"I just can't sleep!"

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shahseh22

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I've been getting a lot of these patients that no matter what, they cannot sleep. For a number of them, they have a diagnosis of PTSD and I have been just trying to give them Benadryl/Trazodone/Vistaril. Of course, this is of limited benefit. I have noticed that even Clonidine is not as sedating and I worry because it is not FDA approved for nightmares. Also, a lot of these patients want something PRN instead of scheduled so I worry about rebound Side effects with antihypertensives.

Of course I have them on their morning does of SSRI's which help with anxiety somewhat. However, I was wondering if anyone has had any luck with giving Doxepin or Mirtazapine at a low dose on PRN basis? It is my obligation to inform them about side effects and whenever I talk about possibility of serotonin syndrome, they are reluctant. Is it really that unsafe to give these two with an SSRI, though? Incidence of SS is quite low if i recall.

The other alternative is Seroquel, but I just don't like prescribing Neuroleptics to people (especially kiddos) without trying everything else.

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How young are these kiddos? Are we talking 16 year olds or more like 6 year olds? Do they have legit PTSD? I find that diagnosis becoming like bipolar in that anyone with trauma seems to receive it these days. Is it nightmares waking/keeping them up or are they having trouble initiating sleep (and if so, why?).

I do have patients on mirtazapine. The majority take it nightly, but I inherited a few in my outpatient clinic who swear by prn doses at 7.5 mg (lower doses are more sedating than higher doses). I also have 2 patients on an SSRI who were started on amitriptyline for headaches by neurology. They take it nightly though, not prn.

At my hospital, we use Seroquel A LOT and some of the attendings will also prescribe it in their outpatient clinic to patients who can't sleep (usually starting with 25 mg). That said, I personally try to exhaust other options first, unless there are mood/psychotic symptoms present and for that I'd usually dose higher.
 
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I've been getting a lot of these patients that no matter what, they cannot sleep. For a number of them, they have a diagnosis of PTSD and I have been just trying to give them Benadryl/Trazodone/Vistaril. Of course, this is of limited benefit. I have noticed that even Clonidine is not as sedating and I worry because it is not FDA approved for nightmares. Also, a lot of these patients want something PRN instead of scheduled so I worry about rebound Side effects with antihypertensives.

Of course I have them on their morning does of SSRI's which help with anxiety somewhat. However, I was wondering if anyone has had any luck with giving Doxepin or Mirtazapine at a low dose on PRN basis? It is my obligation to inform them about side effects and whenever I talk about possibility of serotonin syndrome, they are reluctant. Is it really that unsafe to give these two with an SSRI, though? Incidence of SS is quite low if i recall.

The other alternative is Seroquel, but I just don't like prescribing Neuroleptics to people (especially kiddos) without trying everything else.

Mirtazapine does not increase serotonin levels intrasynaptically, it does not inhibit reuptake or promote release, it cannot cause serotonin syndrome. You can give it with MAOIs.

Doxepin 10 mg (I would love if 5 was commercially available as a generic but alas) is one of my go-to's because a) it has pretty good evidence b) it is pretty well tolerated and cheap and c) people who have been through the wringer or through substance abuse treatment haven't heard of it so they will not have the firm conviction that it cannot possibly work. At the doses you would use for sleep (<25 mg) it is incredibly unlikely you are affecting serotonin in any way, the 5HT affinities are incredibly weak in general.

Have you explored what is keeping them from sleeping? Is it nightmares and the anticipation of them or something else? Is there a reason not to try prazosin if you are quite sure it is PTSD?

For kids I get why Z-drugs are off the table but for adults, is it really better to be giving people diabetes? Seroquel at 25 is very active at histamine receptors and we know histamine antagonism pretty closely tracks weight gain...

The answer is going to depend a lot on a good sleep history, though. If they are saying they simply do not sleep at all and this has been going on for more than a couple nights they are a) manic b)mistaken c) part of a very specific Northern Italian kindred.
 
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How young are these kiddos? Are we talking 16 year olds or more like 6 year olds? Do they have legit PTSD? I find that diagnosis becoming like bipolar in that anyone with trauma seems to receive it these days. Is it nightmares waking/keeping them up or are they having trouble initiating sleep (and if so, why?).

I do have patients on mirtazapine. The majority take it nightly, but I inherited a few in my outpatient clinic who swear by prn doses at 7.5 mg (lower doses are more sedating than higher doses). I also have 2 patients on an SSRI who were started on amitriptyline for headaches by neurology. They take it nightly though, not prn.

At my hospital, we use Seroquel A LOT and some of the attendings will also prescribe it in their outpatient clinic to patients who can't sleep (usually starting with 25 mg). That said, I personally try to exhaust other options first, unless there are mood/psychotic symptoms present and for that I'd usually dose higher.

I share your reluctance around Seroquel as a sleep aid; if I get someone new in who is sleeping really poorly and might be legitimately hypomanic or in a mixed state I definitely reach for it but as you say, higher doses (like starting around 100).

If someone seems to be melancholic and the insomnia is part of that kind of a picture, nor/ami make perfect sense. Also migraneurs, folks with chronic pain, etc. Definitely makes more sense scheduled, though.
 
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Aggressive sleep hygiene. Look at the barriers to natural sleep. Make sure they're tuned into the signals for sleep. Explore the process of sleep training for them. Explore how they're fighting their own sleep.
 
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As nitemagi mentioned CBTi could be helpful. Also consider prazosin if PTSD-related nightmares/hyperarousal play a major role (scheduled, not PRN). The latest data suggests prazosin is generally ineffective, though the evidence remains ambiguous re: nightmares and I have seen some patients improve a great deal with it.
 
As nitemagi mentioned CBTi could be helpful. Also consider prazosin if PTSD-related nightmares/hyperarousal play a major role (scheduled, not PRN). The latest data suggests prazosin is generally ineffective, though the evidence remains ambiguous re: nightmares and I have seen some patients improve a great deal with it.
As nitemagi mentioned CBTi could be helpful. Also consider prazosin if PTSD-related nightmares/hyperarousal play a major role (scheduled, not PRN). The latest data suggests prazosin is generally ineffective, though the evidence remains ambiguous re: nightmares and I have seen some patients improve a great deal with it.

When you mention negative evidence, do you mean Raskind et al. 2018? A caveat there is that they specifically were looking at folks with PTSD who were at the VA and whose symptoms were chronic. I am sure I don't need to tell you that this population is not entirely comparable to garden-variety PTSD. Since many previous metanalyses have found an effect, and I certainly have patients who swear by it, I think the harm/benefit ratio is titled pretty heavily in it's favor if you are dealing with awakenings and sleep disturbances due to excessive adrenergic activity stemming from traumatic memories/reexperiencing.

No medication that works is benign but prazosin has a pretty mild side effect profile and certainly wins the adverse effect game if we are going to compare it to the anticholinergic burden or metabolic derangement of some of our favorite go to sleeping medications.
 
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I have found myself doing much more in relation to promoting good sleep hygiene, as these days there's so much electronic device usage which I believe reduces natural melatonin production through the blue light mechanism. Feels there's a subset of people who used to read books before bed, but for whatever reason have been gifted or switched to an ereader or tablet which often is responsible for mucking things up.

Have used low dose doxepin in adult patients with decent results, but it's not something I'd generally use first line and only if I really know the patient well, which is mainly due to the potential for accidental, potentially life threatening overdoses. Have noticed that mIrtazapine can be just as problematic as seroquel regarding weight gain and metabolic effects, but I'd be more inclined to preference the latter due to being more confident that it will work for the intended purpose. As lower doses can be more sedating, I think mirtazapine PRN is less intuitive for patients.

No medication that works is benign but prazosin has a pretty mild side effect profile and certainly wins the adverse effect game if we are going to compare it to the anticholinergic burden or metabolic derangement of some of our favorite go to sleeping medications.

Have often used prazosin with PTSD related nightmares, but as it's a fairly potent antihypertensive the main thing I warn patients about is postural drops and an increased falls risk which can be a big issue if they are prone to getting up in the middle of the night to use the bathroom.
 
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Do you all ever use sleep actigraphy for people who claim that they never sleep or sleep 2-3 hours a night? Not during a manic state but for years? I get this complaint rather frequently in primary care and find it hard to figure if the person is really assessing this accurately. Population heavy with mood disorders and PTSD (and metabolic syndrome and advanced age that make me reluctant to use some of the meds mentioned, including anticholinergics).
CBTI is my go to generally...after the preliminary instruction to stop spending 10 hours in bed if you’re sleeping 4. And then I wrestle with the question of if I’m going to prescribe something then would it be better to prescribe a straight up Z hypnotic with all its cautions, or something with a bunch of additional activity that I’m not really looking for. Doxepin I haven’t used much but sounds promising.
(sorry to butt in your forum but enjoying the interesting discussion and it turns out about half my practice ends up being psychiatric in part or whole)
 
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As lower doses can be more sedating, I think mirtazapine PRN is less intuitive for patients.
While this is the common claim, I don't believe the evidence actually supports lower doses of mirtazepine being more sedating than higher doses.
 
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When you mention negative evidence, do you mean Raskind et al. 2018? A caveat there is that they specifically were looking at folks with PTSD who were at the VA and whose symptoms were chronic. I am sure I don't need to tell you that this population is not entirely comparable to garden-variety PTSD. Since many previous metanalyses have found an effect, and I certainly have patients who swear by it, I think the harm/benefit ratio is titled pretty heavily in it's favor if you are dealing with awakenings and sleep disturbances due to excessive adrenergic activity stemming from traumatic memories/reexperiencing.

Good point, I am referring to data drawn from a veteran population. Risk/benefit-wise I think prazosin is still worth a try (even for veterans).
 
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A big frustration I have with today's medicine is the number of doctors willing to push Zolpidem or similar meds (e.g. Temazepam) for sleep without mentioning to the patient that it should only be for short term use and the risks. Most sleep meds aren't good options for long-term use. I generally have patients using mega-dosages of Melatonin (around 20 mg) or Tryptophan before I consider a sleep med. For these patients many of them told me it did work well but there's always exceptions.

Aside from benzos, TCAs are associated with possibly increasing risk of dementia plus several likely side effects such as weight gain or constipation.

Another major issue going on is as we all know OSA is linked to being overweight. Well guess what? The majority of Americans these days are ....overweight. We're not supposed to be medicating sleep apnea that I suspect is a major cause of a large portion of today's cases of insomnia.

But the way to diagnose it appropriately is expensive-a sleep study. I've seen people where I was highly confident their problem was sleep apnea only to have their insurance refuse to pay for it or only pay an amount that still made it very cost-prohibitive for the patient. While there is now an OSA specific diagnosis method that is cheaper than a sleep lab overnight stay this is relatively new.

Another frustration is, rarely, I get a patient with a severe sleep problem. E.g. I got a guy now where Thorazine 400 mg daily doesn't put him to sleep, nor does several meds at the maximum dosages such as Trazodone, Mirtazapine, and I try a benzo give the warning it's only temporary and as expected they develop a tolerance to it so I take them off of it and now they can't sleep. This type of patient needs a sleep study but he can't get his insurance to pay for one.
 
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Do you all ever use sleep actigraphy for people who claim that they never sleep or sleep 2-3 hours a night? Not during a manic state but for years? I get this complaint rather frequently in primary care and find it hard to figure if the person is really assessing this accurately.

I have met several people who claim this. Unless we are dealing with fatal familial insomnia they are not accurately reporting their sleep. Subjective reported sleep durations do not match up that well to actual lab measures in the sleep literature. It is probably fair to say they have had chronic problems with sleep but actual total insomnia like that is not sustainable for very long, certainly not years.
 
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I generally have patients using mega-dosages of Melatonin (around 20 mg)
I've read higher doses can paradoxically work worse, and that closer to 300 mcg is effective.

It's anecdotal but tart cherry juice is helpful (I just googled it: has melatonin and tryptophan).
 
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Yeah, which is why I tell them to experiment with dosing. E.g. try smaller dosages first and keep a journal on how each dosage did. For the most part Melatonin is good at helping patients fall asleep but not stay asleep. Higher dosages only help, usually, with keeping them asleep cause creates a larger d amount in the body. The half life of Melatonin is only about 1 hr. The federal government did a study showing Melatonin peaks in effect at about 20 mg. (I don't have the study on me).
 
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The original exogenous melatonin studies that demonstrated it was useful for modifying/normalizing circadian rhythms used very small doses, such as 0.1-1 mg. Partly to avoid having to deal with possible intellectual property issues, manufacturers ran with selling melatonin as a supplement using a very different basic dose, i.e. 3 mg and up. This (plus the FDA going along with allowing it to be classified as a dietary supplement) killed the incentives for putting a lot of pharm money into figuring out how to optimize melatonin dosing.

Our sleep people maintain that supraphysiological doses of melatonin (like 20 or whatever) may have a short-lived sedative effect but may be actively unhelpful for total sleep time and sleep efficiency. There are far more studies examining much smaller doses of melatonin and they tend to find a lack of dose-response relationship in that small dose range, which means that in that <5 mg range there seems to be no benefit to increasing the dose.

The researchers who warn against using excessive doses of melatonin regard greater than 0.3 mg as supraphysiological and there is some reason to think this ends up disrupting circadian rhythms significantly, at least in adults.

Megadosing melatonin thus strikes me as not a fantastic or evidence-based idea. To be maximally effective it also needs to be taken 4-5 hours before bedtime, which is a really awkward time to remember to take something. For some people melatonin is useful and kids seem to be a whole 'nother thing but just a handful of pills at bedtime is mostly operating through placebo.
 
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Lunesta is an option, and it's generic now. Low dose TCAs work too, but have more side effects.
 
Best I can tell the evidence for treating poor sleep with trazadone or melatonin is pretty bad. I’ve been trying to focus more on sleep hygiene and if I have to use meds then first focusing on treating the underlying depression/anxiety more aggressively and if an actual sedative is needed then go towards Z drugs. My understanding is the Z drugs are favored by the sleep medicine recommendations compared to trazadone/melatonin. iirc Lunesta seems to have the best risk:benefit ratio for chronic insomnia
 
I have sone patients respond to belsomra. Not sure if the info about quazepam having less abuse liability than benadryl is true.
 
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