|
|
|
Sleep Problems/Insomnia by M. L. Glaser, MD. Difficulty Sleeping Insomnia Mitchell L. Glaser, MD. Problems sleeping is called insomnia. Insomnia can fall into 3 types. These 3 types are: problems falling asleep, awaking throughout the night, and awakening too early in the morning. The number one cause of insomnia is emotional problems such as depression or anxiety. Other common causes are sleep apnea, shift work changes on the job, physical pain, travelling, old age, mania, drugs or alcohol, and plain old primary insomnia. Primary insomnia is the diagnosis for someone who can't sleep well but has no other cause of it. This article will review the causes of insomnia, then the non-medical treatments, then the medical treatments. (This is probably the one area of psychiatry where most psychiatrist actually resist prescribing medications.) Lets first talk about non psychiatric causes of insomnia. Chronic Pain: People in pain simply do not sleep well. For my patients with chronic pain and insomnia, I usually prescribe a sedating antidepressant medication (sedating means it makes you sleepy), like elavil (amitryptaline). Pain is strongly associated with ones attention, mood, and state of mind. Elavil has a long and well studied benefit for pain even if the person in pain is not depressed. Risks and benefits of amitryptaline are described in the antiepressant medication section of this web site. Sleep Apnea: Sleep apnea has two forms, central and obstructive. Central sleep apnea means that your brain for some reason stops sending signals to your body muscles, and diaphragm to breath. Obstructive sleep apnea means something in your throat or lungs clogs the breathing tubes in your body. Usually this blockage is in the back of your throat (pharynx) but it occurs in other places as well. When a person has apnea they usually feel very tired despite sleeping enough hours. Others signs are head aches. If you are over weight and snore, feel tired a lot, have head aches, then you probably have sleep apnea. Being over weight and snoring are key signs of sleep apnea. Another sign of apnea is awakening feeling like you are suffocating. The test for sleep apnea is called a sleep study. A person spends one night at a sleep study center. The sleep study includes wires glued to the scalp of the head to check brain waves (EEG), wires glued to the chest (EKG), and a monitor on the finger to check oxygenation of the blood(pulse oximeter). No needles are ever used, and the test is painless. If the test is positive (positive in medicine means bad), then treatment can include removing tonsils and adenoids in the back of the throat, a CPAP machine that pushes air into your lungs through a mask that one wears while sleeping, or other treatments. Weight loss, sleeping on ones side or stomach and not the back can also be curative and is probably the best treatment if obesity is the cause of the apnea. Lets talk about alcohol and drugs effect on sleep. Alcohol, helps you fall asleep but makes it impossible to stay asleep, enough said. Other recreational drugs can help you sleep at first, but soon you body will adjust and you will be back to where you started, unable to sleep, but now you will be dependant on the drugs and will sleep worse without the drugs then you did to begin with. Depression and Anxiety's effect on sleep is profound. Mood problems are the number one cause of insomnia. People who are sad or who are nervous have a hard time getting a good night's sleep. Treating insomnia with medication for a person who is anxious or depressed will not last for more than 1 to 3 months as long as the mood problem is not fixed. After 1 to 3 months of continuous use, a sleep med will stop working and the patient can become addicted to the sleep med. This means, that your sleep problem will return in full force. But to get the kind of sleep you used to get without meds, all be it unsatisfactory sleep, will now require sleeping meds. The only treatment of insomnia due to mood problems is to treat the mood problem. Some times, I may temporarily prescribe a sleep med to be taken with an antidepressant but that will only be temporary until the anxiety or depression gets treated. Some antidepressants like the old fashioned tricyclic antidepressants and newer ones like Remeron, treat depression and anxiety and help you fall asleep at the same time. Medications for bipolar disorder and depression, like Seroquel, help you fall asleep and help your mood at the same time. Bipolar disorder is a mood problem described in detail in other pages of this web site. The depressed phase, the most common phase of bipolar disorder, can cause insomnia. Manic phase of bipolar is a phase of extreme energy and decreased need for sleep. This means the person can sleep none at all, or very little and not feel tired the next day. Other symptoms of high energy include rapid thoughts and speech. People with mania make excellent house cleaners, sometimes staying up all night cleaning the house. They also can be extremely active sexually. There is little else that mania is good for however, and impulsive behaviors can lead to big trouble. People with mania need much more than sleeping pills to help manage their brain. Sleeping pill are not enough to prevent the brain cell neuronal death that mania causes. Now lets talk about good sleep habits. In the medical world we call this sleep hygiene. No stimulants or alcohol 2 hours before bedtime. This includes all caffeine products: coffee, colas, mountain dew, energy drinks, chocolate in any form, some teas, some soft drinks. No physically strenuous activity 3 hours before bedtime. Do not do anything in your bed besides sex and sleep. No TV watching, reading, or playing games. You should train your mind and body to equate the bed with sleeping. If you toss and turn for an hour, then get out of bed, do something relaxing or distracting, then get back into bed and try again. Repeat this cycle as often as necessary until you have trained yourself to equate the bed with sleep. Go to sleep and wake up at the same time every day. I know this sounds sacrilegious on the weekends, but it is about training your brain to sleep. Changing the sleep time and awake time confuses your sleep centers in your brain. If you are over weight and/or snore, don't sleep on your back. This can cause sleep apnea. One can place a tennis ball into a pocket stitched into the back of a shirt to keep you off your back at night. Medications for insomnia: Due to the reasons above, most physicians resist prescribing sleep meds. If you have sleep apnea, and your body is deprived of oxygen, you should wake up or you can die. If you take a sedative drug and don't wake up when you need to, big problems. Additionally, many but not all sleep meds are addictive physically and emotionally. If you take sleep meds most nights, your body can easily get used to the med and the med stops working. This is called building up a tolerance. A person can find themselves steadily increasing the dose to get the same desired effect but all the while risking more severe side effects. Sleep medications should not be taken lightly. Sleep medications fall into the following categories. 1. antihistamines 2. benzodiazepines 3."non benzo- benzodiazepines" 4. antidepressants medications 5. antihypertensive medications 6. anti-psychotic/anti-bipolar medications 7. melatonin receptor agonists. Sleep medications differ in how they effect your sleep and your feeling of wakefulness the next day. A persons sleep is divided into stages. One stage is called deep sleep and seems related to how awake you feel the next day. Some sleep meds suppress this stage and therefore even if you sleep a long time, you may still feel tired upon awakening. Also, some sleep meds hang around in your body for longer then you need. This will lead to feeling sedated the next day also. Antihistamines: All, and I mean all, over the counter sleep medications are antihistamines. (I am not talking about sleepy time tea or melatonin type treatments, or non empirically proven treatments AKA alternative medicine). If you go to a drug store and by an over the counter sleep med, it is an antihistamine. Benadryl (diphenhydramine), Nytol, Unisom, Advil PM, Tylenol PM, etc.... These are all antihistamines. If you are taking Tylenol PM or Advil PM just to sleep. You should just take Benadryl or another sleep med brand and forget about the pain reliever part. Why expose yourself to more risks of side effects from more medicine then you need. Antihistamines are not good sleep meds for one main reason: the hang over feeling the next day. The dopey feeling the next day is due to two reasons. The first is that they negatively effect your sleep cycles and can hang around in your body for longer then your like. This can effect your ability to focus the next day and can negatively effect your storage of memories while you sleep. Antihistamines have a maximum effective dose. Above this max dose, you get no further benefit but big time side effects such as a heart attack, priapism, or wrestles legs. Also, antihistamines probably lead to rapid tolerance and stop working with daily use rather quickly. Non benzo-benzo diazapines are extremely popular meds for sleeping recently and for good reason. This class of meds work very similarly to benzodiazepines but without a certain component so they are less likely to be used recreationally. They seem to work very well for sleep, are less likely to mess with the sleep cycles, and leave the body when you need them to. These have a low rate of a "hung over" feeling the next day. The three meds in this category are Ambien (zolpidem), Sonata , and Lunesta. Since regular Ambien is now generic, and no longer is very expensive, I prescribe it much more often. Most of my patients who take it, love it. There is one very, very, very serious draw back. I have had some patients sleep walk, or do bazaar things while sleeping while on Ambien. This bazaar behaviors usually include going to the kitchen and getting food and eating it in the bed. The patient then wakes up with food in their bed and they don't know how it got there. This is rare but it has happened to few of my patients. Usually it only happens to patients who also have severe psychiatric problems of a bipolar or psychotic nature. I have not seen this side effect occur in patients with simple insomnia or mild depression or anxiety. Sonata is only in your body for 1 to 2 hours so it is perfect for the patient who only needs help falling asleep but not staying asleep. I have not prescribed Ambien CR as of yet. I am unaware of any benefit that justifies the cost difference between generic Ambien, and long acting Ambien CR. While it is preferred to take sleep medications only once in a while (like no more than once a week), there are studies that show that Ambien can be taken daily for several months without losing its efficacy. This is not clear and more studies are needed to answer this question. My experience with patients is that the more any sleep med is taken, the less effective it becomes over time. (The exception is rozerom) 3. Psychiatrist tend to prescribe anti- depressants the most for insomnia. One reason is that depression or anxiety is usually the cause any way. Also, they can be taken every night without becoming physiologically and or emotionally dependant on them. The most common sleep med prescribed by psychiatrist is trazadone. It is very safe, effective, non addictive, and dirt cheap. I have heard reports of heart rhythm problems associated with this drug told to me by a physician representing a drug company competing with trazadone, but I have not seen this side effect in the literature nor I have come across any heart problems with this drug in my patients. This is my most prescribed sleep med. Occasionally a person will feel hung over the next day but that is rare. It definitely occurs more often than with Ambien, but bazaar sleep behaviors occur far less frequently than with Ambien in my clinical experience. I have yet to see it occur in any of my patients. The starting dose is 25 or 50 mg and can be taken up to 600 mg a night. The side effects include priapism (dangerously prolonged penile erections) and restlessness. Other antidepressants used for sleep are Remeron which works very well for depression and sleep but has a severe weight gain side effect for many people. Another is imipramine and amitryptaline. These have severe cardiac (heart) side effects and one must have an EKG test of your heart prior to starting them and they are very dangerous if overdosed. A large overdose of imipramine or amitryptaline will likely kill you. Benzodiazepines (benzos) are not used as much for sleeping as they used to be since the non-benzo benzodiazepines have been invented. Benzodiazepines are far more addictive and usually leave a person feeling hung over the next day because these meds tend to hang around in the body much longer then desired. They also can suppress your natural sleep cycles and can be abused for recreational purposes. These meds also are used for panic attacks because they also calm you as well as make you tired. Benzos if taken in an overdose can cause you to stop breathing all together and therefore have a risk of death. For some people, they are highly addictive and foster dependancy. If they are taken too often, they stop working and your body can get so dependant on them, if you were to all of a sudden stop taking them, you can have a severe increase in blood pressure leading to a stroke, heart attack, and death. Benzos are great for alcohol and heroine withdrawal to be used only temporarily. Benzos are also awesome for panic attacks if taken sparingly (no more than 3 pills a week). The less often they are taken, the better they work when they are taken! Benzos include Ativan (lorazepam), Valium (diazepam), Klonipin (clonazapam), Xanax (alprazolam), Halcyon, Restoril, and others. They all work the same but differ in how long each stays in your body, and how strong it is milligram per milligram. One should not drive, operate heavy machinery or chain saws while taking this medication. There are four medications used to treat bipolar disorder, schizophrenia, and resistant depression that also cause one to feel tired and sleepy. They are olanzapine, seroquel, risperdal, and geodon. They are discussed in detail under the bipolar treatment section of this web site. These meds should only be used for insomnia if it is also being used to treat a mood or psychotic disorder at the same time. The newest sleep medication is rozerom. It works by strongly binding to the melatonin receptor in the brain much stronger than melatonin does. Rozeram's benefits is that it is not addictive, and can be taken for months or years safely. It's main drawback is that it takes 1 to 2 weeks to work and must be taken every night for it to work. I have prescribed it only a few times but it worked very well so far. Mitchell L Glaser, MD. Chicago Il. |
|
|
|||||||||||||
