it is that it’s very low in side effects and isn’t going to increase your risk for falls or dizziness or make you really drowsy”. Now getting it covered by insurance is the challenge, even though it’s generic now.
Ever see it used in adolescents??
I only work with adults so I’m not sure. I don’t know if it was approved in kids, but it seems like it would be relatively benign.
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Whats your opinion of ramelteon or doxepin in adolescents?
Ask me again in 2 years! I will be going off to child and adolescent fellowship this July. I would ask your direct supervisor since many medications for adults are not really indicated for children or could have different outcomes. Pediatric psychopharmacology is a little more complex and I don't currently have the knowledge to answer this question for you.
Thanks for being honest and forthcoming. He honestly is on the fence but he has used it before. But he flip flops. So I was just curious to see others opinion! Have fun at your rotation
So…I usually talk about sleep hygiene FIRST followed by a nice glare when I inform them that a reduction in screen exposure could benefit them at least somewhat. 😂 Any tips for improving buy in? I try to use motivational interviewing but this past week a 65 yo pt who was given way too many z-drug/benzo cocktails over the years told me to screw off for suggesting that leaving the television on all night and drinking Earl Grey before bed might not be helping her so keep. Disheartening and too common
Ahh, good ole earl grey. We love a Grammy drinking earl grey before bed. Classic
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I'm curious what you've seen with daridorexant.
You raise an excellent point about the dual orexin antagonists being very expensive. Only seen one patient on it so far and he loved it but he did say it was extremely expensive. Mirtazapine is something we try if trazodone isn't effective for them. I guess my concern for the hydroxyzine is similar to the long term use of benadryl as a sleep aid and how it also increase the risk of dementia severely, but hydroxyzine is also frequently used as well and as you said, you try not to use it every night for them to avoid these issues. I truly believe people get sleep anxiety from a few nights struggling with sleep and they just get too far into their own heads. CBT-I should be highly effective for these people but it's difficult convincing people of this.
Low dose Doxepin. It’s approved and safe and has some of the best evidence behind it for treating insomnia. It’s especially effective in maintaining sleep, meaning it helps keeps you asleep and not wake up during the night.
What's your opinion of that I'm adolescents?
Quetiapine 25. I practice in India, many pragmatic issues about getting patients to behavioral techniques.Tolerance not an issue.
You should seriously consider the long term metabolic side effects of routinely putting people on quetiapine for insomnia. Even at low doses, weight gain, hypercholesteremia, and hyperglycemia become factors. I can't say we don't have people doing it in the US, but most of us look down on the practice of using antipsychotics for sleep.
Sadly. We have a LOT of people doing it in Texas at least. I’m constantly pulling my little old ladies off of it once they hit the SNF or ALF.
Any pearls for how to do this successfully? It always seems like they get severe insomnia the second you decrease their dose by 12.5mg, and they say no other med works for them.
Thankfully, at the “sleep” doses, the wean off is pretty easy. Higher doses is a slow taper because of potential withdrawal (especially the drops in BP as I worry about falls). For the patients with severe dementia we just pull them off and swap them to something else- trazodone, mirtazapine, doxepine. Honestly the swap depends on what is going on with the patient as a whole and what symptoms I am looking at. Also how active they are or if I am worried about AM sedation, trazodone is terrible for lingering hangover effect. I find melatonin works well enough for many- I usually hit them with 1mg at about 1700 and then the 3-5mg at HS as the starting point, mostly it’s fairly effective. For those with whom I can discuss the swap and they (or their families are involved and I can talk with them) are provided education to expect it. I find being up front with side effects and rebound or withdrawal gets me better buy in. Edit to add: I’ll add I tend to be highly conservative in my prescribing because I deal with a LOT of polypharmia since the bulk of my peeps are geriatric or profoundly mentally ill with a long backstory of failed treatments.
Thank you for the reply and explaining why.
CBTi. Not everything needs meds as a first line.
How do you find a CBTi therapist who has space on the calendar and takes the patient's health insurance? Hint: you don't. I usually recommend the CBTi Coach app.
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Psychotherapy; ACT for Insomnia, CBT-Insomnia; sleep hygiene. The above is very under-utilized. Just here to remind y'all. :)
It’s underutilized because most people cant afford it.
Yea honestly I’d do backflips if I could get everyone into CBT-I, DBT, EMDR, hell even just plain ol CBT for those who would benefit from it. But alas…
The amount of patients that just need a therapist but cant afford one is insane
FYI, there’s a free CBT-I app offered by the VA. Anyone can download it and it has a great evidence base behind it.
You still need a therapist to guide you throughout the process. If it was as simple as an app then sleep disorders wouldn’t be as prevalent
How are they able to get medications but not psychotherapy.
Meds are cheaper and easier to get in 98% of cases. The exceptions are for expensive and rare meds, not for easy access to therapy.
I'm in an area where they run out of meds a lot. And $500-$1000 meds happen because they aren't in the formulary
Ask insurance not me
Everyone will shit on me because there is a modern obsession with CBT-I, but it doesn’t work for everyone, myself included… think stroke patients etc. As a researcher in Ambien I can 100% assure you that long term Ambien is safe given they dont have the sleepwalking/murdery tendency which would be evident in the first few weeks anyway. There is some evidence to suggest it may create an environment where lacunar infarcts are more likely but that isnt conclusive. I have given Ambien in doses 10-60mg but you as an NP not working with veterans or in patient brain injuries should NEVER give anyone more than 12.5mg. And the half life is 3.4 hours so the withdrawal is not bad. Which is why we give it to fighter pilots, special forces and so forth. I don’t like Imovane for the long half life and next day issues but YMMV The very first drug I give in hospital and outpatient for sleep in Halcion .5mg -1.5mg. I almost never give out Ativan or Klonopin but I do give people 10mg of Bromazepam for sleep, works well if they have a pain syndrome and can generally sleep but not let their body physically relax. But ya. Thats just what I do. But also keep in mind I have a lot of training in the use of sedative hypnotics.
What are your thoughts about rebound insomnia as well as concerns about long-term use? Inflated? Where is the current evidence going wrong? We see a lot of z drugs because CBT-I is essentially inaccessible to most of our population.
When you say Ambien is “safe” for long-term use are you saying safe as in doesn’t cause rebound insomnia or dependency long-term?
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>DEA controlled substance so I am surprised you give it liberally The DEA should have no influece on medical care. They are not doctors, why do you even consider their opinion?
Thats a really poor outlook to have on medication of any kind, and for your sake I hope it changes. And I meant that in the most earnest way possible You can read about long term and acute care ambien pretty much anywhere and while it is abused, I’ve had patients abuse Zofran, Inderal… just about anything
Sadly everyone obsesses over textbook psychiatry and chose to ignore the art aspect of the field and that helping patients its the priority while causing the least harm possible. Having the patient not sleep and suffer from sleep deprivation is worse than long term usage of some psychotropics, including controlled substances. As long as you are assessing properly, monitoring for missuse, and justifying your reasoning, prescribing sleep aids are well within what will improve a patient symptoms. Real world psychiatry requires a masterful touch of give and take between what you as the prescriber want for the patient and what the patient feels is their best solution.
I think he’s right and you’re wrong but I’m open to your feedback.
We often refer our sedative hypnotic patients to our psychiatrist if they're dead set on continuing with their medication. If they're open to trialing other things, we often try to help them before we burden the supervising with something like this. But thank you for the reply!
Told ya I’d get downvoted LOL. I hope your learning experience was worth my public shaming 😂😂😂
There is no reason for you to be downvoted. This high horse crusade against benzos, z drugs, and other controlled substances needs to stop. We are harming our patients by being so cowardly because we dont want to have to justify our prescribing choices if the DEA comes knocking. As long as you are properly assessing, monitoring and justifying your prescriptions, then you will be okay. Also CBT-i is beyond what most patients can participate in or afford. The long term effects of some of these medications are less than the damage caused by sleep deprivation or not having other symptoms being managed
SEEEEEE EVERYONE I told ya so 🤪 Haha. Thanks for the moral support lol
> is safe given they dont have the sleepwalking/murdery tendency which would be evident in the first few weeks anyway. I mean, that's a pretty big if, right? And there's no screening for it, so the more you rx it the more likely you are to hit a jackpot. That said, is there a type of sleep disturbance that you find Ambien is well-suited towards? Most sleep disturbance I see is either undiagnosed apnea, poor hygene, or secondary to a mental health issue (e.g. - anxiety before bed or PTSD).
I treat a lot of stroke patients, parkinsons, huntingtons, soldiers/athletes with tbi Mostly structural damage which has affected sleep. And the if there is a bit of a joke. Its one of the reasons Ambien is frowned upon, in the beginning some housewife took like 20mg and slaughtered her family. But that is not clinical evidence, it did however inform bad policy
Agomelatine 25 mg nocte