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:
-
Requests for advice and / or encouragement. On basically any topic and for any scale of problem.
-
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.
-
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.
-
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 -
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
More options
Context Copy link
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.
More options
Context Copy link
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.
More options
Context Copy link
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
More options
Context Copy link
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.
More options
Context Copy link
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.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
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!
More options
Context Copy link
More options
Context Copy link
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.
More options
Context Copy link
More options
Context Copy link
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.
More options
Context Copy link
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.
More options
Context Copy link
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.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link