Benzos as first line?

[randomdoc1]

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I'm not sure if this is even thread worthy but I like chatting with other colleagues on this forum. I just can't help but keep wondering some of the things I see from non psychiatrists. But I guess this is to be expected anywhere in medicine where the other person is not the specialist (although some of this stuff sounds a bit obvious even for a non psychiatrist to know?). I see benzo as first line for so much in the community. Most recently, seeing a flurry of patients who lost children and they got started on a benzo as first line and that seems to be all they got. I was like whaaaaaa? Last thing you'd want to do for a traumatic event. Some are coming in with use disorders going so far as claiming theirs were stolen as asking for early refills of 1mg xanax tid. One lady filled 210 (1mg) xanax tabs in less than a month and calls the clinic sounding (&*$'ed out of her mind.

That would be like a patient coming to my office complaining of chest pain radiating to the arm and i send them home with NG and tell them to sleep it off...

 

[Stagg737]

Some are coming in with use disorders going so far as claiming theirs were stolen as asking for early refills of 1mg xanax tid.

Had this happen with the same guy multiple times in one month except he had been placed on xanax 2mg qid. Even worse was the guy had PTSD and was getting them for his flashbacks which he said only occurred a few times a month. Claimed to have no idea why he was getting them qid.

The kicker was he had only ever been on his current SSRI which I think was Zoloft (wasn't Prozac) and it was a sub-therapeutic dose (I think it was Zoloft 25mg, may have been celexa, can't remember exactly).

Me after the encounter:

 

[futuredo32]

I took the board exam this fall and it is first line sometimes per the APA.
I am in the minority here, a lot don't prescribe. I feel if someone has panic disorder and isn't functioning and can't work, care for their children etc, it is appropriate to start so they can function while also having the patient in therapy and started on an SSRI. I also use them with severely anxious patients who can't handle the initial anxiety of an SSRI for 2 weeks until that side effect wears off.
And now lots of others will say the exact opposite. …………………………………….

 

[VA Hopeful Dr]

I'm not sure if this is even thread worthy but I like chatting with other colleagues on this forum. I just can't help but keep wondering some of the things I see from non psychiatrists. But I guess this is to be expected anywhere in medicine where the other person is not the specialist (although some of this stuff sounds a bit obvious even for a non psychiatrist to know?). I see benzo as first line for so much in the community. Most recently, seeing a flurry of patients who lost children and they got started on a benzo as first line and that seems to be all they got. I was like whaaaaaa? Last thing you'd want to do for a traumatic event. Some are coming in with use disorders going so far as claiming theirs were stolen as asking for early refills of 1mg xanax tid. One lady filled 210 (1mg) xanax tabs in less than a month and calls the clinic sounding (&*$'ed out of her mind.

That would be like a patient coming to my office complaining of chest pain radiating to the arm and i send them home with NG and tell them to sleep it off...

My standard non-psychiatrist treatment for people who've just lost a family member is a benzo of some kind at bedtime only. Shouldn't mess with them too much during the day but does let them get some sleep hopefully.

 

[futuredo32]

My standard non-psychiatrist treatment for people who've just lost a family member is a benzo of some kind at bedtime only.
.

I never use them as sleepers personally. I usually go with Ambien

 

[Crayola227]

I never use them as sleepers personally. I usually go with Ambien

I agree. Trazodone as well.

Actually, when I do sleep medicine I do melatonin, trazodone, benadryl, ambien. Not benzos. Maybe hold the melatonin because you can get vivid dreams/nightmares.

Call me crazy, I usually push herbal tea or warm milk if it's not contradindicated (reflux, BPH, etc). Come to think of it, a ton of sleep hygiene and other suggestions. These things really do work better when a doc prescribes them, and then people are so impressed with your "holistic" and "natural" approach.

 

[Crayola227]

I took the board exam this fall and it is first line sometimes per the APA.
I am in the minority here, a lot don't prescribe. I feel if someone has panic disorder and isn't functioning and can't work, care for their children etc, it is appropriate to start so they can function while also having the patient in therapy and started on an SSRI. I also use them with severely anxious patients who can't handle the initial anxiety of an SSRI for 2 weeks until that side effect wears off.
And now lots of others will say the exact opposite. …………………………………….

Thank you for bringing this up. I was really surprised to find out that yes, benzos are 1) first line for some things and 2) most effective for others. We act like it's the most evil drug ever and last line for everything, and I think they should be treated that way, except for when that doesn't apply.

 

[Crayola227]

One psychiatrist has told me that studies have shown propranolol to be more effective for akathisia from atypicals, and another told me that benzos are. I've seen more than one movement disorders neurologist use benzos in those cases.

I never got a chance to see which claim was better supported by the evidence.

 

[VA Hopeful Dr]

I never use them as sleepers personally. I usually go with Ambien

My logic is 2 fold. First, in acute grief I like having a bit of anxiolytic in the mix. Once/day usually isn't enough to impact processing what happened but can be enough to help at bedtime. Second, my experience has been in that in people whose insomnia isn't just pure insomnia (for lack of a better word), benzos often work better than ambien. I have a number of patients who do very well with Restoril but didn't do well on Ambien.

Plus, people seem to have less trouble with rebound insomnia from benzos than Ambien. That's just been my experience, I have no data to back that up.

 

[MacDonaldTriad]

I never use them as sleepers personally. I usually go with Ambien

So you are buying the Ambien isn't a benzo thing? If you are withdrawing from Xanax, Ambien will reverse this, it enhances GABA, and prisoners will beat each other up to get it. It has street value and it get preferentially "lost" more often than other psychotropics. The duck test says it is a benzo in everyway but shape.

 

[Crayola227]

I don't use the standard that prisioners beat each other up for anything, as meaning anything. They beat each other up for pudding cups.

I hear what you're saying about Ambien from a pharmacodynamics standpoint. The one point I'll beg to differ, is that while I can believe it's addicting, and people go after it for the same rat brain reasons they want booze or benzos, there is a different... what's the word? Qualitative or psychological aspect.

I've never known anyone to take Ambien for a "head change" or to be awake on it.

To me discussing drugs of abuse and their potential and risks and the whys, I do sorta look at that. It's not a party drug, fwiw. Everyone I've ever met that was enthusiastic about it, wanted to take it and sleep. I can't say that at all for benzos. To me this means they may have a similar addictive quality, but for different reasons, and it also presents to me different risks.

Come to think of it, whenever one is discussing addiction, it's pertinent for what specifically the patient is using the drug, not just its MOA.

 

[Crayola227]

But I lived with someone before med school who came to be dependent on Ambien for sleep, and I only realized it when they stole my mostly unused script. I also lived with them for the detox and that was messed up.

It's one of the last on my list for sleep, right before benzos, because at least I don't see people taking them to get high, or really to do anything except sleep. I've used it exactly as prescribed myself and it was great, but not everyone does that.

I also prefer it less because of the weird night behaviors thing. The car driving is pretty rare, there's other less common stuff too, I'd just as soon use something else first.

 

[OldPsychDoc]

I don't use the standard that prisioners beat each other up for anything, as meaning anything. They beat each other up for pudding cups.

I haven't prescribed a pudding cup since residency.*

*(Valproate sprinkle delivery vehicle for 84 y/o F with Lewy Body dementia)

 

[whopper]

Don't recommend any benzos unless it's extremely short-term or low dosages, or not used very often.

The patients I have who I have kept on benzos usually came to me already on them and I work to get them off but that could take several months, even over a year.

For sleep I recommend these first: Melatonin up to 20 mg (more so if 20 mg gets them to fall asleep but not keep them asleep), Tryptophan, Glycine. If these don't work then Trazodone or Gabapentin.

Ambien should only be used short-term. Studies show the more it's used the less effective and that if used for several months actually makes sleep worse. Also I've seen several patients have serious side effects from it such as sleep-drive, crash their car while driving (I wasn't the prescriber), sleep walk, or otherwise have impaired motor-skills from it causing bad outcomes. I only give it out chronically if the patient doesn't use it often (e.g. less than 2x a week).

I had an addict patient that OD'd on Ambien, wasn't trying to commit suicide but just get high off of it and ended up in an ICU.

 

[winniehoney]

I took the board exam this fall and it is first line sometimes per the APA.
I am in the minority here, a lot don't prescribe. I feel if someone has panic disorder and isn't functioning and can't work, care for their children etc, it is appropriate to start so they can function while also having the patient in therapy and started on an SSRI. I also use them with severely anxious patients who can't handle the initial anxiety of an SSRI for 2 weeks until that side effect wears off.
And now lots of others will say the exact opposite. …………………………………….

There's nothing wrong with this and I agree with you. Benzo's are perfectly well indicated for anxious individuals who have severe impairment or during the time period when you are up-titrating an SSRI. However, this should be short term, and this should be clearly stated to the patient. You should develop and understanding that the Benzo will be tapered after a few weeks. Also, you should use your judgement as to what patient you are doing this for. If it is someone who is responsible, then I have no problem starting it, however, the ones with chronic substance abuse, I would be weary of.

One thing that kind of pisses me off though, is that people try to use Vistaril for anxiety for people who have been on Benzo's for years. I'm thinking, unless their susbtance abuse, you're wasting your time, Vistaril won't touch their anxiety.

 

[Sushirolls]

I've only started benzos, after residency, for RBD or meeting Acute Stress Disorder from something recently traumatic. Explain to the patient its a short one time prescription no refills. However, recent discussions with a sleep medicine doctor have caused some pause in my paradigm of benzos for RBD, and now I simply make sure they get in to sleep medicine to be addressed.

I taper off all benzos that are prescribed for mental health reasons, and discuss the litany of evidence against them. As Whopper pointed out, some patients may take 6-12 months to do so. Some patients are very unhappy about it, but the Thank You received months after the taper is complete and they start to feel more normal again makes it worth the effort.

I no longer prescribe z drugs for sleep.

There are numerous meta-analysis publications, for CBTi. It is the gold standard for insomnia. Sadly, there aren't many people who do CBTi, and few patients who want to commit to it. I at least aspire to discuss it with patients and document that they were offered the evidence based first line for insomnia symptoms.

 

[whopper]

One thing you mentioned that I should've emphasized....

If the patient has Acute Stress Disorder I'd actually strongly recommend use of a benzo unless there's other complicating factors (e.g. prior addiction to alcohol or benzos). Data shows that benzos could reduce risk of ASD becoming PTSD, but only in the first few weeks. After that taper them off of the benzo or only give it low dose.

If you give the benzo under these circumstances warn the patient you'll get them off after about a month and why. They might get too comfortable with the idea of taking a benzo and get real ticked off when you take them off.

 

[futuredo32]

I agree. Trazodone as well.

Actually, when I do sleep medicine I do melatonin, trazodone, benadryl, ambien. Not benzos. Maybe hold the melatonin because you can get vivid dreams/nightmares.

Call me crazy, I usually push herbal tea or warm milk if it's not contradindicated (reflux, BPH, etc). Come to think of it, a ton of sleep hygiene and other suggestions. These things really do work better when a doc prescribes them, and then people are so impressed with your "holistic" and "natural" approach.

I push sleep hygiene, 10% go with it. At a clinic where I work it's kind of a factory town and they work different shifts so going to bed at the same time and awake at the same time isn't an option. Benadryl stops working after awhile and both Benadryl and Trazodone leave most with a sleep hangover, I like Ambien because most wake up feeling refreshed not groggy.

 

[futuredo32]

Ambien should only be used short-term. Studies show the more it's used the less effective and that if used for several months actually makes sleep worse. Also I've seen several patients have serious side effects from it such as sleep-drive, crash their car while driving (I wasn't the prescriber), sleep walk, or otherwise have impaired motor-skills from it causing bad outcomes. I only give it out chronically if the patient doesn't use it often (e.g. less than 2x a week).

I have been on Ambien CR for 8 years. Trying to sleep like a normal person in residency? I was never a good sleeper. It still works. I don't have the side effects. I love my Ambien .

 

[futuredo32]

So you are buying the Ambien isn't a benzo thing? If you are withdrawing from Xanax, Ambien will reverse this, it enhances GABA, and prisoners will beat each other up to get it. It has street value and it get preferentially "lost" more often than other psychotropics. The duck test says it is a benzo in everyway but shape.

Ambien isn't a benzodiazepine. Never heard of a single patient having withdrawal seizures after stopping Ambien. It is not classified as a benzo.

 

[winniehoney]

Ambien isn't a benzodiazepine. Never heard of a single patient having withdrawal seizures after stopping Ambien. It is not classified as a benzo.

It can happen, though, almost never does.

 

[futuredo32]

There's nothing wrong with this and I agree with you. Benzo's are perfectly well indicated for anxious individuals who have severe impairment or during the time period when you are up-titrating an SSRI. However, this should be short term, and this should be clearly stated to the patient. You should develop and understanding that the Benzo will be tapered after a few weeks. Also, you should use your judgement as to what patient you are doing this for. If it is someone who is responsible, then I have no problem starting it, however, the ones with chronic substance abuse, I would be weary of.

One thing that kind of pisses me off though, is that people try to use Vistaril for anxiety for people who have been on Benzo's for years. I'm thinking, unless their susbtance abuse, you're wasting your time, Vistaril won't touch their anxiety.

I've done ok with Vistaril for patients on benzos, Buspar NO but Vistaril 50%.

 

[futuredo32]

It can happen, though, almost never does.

Hmm never heard of it. Does anyone taper patients off of Ambien?

 

[Sushirolls]

Hmm never heard of it. Does anyone taper patients off of Ambien?

Yes.

 

[Crayola227]

If the reason they're taking Ambien is work schedule.... doesn't seem time limited to me. I HATE anyone to be habituated to Ambien and I would never write where that would even be a possibility, at least not from pills they're getting from me.

Agree that some get the trazodone hangover.

I would be surprised to hear such a population balk at things like blackout curtains and melatonin, because they have been shown to be very helpful with shift work sleep issues. I've never had anyone with significant sleep issues (real) that I couldn't get a great deal of lifestyle intervention out of. It depends on how bad you want to sleep, I guess, lol. Which is actually something I say to patients. If you want sleep, you get curtains. If you want pills, you don't bother.

Earlier I said hold melatonin, but that was in context to insomnia secondary to some sort of trauma or upset.

 

[Crayola227]

The real limiter I've found with lifestyle sleep interventions has more to do with environment things really hard to control, like roommates, spouses, noise, pets, etc.

 

[Crayola227]

I have been on Ambien CR for 8 years. Trying to sleep like a normal person in residency? I was never a good sleeper. It still works. I don't have the side effects. I love my Ambien .

Of course you do. Everyone who loves their Ambien loves their Ambien.

Doesn't make it good.

8 yrs? When was the last time you slept without Ambien? Do you think you're even capable of it?

That question could be applied to BPAD pts on seroquel, but the point I'm putting to you is, how necessary is Ambien for sleep?

Under what circumstances do we think chronic long term Ambien is needed for sleep?

I'm sorta big on the idea if it ain't broke don't fix it, if it feels good do it, and I'm not doing a good job explaining why this doesn't seem ideal.

You do you. I personally hate to be dependent on pills for any basic life function like sleeping or pooping unless I think it's either really harmless or really necessary. Not sure where this falls.

 

[wolfvgang22]

It only takes 14 days to develop dependence on benzodiazepines.

Buspar and Vistaril can have placebo effect and do work sometimes. Many patients I have tapered off benzos and zolpidem demand "something else to replace my Ambien/Xanax."

I talk them into therapy if I can.

 

[Crayola227]

This reminds me of something I was saying to someone about quitting smoking or drinking or what have you. It seems impossible to "do" certain things without certain substances, like drive, dance, walk, sleep, but we're generally born and spend many years doing these things un-drugged.

So at what point could one not sleep unassisted by exogenous substances? I mean, I can't sleep unassisted myself, so the struggle is real. Things change over the lifespan.

Still, my principle is that natural things should happen naturally, and if/when they don't, it's worth asking why not, and also what's the best way forward.

 

[watto]

Re: melatonin, the original study alluded to in this full text article is a good read:

Poor Quality Control of Over-the-Counter Melatonin: What They Say Is Often Not What You Get

What's on the label is very likely not what is in the med. The original study found almost 30% of the OTC melatonin in capsule form contained serotonin. My patients who have had "bad reactions" to melatonin may very well have been reacting to that component.

Also, there is some older research that taking high doses of melatonin may eventually downregulate your MT receptors. I wouldn't want to go into old age, where your circadian rhythm amplitude is already dampened, with that problem.

I do sleep, primarily tx of insomnia, and the melatonin lecture with my patients can take 10-15 minutes. Melatonin may be OTC, but it is a complex drug with a complex MOA depending on your intentions for use. If interested, read the Lewy research about phase angle delay and the doses used there to advance phase (o.3 to 0.5 mg depending on calculation of sleep midpoint, or 5 hours prior to lights out).

 

[watto]

This reminds me of something I was saying to someone about quitting smoking or drinking or what have you. It seems impossible to "do" certain things without certain substances, like drive, dance, walk, sleep, but we're generally born and spend many years doing these things un-drugged.

So at what point could one not sleep unassisted by exogenous substances? I mean, I can't sleep unassisted myself, so the struggle is real. Things change over the lifespan.

Still, my principle is that natural things should happen naturally, and if/when they don't, it's worth asking why not, and also what's the best way forward.

Yes, I tell many of my patients that sleep is something their body wants to do. It is about removing barriers to that happening and generally putting yourself into a position where, if it's going to happen, you are ready for it.

 

[clausewitz2]

Re: melatonin, the original study alluded to in this full text article is a good read:

Poor Quality Control of Over-the-Counter Melatonin: What They Say Is Often Not What You Get

What's on the label is very likely not what is in the med. The original study found almost 30% of the OTC melatonin in capsule form contained serotonin. My patients who have had "bad reactions" to melatonin may very well have been reacting to that component.

Also, there is some older research that taking high doses of melatonin may eventually downregulate your MT receptors. I wouldn't want to go into old age, where your circadian rhythm amplitude is already dampened, with that problem.

I do sleep, primarily tx of insomnia, and the melatonin lecture with my patients can take 10-15 minutes. Melatonin may be OTC, but it is a complex drug with a complex MOA depending on your intentions for use. If interested, read the Lewy research about phase angle delay and the doses used there to advance phase (o.3 to 0.5 mg depending on calculation of sleep midpoint, or 5 hours prior to lights out).

This so hard. There is a reason melatonin is a prescription-only drug in some EU countries.

 

[watto]

This so hard. There is a reason melatonin is a prescription-only drug in some EU countries.

Totally agree. Add to the mix that dosing melatonin improperly can disrupt the circadian rhythm further and you have a recipe for confusion. Anecdotal reports of melatonin success or failure mean so little as you never know what dose was used, where in the person's melatonin response curve it was used, was there light exposure obliterating the effects, etc. etc. etc. ad infinitum

 

[Crayola227]

Re: melatonin, the original study alluded to in this full text article is a good read:

Poor Quality Control of Over-the-Counter Melatonin: What They Say Is Often Not What You Get

What's on the label is very likely not what is in the med. The original study found almost 30% of the OTC melatonin in capsule form contained serotonin. My patients who have had "bad reactions" to melatonin may very well have been reacting to that component.

Also, there is some older research that taking high doses of melatonin may eventually downregulate your MT receptors. I wouldn't want to go into old age, where your circadian rhythm amplitude is already dampened, with that problem.

I do sleep, primarily tx of insomnia, and the melatonin lecture with my patients can take 10-15 minutes. Melatonin may be OTC, but it is a complex drug with a complex MOA depending on your intentions for use. If interested, read the Lewy research about phase angle delay and the doses used there to advance phase (o.3 to 0.5 mg depending on calculation of sleep midpoint, or 5 hours prior to lights out).

This is great, thank you.

I have heard that about high doses, too. Paradoxical effect can be seen at least short term, I don't know long term, but yeah I never do more than 2 mg.

 

[Mad Jack]

My standard non-psychiatrist treatment for people who've just lost a family member is a benzo of some kind at bedtime only. Shouldn't mess with them too much during the day but does let them get some sleep hopefully.

Benzos are like, fifth line for sleep where I'm training. Remeron, trazodone, melatonin (these first three may be tried in any order), then Ambien, then benzos. If the problem also includes nightmares, mix any of the first three with prazosin.

 

[Crayola227]

I just read that paper, and I'm thoroughly unimpressed.

My big takeaways would be not to use in kids (other providers can figure that out if it needs figuring out), don't take a big dose, don't take it without reason, and as with anything OTC, quality matters.

As far as containing serotonin, they indicate that it isn't some sort of factory cross-contamination but is a normal biproduct of melatonin breakdown, which is what it does in the bottle. This was in a quarter of the samples, in amounts that *might* have significance. All of which has low bioavailability.

More concerning seemed to be what often is an issue with OTC supplements, and that is the variation in dosing.

I also never read anything into the differences in drug regulation between countries without reading what the rationale behind it is. Sometimes the FDA is ridiculous and sometimes it's the EU.

This paper didn't really tell me anything I didn't already know except that bit about the serotonin.

When I prescribe melatonin for sleep, I'm basically within all of this except that I use it for sleep conditions broader than what is cited in this paper, and I can't control for sourcing. Otherwise I treat it as something to be prescribed, clear instructions, follow up.

I'd be curious to know what source my hospital uses when it fills inpt orders. Probably whatever manufacturer is cheaper that quarter.

I agree that melatonin should be treated with care and like the hormone that it is, and not like a damn water soluble vitamin.

 

[watto]

I just read that paper, and I'm thoroughly unimpressed.

Really? I feel like if I were recommending something that, as the authors found, contained a range of -83% to +478% of actual labeled product, I would be much more cautious. Or at least find a single supplier with better data.

 

[Crayola227]

Really? I feel like if I were recommending something that, as the authors found, contained a range of -83% to +478% of actual labeled product, I would be much more cautious. Or at least find a single supplier with better data.

That's basically the most concerning thing, definitely suggests you find a quality supplier, and that you don't switch if anything, because I think the main issue is not getting consistent dosing, rather than overdosing. And we're not talking about something where underdosing is dangerous, just not efficacious.

The most concerning formulations were exactly the ones I would avoid, one being "chewable" and the other mixed with herbals.

>70% of what they studied had LESS than what was labeled, not more.

I take 1 mg tablets and split them. If I'm getting ~500% of 0.5 mg = 2.5 mg. Outside the 2 mg I don't like to go beyond, but hardly danger-zone under the worst conditions this study suggests, one that was done in Canada. There are reasons it's illegal to source your drugs from Canada. So this is reason to find a decent supplier, start literally as small as you can. I tell patients to start with 1/2 of a 1 mg tablet and never go past 2 mg without talking with me. I've had a few go to 3 mg, at least as fake-labeled it would seem.

I look at absolute values. If my risk of butt cancer from being on SDN goes up 500%, that could be 0.0005% to 0.0025% or 1% to 5%. Depends on how you like to gamble and the actual values, for what risk you take.

I'm not impressed with the danger here, but I do appreciate caution. It is something to be nibbled and then assessed, not gobbled. I do really appreciate that you shared this paper though, I will be more cautious in the future.

Done as directed and with reason, I think melatonin is the least of most of what we've discussed here as far as pills for sleep and this paper didn't change that, that's all I meant by saying I wasn't impressed with the dangers.

 

[Crayola227]

I will say that it was awesome you brought a recent review from a reputable journal on a frequently recommended and seemingly safe intervention, one might suspect is prone to all the other problems unregulated OTCs have. Take nothing for granted.

And they say psychiatrists and all us other docs don't read papers and just push pills for money.

 

[watto]

I will say that it was awesome you brought a recent review from a reputable journal on a frequently recommended and seemingly safe intervention, one might suspect is prone to all the other problems unregulated OTCs have. Take nothing for granted.

And they say psychiatrists and all us other docs don't read papers and just push pills for money.

Thanks. I still read papers to ward against the sense we are all just more expensive versions of the 10:30pm act at The Magic Castle's Houdini Seance Room.

 

[clausewitz2]

Benzos are like, fifth line for sleep where I'm training. Remeron, trazodone, melatonin (these first three may be tried in any order), then Ambien, then benzos. If the problem also includes nightmares, mix any of the first three with prazosin.

Our sleep specialists hate mirtazapine for sleep with a fiery passion and generally do z-drugs after melatonin and psychosis action/coaching on sleep restriction (CBTi being ideal of course but not usually available, although the data are encouraging for online, self-paced delivery). They also rightly point out that doxepin has much better sleep data than trazodone and that the generic 10 mg is probably fine so you don't have to be writing for Silenor.

For some of my bipolar/schizomanic patients I have a low threshold for a short course of a benzo for sleep (like 3-5 days worth) when they seem headed into a manic episode.

 

[wolfvgang22]

Our sleep specialists hate mirtazapine for sleep with a fiery passion and generally do z-drugs after melatonin and psychosis action/coaching on sleep restriction (CBTi being ideal of course but not usually available, although the data are encouraging for online, self-paced delivery). They also rightly point out that doxepin has much better sleep data than trazodone and that the generic 10 mg is probably fine so you don't have to be writing for Silenor.

For some of my bipolar/schizomanic patients I have a low threshold for a short course of a benzo for sleep (like 3-5 days worth) when they seem headed into a manic episode.

Why do they hate mirtazapine?

 

[Mad Jack]

Our sleep specialists hate mirtazapine for sleep with a fiery passion and generally do z-drugs after melatonin and psychosis action/coaching on sleep restriction (CBTi being ideal of course but not usually available, although the data are encouraging for online, self-paced delivery). They also rightly point out that doxepin has much better sleep data than trazodone and that the generic 10 mg is probably fine so you don't have to be writing for Silenor.

For some of my bipolar/schizomanic patients I have a low threshold for a short course of a benzo for sleep (like 3-5 days worth) when they seem headed into a manic episode.

We don't prescribe it for sleep, we prescribe it for depression with trouble sleeping. I'll have to look into the data for doxepin- might be worth changing SOP around the inpatient unit if it's that good

 

[VA Hopeful Dr]

Benzos are like, fifth line for sleep where I'm training. Remeron, trazodone, melatonin (these first three may be tried in any order), then Ambien, then benzos. If the problem also includes nightmares, mix any of the first three with prazosin.

Do keep in mind this is short term as part of an acute grief reaction, I don't start with benzos for primary insomnia.

For general insomnia, I've been using less trazodone and melatonin since this came out: https://aasm.org/resources/pdf/pharmacologictreatmentofinsomnia.pdf

 

[Mad Jack]

Do keep in mind this is short term as part of an acute grief reaction, I don't start with benzos for primary insomnia.

For general insomnia, I've been using less trazodone and melatonin since this came out: https://aasm.org/resources/pdf/pharmacologictreatmentofinsomnia.pdf

Their method of analyzing melatonin was quite unusual, including only low-dose formulations (2 mg), with studies finding improvements in those over 55 even in said studies. I'll have to do some digging through the literature or maybe I'll have to do a study of my own, but 6 mg is about the lowest I see people with chronic insomnia respond to.

Trazodone was similarly analyzed in a very narrow fashion- they only looked at one study, which did find clinically significant increases in total sleep time and did show improved sleep onset time. Only one study including a 50 mg dose was used, which is about half of what we typically use for sleep.

When guidelines come out that have nothing but weak category recommendations for or against, they basically mean nothing when you look at the studies involved and their inclusion criteria more often than not. Another major issue is that abuse and dependence potential was not included in their consideration of agents, which is concerning in light of the patient populations I'm typically working with (>90% have substance use disorders). Oh yeah, and hospital formulary issues (I do inpatient at this point in my training which really limits prescribing options). I'll have to read it a bit more over the weekend, as I'd be curious to further evaluate the reccomendations, studies, and authors.

 

[clausewitz2]

Their method of analyzing melatonin was quite unusual, including only low-dose formulations (2 mg), with studies finding improvements in those over 55 even in said studies. I'll have to do some digging through the literature or maybe I'll have to do a study of my own, but 6 mg is about the lowest I see people with chronic insomnia respond to.

Trazodone was similarly analyzed in a very narrow fashion- they only looked at one study, which did find clinically significant increases in total sleep time and did show improved sleep onset time. Only one study including a 50 mg dose was used, which is about half of what we typically use for sleep.

When guidelines come out that have nothing but weak category recommendations for or against, they basically mean nothing when you look at the studies involved and their inclusion criteria more often than not. Another major issue is that abuse and dependence potential was not included in their consideration of agents, which is concerning in light of the patient populations I'm typically working with (>90% have substance use disorders). Oh yeah, and hospital formulary issues (I do inpatient at this point in my training which really limits prescribing options). I'll have to read it a bit more over the weekend, as I'd be curious to further evaluate the reccomendations, studies, and authors.

The original studies that established the role of melatonin in circadian regulation and found a treatment effect, as noted above, were looking at doses like 0.5 mg. Supraphysiologic doses do not appear to be helpful and are actually probably harmful for well-regulated sleep.

When I have a patient who insists they need their 10 mg of melatonin it is not the hill unusually choose to die on but I do provide psychoeducation about the better efficacy of lower doses and, as noted above, the fact that taking it qHS is unlikely to be useful (as opposed to five hours or so beforehand as @watto was laying out upthread). Melatonin 6 is probably a placebo in adults if qHS.

@wolfvgang22 , what I hear from them is that you get significant metabolic downsides for unimpressive results when used for sleep alone. And certainly the literature evidence base is not robust. I find it sometimes hard in the absence of clear empirically results to square the clinical experience of experts with the clinical experience of so many other people. Not sure where I land tbh.

 

[clausewitz2]

We don't prescribe it for sleep, we prescribe it for depression with trouble sleeping. I'll have to look into the data for doxepin- might be worth changing SOP around the inpatient unit if it's that good

Prepare for a pharmacist shrieking about serotonin syndrome for all your patients on SSRIs because you are prescribing a TCA. You will need to be prepared to point out that doxepin at 10 mg has negligible serotonin activity and is mostly hitting histamine.

 

[Mad Jack]

Prepare for a pharmacist shrieking about serotonin syndrome for all your patients on SSRIs because you are prescribing a TCA. You will need to be prepared to point out that doxepin at 10 mg has negligible serotonin activity and is mostly hitting histamine.

Oh god, the pharmacy calls I get... Yes, yes I'm sure. No, no it won't kill the patient. I appreciate that they care I guess, but y u gotta clutter up my tiger text

 

[Mass Effect]

I was taught never give a benzo for acute stress reaction, PTSD, or grief. I second mirtazapine or trazodone for sleep. At the most affective sleep dose, melatonin doesn't do anything for depression.

 

[whopper]

Very interesting and a reason why I still frequent this forum.

I pretty much never prescribed benzos except in limited amounts but a few years ago a NP (a good one, better than some attendings) showed me a study showing that benzos could reduce the risk of Acute Stress Disorder turning into PTSD. I figured it could make sense since benzos inhibit memory-formation and reduce anxiety.

So I did some lit-searching and this was also published in UptoDate and a few other studies although all of them had small populations. So just in case I did another lit search.

The newer data is showing benzos not having any significant benefit in reducing PTSD, same with B-blockers despite prior data showing it helped. Oddly and suprisingly it's doing opioids and hydrocortisone in preventing PTSD.

A Review of Psychopharmacological Interventions Post-Disaster to Prevent Psychiatric Sequelae. - PubMed - NCBI
So I'm going to change my practice algorithm based on the above.