The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:
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Requests for advice and / or encouragement. On basically any topic and for any scale of problem.
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Updates to let us know how you are doing. This provides valuable feedback on past advice / encouragement and will hopefully make people feel a little more motivated to follow through. If you want to be reminded to post your update, see the post titled 'update reminders', below.
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Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.
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Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).
Jump in the discussion.
No email address required.
Notes -
People who are AI Doomers/on the doomer spectrum and have kids, how has it changed how you parent/plan for life?
I wouldn't say I'm a doomer, but I generally respect Scott's opinions so the latest AI forecast they dropped does seem somewhat concerning to me. Wondering if I should be stepping up the amount of time and money spent on eg family vacations while the going is good.
I’m not a doomer. I don’t even think Scott’s piece is doomerish. But yeah, I’m trying to enjoy the strange world we live in now, because I don’t think it’s going to last much longer.
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Quick request for a spot check:
I've had the build for a new pc in my apartment trickling in. So far, I've ordered/received/have:
The audio quality of my phone is good enough that I'd be happy to use it as a mic, and as a webcam. I have Bluetooth earphones and a mouse that I like. I think the PC came with power cables, but I haven't unboxed it yet. Wired internet is not an option, so I have to settle for wifi running off a 5g uncapped service. Should be fine, if not ideal.
?buy:
Am I missing anything? Any QOL improvements?
A cheap UPS to give you the time to do a proper shutdown in case of power failure.
Even in India, I never particularly missed an UPS despite the worse electricity infrastructure. I think blackouts where I currently live in Scotland are on the scale of hours a year, so I'm willing to do without it. I'll keep that in mind in case my optimism is disabused, thank you.
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And protect from voltage transients. Power supplies are incredible at eating anything you throw at them, but tree branches on power lines can cut mains voltage in half several times a second.
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Get a PS5 controller.
Compatibility with a pc, while not non-existent, can be a headache at times. I prefer the Xbox layout too!
For the sake of others reading this: There's no headache. Some games have native support, others require an app like DSX. Takes a few minutes to set up the first time. Reliable after that.
There aren't many PC games that support the unique DualSense features, but I strongly prefer the shape and feel of the PS5 controller over the XS one.
That's fair. I've heard of DSX, but only just looked into it in more detail and found out it does a good job of getting proprietary PS5 controller features to work in games without native support.
I still find the ergonomics awkward, though that's likely an idiosyncratic thing. I like my left thumb resting on the d-pad, instead of the stick.
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Get a cheap set of cable ties -- I'm a big fan of velcro, but there are moderately good magnetic or flex-plastic ones. Good wire management starts on day one, and if you let it get bad you'll never fix it.
A moderately good USB dock can make your life a lot more pleasant, both to just have extra options to put a plug in, and since USB-C ports fit pleasantly-and-destructively inside USB-A ports. They're not very expensive, but the lowest-end ones can be worse than nothing; expect 15-25 USD for something notTemu grade. Some, but far from all, B560s support Thunderbolt, either stock or as a generally pretty cheap add-in card, and while desktop users will seldom if ever want to use it as an expansion for graphics cards, it can be useful for data transfer or other high-throughput peripherals.
Contra ToaKraka, I'm not a huge booster for RAID at home, since there's a lot of subtle failure modes and it doesn't protect you from the most common failures (RAID is not a backup). That said, a cheap USB platter drive can set you back around 50-80 USD, be trivial to automate, and save a lot of potential frustrations even if everything Is On The Cloud. Does require regularly unplugging it to get the most out of it.
If you have available PCIE slots, NVME expansion cards will set you back 10-30 USD, depending on quality, and are a nice way to bulk up on storage if your motherboard is limited. That said, unless you get a B560 in mini-ITX, I'd expect three slots in a prebuilt, and that's more than enough for most users.
Your monitor and GPU will very likely support HDMI, knowing nothing other than the stats you provide, but double-check both support and compatibility -- a lot of highest-framerate options work best over DisplayPort. Adapters are cheap (though I'd recommend splurging around ~15 USD), but they suck to have to wait a weak for, and with tiny number of exceptions these adapters are unidirection.
There's some specialty things (eg, if you get water cooling, a cheap pump shutoff humidity sensor can save you a lot of frustration; if you do a lot of console- or simulator-like gaming there are some recs I can give for gamepads or throttles; VR headsets can change a lot of interests), but I'll assume that if you had those constraints you'd have mentioned them (and water cooling is pretty marginal today).
Thank you, that's excellent advice.
Why is that the case?
Since I ended up opting for a TV instead of a monitor (a 4K OLED VRR TV is cheaper than a smaller QHD OLED monitor), HDMI 2.1 is the only option. I've confirmed compatibility.
This PC is watercooled. I didn't want that, but since it was the cheapest model with a Ryzen 9800X3D and an RTX 5080, my frugality won out. Is that humidity sensor easy to install?
I am somewhat interested in a controller, I prefer the Xbox layout over a PS4/5 one. I'm familiar with VR, I owned a Quest 2, but didn't bring it over from India. There's not much room to properly use it, unfortunately.
Having a spinning secondary disk that's constantly plugged into your computer helps prevent some concerns that overlap with RAID benefits (eg, single disk hardware failure) and some that RAID can't help with ("oops I overwrote this file I need"). It only partially mitigates catastrophic physical risks (such as theft), and does not mitigate at all mitigate catastrophic malware or user error concerns. I have dealt with multiple users who've had ransomware not only hit their main drive, but every drive plugged into every computer on their home network; I've seen a couple people accidentally overwrite their storage drives when reinstalling Windows or Linux.
This is a low risk, especially if you're computer-savvy, but it's also very low-cost.
Ah, sorry, misread that.
No, unfortunately. There used to be some decent commercial ones, but the brands I know about look to have stopped manufacture. That probably means that, with the growth of good AIOs, leaks are a lot less common, but I do know of a few major AIO manufacturers that have had recalls over leaks.
I've usually stuck with condensate cutoff switches and put them inline for the power cable, but this requires some familiarity with wiring and crimping 110v or 220v AC power. Home water leak detectors can be useful and they're literally set-and-forget (modulo The Apps), but make sure to get one that has a humidity function, not just direct drip detection. Be aware that they won't shut off the system, they'll just beep at you to do so.
It's reasonable to skip one, and most people do. If you do not use a leak detector, do regularly inspect (1/month) your PC internals, especially at fittings near the CPU waterblock, for any signs of corrosion, 'grit', or dampness. I'd also recommend being extremely aware of the PC's intended physical orientation: AIOs are very dependent on gravity feeding the pump, .
Thank you, that's very helpful. I've never handled a water cooled rig before, so fingers crossed I don't break anything.
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More storage is always good. 2tb nvmes are as cheap as they're going to get right now (as is ram: big memory chip oversupply), so you may as well buy plenty of both. As long as your mobo has m2 slots for the drives ofc
I'm quite confident that it does have spares, but I haven't unboxed it yet (I need to move it over), and the manufacturer is rather coy about the specific brand of B650 motherboard in use. I'd expect, given the price I paid for it, there should be a few handy.
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The point of an SSD is to provide fast loading times for your operating system and your video games. In my personal experience, a 1-TB internal drive is good enough. But if you keep a lot of bloated modern video games installed simultaneously then you may need something bigger.
If you need storage for your collection of 4K60 dashcam videos, there is no need for an SSD's high speed, so you should instead use HDDs (16-TB, 24-TB, etc.)—preferably in a RAID 6/RAIDZ2 configuration, to prevent data loss. Note that RAID does not work well with external USB enclosures, so you would be better served using a separate, lower-power, Linux-running computer as a server and connecting it to your main computer with Samba. But that may be beyond your price range.
I have an unfortunate habit of downloading games that are maybe 50 gigs in size and then adding on several hundred gigs of mods. I think I was well past 300 gb for Arma 3, and even poor old Rimworld, which is sub 1 gb by itself, bloated to 17+.
I can see a good deal for 4tb M.2 NVME drives with decent reviews, so I'm inclined to future proof. I'm not the target audience for a RAID setup, anything critical is likely a small file and backed up to the cloud.
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I am alive, I have blocked youtube, twitter, Instagram (deactivated my account back in October), Reddit and everything distracting from my laptop and my phone. My co-working idea from 2023 finally took off, I co work with two other people, one being my mentor, the other being an extremely competent friend of my age who si may age.
Progress so far
I am nearly done with Math Foundations 3 which is MathAcademy's final pre-university module that also covers calculus right before Multi variable calc. I will head on to Logic and proofs followed by Discrete Math. Math for ML will follow these two. In the meantime, I will do some math that I learnt in Math Foundations 1, 2 and 3 from a rigorous textbook so that I have a decent level of mastery and fluency with regard to math. I ultimately want to be a really good research ML engineer.
My mathacademy total xp is now close to 11k, every xp is worth a minute or more, it feels trivial compared to people who do real STEM stuff at a high enough level but I know how hard differential equations, sub topics in integration was. It seems laughably easy once I have done it but I can never appreciate myself for doing any of it. Its way beyond what I ever did, I just dont like myself enough to say anything nice, not being whiny, I dont want to be known as the guy who considered basic math literacy to be a milestone. I hit 180 or 3 hours in an airport and one time in a fucking train with a pinhole light, without even having a seat to sit properly on. The same guy who could not study for a decade, pissed away his chances at grad school, flunked two classes was able to do something that. I do respect myself for that though, quite a bit.
I dropped Clojure and front end, opting to double down on Python instead. I do Boot.devs material; I finished their OOPs course a few minutes ago. I will do the Python workbook and aim to finish that in three weeks while doing my daily three hours of math and an hour of Boot.dev. I will still need money since I wont be able to afford meds after july but I will find some ways around that, my sabbatical will last at least 4-6 more months.
My life is boring in ways. I wake up, work out (three days), meditate, study, and sleep. My phone time is much lower since I track it and would be zero if I were not a massive coombrained person. Which is why I also nuked all the images I had of girls from my past life. That stuff will not help me live now.
If I am late in posting updates, know that I am in a better place than what I started in. 6 years ago I posted here and on slatestarcodex as a delusional cram school kid who was shit scared of failing his high school equivalent exams and never getting to a uni. It took me half a decade but I am at least on an ok track now. My co working mates are genuinely very good engineers and they do celebrate my progress but I cannot feel nice.
Maybe I will in some time. My time here has always been great, this is not a goodbye post, I will post, I am just not going to be as regular but I will update. People here saw me go through life and I think they deserve to read the good parts too.
Routines
Working out first thing in the morning kickstarts my concerta. I feel relief climbing out of the dingy pajeet gym I work out, the stairs connecting the basement to the ground, lit up with the sun. My mind feels clear after I meditate, I feel zero friction when I work. The day feels amazing, my only issue is sleeping on time, I must sleep by 11 daily and did that zero fucking times in all these months. It pisses me off and makes my bi onthly therapy session feel like a waste since she wants me to sleep by 11 every day to help fix my circadian rhythm. 1:30 am right now, fuck. Sleeping full 8 hours should do wonders for my life.
Birthdays
My grandad turns 92 this Saturday. We are throwing a party and it reminded me of my more recent Wednesday update about nostalgia. I remember watching movies with my cousins in late March, playing Holi and all four of us (the two of them and my younger brother) being there for grandads birthdays. We get the front yard done and throw a large get-together. This year, neither of them are turning up for his birthday, thier mom, my aunt is since she can't miss her dad's birthday but I do feel a little bad about it. You cannot go back, still for a moment, I wish they came. We even had a golden week where we saw holi, grandads birthday and a literal movie shoot happen in the same week. They shot a movie in our front yard since I live in a large old-fashioned house, ones built for feudal lords of the day. Remembering it makes me smile. We spent the entire night playing FIFA, saw a lot of decent movies and I got introduced to electronic music via Swedish House Mafias albums. Not the best music but I still mosty listen to electronic music, much better kind though.
Oneitis
The girl I was into out of my betaness and low status is now just another girl. A friend of mine recently told me about bumping into her in a nightclub in Delhi where she was coked out of her mind, chatting up everyone whilst looking fatter. In that moment I felt sad for her. Every girl I have ever always ends up worse once I lose my rose-tinted glasses and she seems the same honestly. Doing substances in a bar with your friends and going back home to your parents, working a dead-end job where you only make enough to live paycheck to paycheck because you have a lifestyle to afford (do not blame her here tbh, the Indian economy is the culprit). For the first time, I felt a lot of pity for her. I was 21, 4 years ago exactly when I posted about how she was sleeping around with other guys, being super emotional about it instead of manning up and just meeting her. Me from the past would not believe that I genuinely don't like her at all now.
Why post
Moreover, I am coming to terms with the fact that things have changed, the people I knew in the past, are well in the past and they should stay there. I am still unemployed, unskilled, skinny and living with my parents but I am better each day. Every day I try my hardest to be better, or at least try harder at trying my hardest. I am in the top 5 percent of both math academy and boot.dev, much higher in mathacademy, maybe top 5-10 people all time in terms of weekly volume done.
I just hope that I can continue my progress and that everyone around me is alive, happy and healthy to see me do well. I came to this place at a very difficult time in my life, everyone here helped me be who I am in a very literal sense. Strength training, meditation, pua, a pursuit of mastery, and the belief that I can do better, are things I picked up along the way. Some kind souls still read my life's updates and my new arc of being a guy who learns math and backend engineering to eventually do cutting-edge ML stuff is not all that exciting.
My bad days are about 4 hours and at about hour 8, I can no longer work, though I suspect with enough practice, I can stretch that to 12 but that will take a while. Working on hard things, learning this stuff, meditating, working out, all of it is extremely humbling. Every single session makes me aware of just how far behind I am from where I wish to be. The bright side is that each time, I get better. Many in life just mentally check out and live in deluded fantasy lands where they are too smart to do anything, only to wake up at 40 and realise that they have failed at life. There are days when my brain just gives out and it is satisfying in a way. Every time I drag myself out of the gym having struggled with benching less than 135, I get closer to benching 225 or dipping and chinning half that as long as I don't get injured and don't miss a session. 225 is not unreasonable in a year given I am quite untrained.
Coda
Life is not something that happens to me, I have some control over it. Everyone I know besides a few is out of shape, sad, not earning as much as they wished to, and living in total denial of reality. That was me too, for the longest time. @Standard_Order once told em to seek sun and steel, and chase natural happiness, I get what he meant now.
My posting history makes me cringe, a lot. Why would someone like me post about his life on a place dedicated to culture war discussion, why even would the people there help and how on earth did I not get banned years ago? I posted earlier because I had nothing going on in my life, the attention I got online helped soothe that, and now I am making some progress, which makes me care less about it, hence the abstinence from twitter.
Thank you, to everyone on the motte, to all the people I befriended here, everyone who cared enough to help me. Remember, mrvanillasky is going to get better. May the gods help me, may they help us all.
Hari Om!
I think I mentioned you re: coworking but never got a response.
I apologise, lemme find the link
edit - cannot find it
I am on a coworking space daily, 6 days a week. Helps a lot, I also track my screen time publicly, post my stuff done there daily. I cannot find where you mentioned me though
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Can someone recommend sleeping pills (I assume pills are the conventional form) that work with a minimum of side effects and/or long-term damage?
Lately I've been alternating between nights of 12 hours of sleep, and others with pretty much none. Right now I'm at two all-nighters in a row. This is a little unusual for me, but I can't afford to be groggy all day long, so I'd like to get back on a solid schedule by any means necessary. Any advice appreciated.
Melatonin! Minimal side effects, since it's just your sleep hormone. from scott: https://lorienpsych.com/2020/12/20/melatonin
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For me, it's
I start at the top and add medications depending on how tired I am. Normal day: magnesium, or maybe nothing. Exhausted/sick/in pain but need to sleep ASAP: all of them. I have never had any sort of hangover from taking these together.
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20mg dyphenhydramine works for me but only sparingly. over the counter, safe, effective. mix with a responsible amount of alcohol to ensure unconsciousness.
some people like myself get terrible nightmares on it but it's still worth it for trips and special situations
you need to find yourself multiple solutions to cycle through to not build a tolerance, but there really is no easy cure for chronic insomnia.
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Orexin inhibitors have been a god send for my insomnia. Specifically I like Dayvigo. It’s a bit expensive but I consider good sleep worth it, and there’s basically no side effects except a fair bit of morning grogginess
You might want to consider some mild sleep restriction therapy as well. Getting 12 hours of sleep in bed is why you’re not getting any on other nights
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I started drinking a cup of tart cherry juice about an hour before bed (I prepare it from 2 tbsp of concentrate) and it works better than melatonin for me as far as making me sleepy on schedule and improving my overall sleep quality and consistency.
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The following is an abbreviated version of the talk I give students on this topic.
For a resource that is reasonably easy to parse (and free) you can check out this link. It has a chart at the end that is very helpful.
https://www.aafp.org/pubs/afp/issues/2017/0701/p29.html
TLDR: Pharmacologic intervention is not first line. Proper assessment, lifestyle modification, therapy, and treatment of underlying conditions are first line treatment. Neglecting this can render medications ineffective or outright dangerous. Talk to a doctor.
Okay so occasionally a student comes up to me and goes: "Um, what do we do for patient's with insomnia? It seems to have a ton of different causes and the AAFP, ABPN, and AASM all have different guidelines.
And then I go "GLAD YOU ASKED!!!! If you look closely the guidelines are actually quite similar, but now that you have activated my trap card (students are starting to no longer get this reference sadly) you have to listen to me ramble for an hour instead of going to get lunch.
I will organize this into clinical pearls since it is in written format.
A very large amount of insomnia is not primary insomnia. In essence that means that most insomnia has a cause that should be targeted as your first goal. If you have sleep apnea... medication will not help you. Your problem is that you are not breathing while you are asleep and your body is very concerned. Medication can be counterproductive or dangerous. Treat the sleep apnea and magically you will sleep much better. Americans are fat, it is common and people do not want to treat it. If I had a dollar for every family member or coworker who had sleep apnea and knew about it and didn't treat it I would retire. Other medical problems can also cause insomnia. Nearly every psychiatric condition has insomnia as a symptom. People who might not otherwise notice they are depressed will notice sleep quality changes.
Patient's feel very strongly about insomnia (as they should! That shit is miserable). Therefore is a lot of lore and STRONG OPINION some of which has insufficient high quality evidence. Some of which is clearly bullshit but you will never convince people. For the former - one of the best evidence based physicians I know uses magnesium and is insistent it helps. Whether it shows up on treatment algorithms is a bit complicated but it certainly seems to do something helpful for some people. Many, many people use Weed and Alcohol. They will swear by them. Don't.
What type of insomnia you have is very important. Different treatment interventions (including lifestyle but also meds) will vary depending on what type of insomnia you have.
Meds don't work part 1: they don't work.
Lifestyle change and therapy work. CBT-I is one of the most effective treatment modalities in medicine. People hate the sleep restriction portion but that shit works. However it's kinda similar to recommending exercise to a pre diabetic. Will it fix the problem? Sure! Will they do it? No.
Some of the CBT-I components actually work great and are easy to do (like sleep hygiene). It can sounds stupid but screen time changes, reading war and peace, and so on are actually extremely effective when you can implement them. Google sleep hygiene for more or talk to a competent physician.
Meds don't work part 2: Patients want meds instead of treating underlying conditions. If you are anxious that is the problem and you need to fix it. If you have OSA meds won't work.
Meds don't work part 3: Okay meds do work. The situations in which they do work are complicated and beyond the scope of this lecture. Snowing someone with Seroquel to help them sleep because they are manic is not unreasonable. Same thing with aggressive grandma who is awake at night and hitting the nurses (or wait - no, you aren't supposed to do that, except sometimes you are...complicated).
Okay, the effect sizes of meds are pretty small. Some seem to work better but are more expensive. Some are extremely dangerous for one reason or another. BZDs cause dementia, IQ loss and all cause death. Ambien causes sleep driving. If you are actually sleeping on these is a complicated question.
Getting treatment for insomnia is super fucking important, so we will prescribe and recommend even when on paper things don't work or are dangerous or otherwise problematic. Often this is harm reduction. Patient won't get a CPAP but at least they will sleep this way...
Because of all the above it is EXTREMELY easy to get VERY poor quality care for insomnia. Insomnia is miserable, patients have preconceptions about works, they are very demanding. Even if YOU aren't very demanding many doctors will be like "fine, whatever" because they don't want to have "one of those" conversations. Be careful.
Sorry. I know this is not what people want to hear.
Excellent work! God knows that sleep disturbances keep many a shrink employed, so I have the bare minimum clinical experience to comment.
A lot of insomnia isn't primary, as you said. I'd know, I went half a decade being told I snore by my parents, and then my ex, before I bit the bullet and had a polysomnography suite conducted. I ended up with a diagnosis of borderline severe sleep apnea, I was going minutes between breaths. I was quire happy with the quantity and quality of my sleep, but I did notice tiredness and daytime somnolence for a while. Unfortunately, as someone with moderate-severe depression, it's unclear which way the causality ran. I was slightly overweight but not obese. I also had a mildly deviated nasal septum.
Even more unfortunately, I found out that I just couldn't tolerate a CPAP. My willingness to look ridiculous, while there, doesn't extend that far, especially when the machine was noisy and the strap quite uncomfortable. I gave it a few nights, didn't notice much change, and surrendered. I'd lie if I said I tried any lifestyle modifications either, so I have immense sympathy for patients who don't adhere to our exhortations.
More recently, I noticed a combination of insomnia, early awakening and tiredness in conjunction with my depression worsening for (reasons). I ended up with a prescription for mirtazapine, which definitely helped with sleep (it's unclear if the improvement in my mood was because it worked, or because I finally found a stimulant for ADHD that didn't make me feel awful or keep me up all night).
I think I'd consider myself a nightmare patient, one who was too impatient to bother with sleep hygiene. The meds worked, though insomnia wasn't the sole reason for starting them.
One day US doctors will learn to use generic names. Get with the times old man. Quetiapine isn't a bad sedative, but just about nobody would prescribe it outside of psychosis or manic conditions because of the laundry list of side effects. If there's anybody doing it just for sleep, haven't heard about it.
While my bosses try to be Good Clinicians, and refrain from attempting to treat such behavioral disturbances with medication where feasible, I'm afraid that in the majority of cases, the demented granny gets a nice cup of covertly administered lorazepam. It makes the nurses lives easier, and by extension, ours.
Funny you'd bring that up. I was just talking about it with my boss, and in my attempts to show clinical curiosity and ingratiate myself, I brought up the topic of benzos and dementia. I'd already read up about it, the causation is fraught. It's very hard to rule out protopathy, where the anxiety and insomnia of early dementia forces doctors to resort to benzos, with the actual diagnosis of dementia coming later. In his opinion, the evidence is too mixed to speak about conclusively. Especially in the elderly, where sedation risks outweigh other concerns (half the patients already have dementia, what does it really matter if their risk increases?). They will, however, make you dumber and increase mortality.
Because of my own personal issues with leading a healthy lifestyle, I tend to be unusually sympathetic and non-pushy about lifestyle modifications when patients are recalcitrant. I still think thrice before prescribing benzos beyond a short course, though something like melatonin is so harmless that it's almost always worth a shot. (I lean towards Scott's opinion that most clinicians are retarded and prescribe far too high a dose. An adult is best off starting at 300mcg)
I've mentioned the new drugs targeting orexin receptors. They're big news, a novel hypnotic with good effect sizes and no demonstrated dependency risks??? Maybe we can move away from benzos. I haven't prescribed them, haven't seen them prescribed, but I have read the literature and will just about say they're worth a shot and better for you than benzos.
My working algorithm for someone with sleep issues:
So that was totally a senior trap but good job in your response haha.
Some thoughts:
-Sleep isn't just for Shrinks. In the U.S. it's bread and butter for Psychiatry and Sleep Medicine (duh) but also Family Medicine. And......everyone needs to know it. What impact do you think insomnia has on surgical wound healing times? Behavioral regulation and thus overall care while admitted under care of a hospitalist? Knowing this well is important and it's a great thing you can use to help out other specialties.
-Remember OSA cause psychiatric disturbance. The DSM emphasizes that psychiatric problems are not otherwise caused by a substance or medical problem. Consider this with respect to correlation and causation. A strict doctor will not diagnose someone with depression with untreated OSA for the same reason you won't diagnosis someone with mania if they are high on meth.
-There are more CPAP and other OSA treatment options than you can imagine. Obviously the UK probably has some limitations on this front but you'd surprised where you can go with this. Don't give up (for yourself OR the patients)!
-Meds do work sometimes. Knowing when they are likely to work is why we get paid. Controlled situational depression in a high functioning patient (during for instance...residency) is a good example.
-Bitch I will use whichever is easier to spell or say. And yes don't use Seroquel for sleep (usually- general and psycho-geriatrics will use it in certain populations and that's actually the right move, also can be used in certain acute settings with care and deliberation), but you'd be shocked at how often it's used when it shouldn't be. Especially cough cough NPs.
-Do not give granny Ativan. It worsens delirium. If consulted tell medicine to fuck off and prescribe it on their own recognize and copy paste whatever your delirium protocol is into the consult note. ...and then rec Ativan anyway because your attending long ago gave up.
-You are correct! I always overstate Benzo risk with patient facing communication and writing because what we are certain on is quite bad enough and it's probably better to emphasize what we may later find to be true. AND...in the best case the Benzo is impairing establishment of more definitive care anyway. I find most patients and clinical staff underestimate just how addictive Benzos are.
-Check out the AAFP and other more updated guidelines, you'll benefit from them and they lay out the thinking and some include the evidence base for the new agents. The sleep medicine ones also.
-Put rule out other processes including OSA much higher up in algo.
-Work on your lifestyle mod, you can get some common sense sleep hygiene done usually.
-CBT-I is magic if you can get them to do it. IF but it is magic.
While this is good care, I rarely see this implemented in practice. GPs bear the brunt of insomnia, though of course it's a perennial concern in psych. I've never seen my bosses actually order formal assessments for sleep apnea, not that we have the equipment to do PSG in a psychiatric hospital.
I sleep just fine these days, thankfully. When it comes to patients, I'll keep an eye on whether GPs have attempted to exclude behavioral or medical causes like OSA, but if they do, it never seems to come up in the notes or referral letters. No mention of CBT-I that I can recall, even if NICE recommends it as the first line intervention, and there's even a dedicated app.
Even if the dementia risk wasn't an issue, just the addiction potential and cognitive effects should put most reasonable people off them. The former is nasty, but I guess they beat barbiturates.
Thanks for the pointers!
In a medical setting you should always be thinking this way - just because a patient has a psychiatric complaint doesn't mean your brain should turn off. You'll miss autoimmune encephalitis this way. Also I'm looking at you 95% of emergency medicine physicians.
In psych you should be considering sleep study in a residential or outpatient setting but for crisis or inpatient I get it, other things need to be dealt with first.
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Benzos and z-drugs are right out. Melatonin is only modestly effective. Antihistamines? Eh, they're not my first choice for prolonged use, they have deleterious effects on cognition.
Very recently, a new class of sleeping pills that target orexin receptors has come out on the market. An example would be daridorexant. They're reasonably effective, and surveillance after 12 months of sustained use hasn't demonstrated any addictive properties (and we're much better at evaluating that, not like when benzos were marketed as non-habit forming).
They seem to me to be significantly more effective than melatonin, and roughly on par with benzos (which do work! They're just risky and addictive). Ask your doctor if they're willing to prescribe for you, but I haven't seen them used myself (they're very new and the consultants haven't caught on).
I'd love to see your critique of my rant!
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You have legal weed in Germany now, right? What’s the situation with edibles like? Strictly control dosage, don’t consume recreationally during the day and you might find it works well for you.
Interesting idea, but no. Too distasteful, and I'll have a hard time telling my daughter why she shouldn't if I lead by bad example.
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You could try any of the sleep inducing antihistamines like Promethazine or Hydroxyzine. You'll likely need a prescription but in my experience doctors are happy to prescribe these because they're not habit forming or have any recreational uses. The worst thing that can happen is that the side effects are uncomfortable or that one builds tolerance.
I've tried Propiomazine (another antihistamine used in Sweden) and they've worked for me, albeit leaving me a little groggy in the morning when on a higher dose. I found the sleep to not be as good as regular sleep but when the option is between little to no sleep and substandard sleep the choice is easy.
As with pharmacological treatment for insomnia, these are not supposed to be used for some kind chronic treatment where you take them every day of the year, but if you have occasional periods of insomnia they work well.
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I think you have to pick between effectiveness and sustainability. Pretty sure you can't have both. The effective ones are addictive.
You could try melatonin though. It works pretty well for some people. Get one of those sprays and spray it under your tongue. Keep it there for 15 minutes. Wait until sleepiness sets in, go to bed.
You might want to look into newer drugs that target orexin receptors, like daridorexant. I've discussed them above.
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I had one of those melatonin sprays a few years ago. Not sure if it did anything, but I guess it's a good idea to try that first. Worth an attempt. Thanks!
I recommend reading https://slatestarcodex.com/2018/07/10/melatonin-much-more-than-you-wanted-to-know/ before using melatonin, as there are some misconceptions out there. Specifically, the standard pills you can buy have about 10-30x the dose you want.
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