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.

 



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