Podcast Summary
Exploring Less Common Approaches to Insomnia Treatment: CME programs, like psychiatrypodcast.com, offer convenient access to essential knowledge, reducing burnout and increasing job satisfaction. This episode focuses on insomnia treatment, featuring experts discussing less common approaches and valuable research on mental health and sleep.
Continuing medical education (CME) can help reduce burnout and increase job satisfaction for healthcare professionals. The convenience of joining a CME membership, like the one offered through psychiatrypodcast.com, can save time and provide easy access to essential knowledge. In this episode, the discussion revolves around treating insomnia, with a focus on less common approaches like managing screens before bedtime and the use of various sleep medications. The podcast also features guest speakers, doctors Tomatsu and Krishnan, who bring valuable insights from their research on the biopsychosocial connection between mental health and sleep, as well as trauma therapy for the LGBTQ community. The comprehensive handout they've prepared is an impressive resource for healthcare professionals. The episode addresses a multitude of questions from listeners, making it a valuable learning experience. Overall, the goal is to provide practical, translatable knowledge that can be directly applied to clinical practice.
Understanding the Different Phases of Insomnia: Insomnia can be caused by various factors and is categorized into three phases: initial, middle, and terminal. Identifying the underlying cause is essential before prescribing medication, and CBT-I is the gold standard recommendation, but it's often not the first choice due to its time-consuming nature and cost.
Insomnia can be caused by a variety of factors, including psychiatric disorders, medical illnesses, and even viruses like COVID-19. Sleep scientists describe insomnia in three phases: initial, middle, and terminal. Initial insomnia is difficulty going to sleep, middle insomnia is waking up during the night, and terminal insomnia is waking up too early. When treating insomnia, it's important for healthcare professionals to identify the underlying cause before prescribing medication. The gold standard recommendation from the American Academy of Sleep Medicine is Cognitive Behavioral Therapy for Insomnia (CBT-I), but it's often not the first choice due to its time-intensive nature and cost. While medication can help a person fall asleep, it may not address the underlying cause of insomnia. Insomnia can be a symptom of other conditions, such as anxiety or depression, or a result of medical issues, so it's crucial to consider these possibilities before prescribing a treatment.
Bright light before bedtime disrupts sleep: Avoid bright light exposure for a few hours before bedtime to improve sleep quality, especially from screens emitting blue-green light.
Exposure to bright light, especially from screens, close to bedtime can disrupt your sleep by suppressing melatonin production. This can cause difficulty falling asleep and delaying the onset of your sleep-wake cycle. Many people engage in activities like drinking caffeine, using bright screens for late-night reading or work, and irregular sleep patterns due to shift work, which can also contribute to insomnia. Humans are most sensitive to light in the blue-green part of the spectrum, which is emitted by many screens, making it even more disruptive to sleep. To improve sleep quality, it's recommended to avoid bright light exposure for at least a few hours before bedtime. The optimal time may vary, but stopping exposure around 8 PM is a good starting point for most people. Additionally, the quality of blue light blocking glasses can be inconsistent, so it might be more effective to simply avoid bright screens close to bedtime.
Improving Sleep Quality with Sleep Hygiene: Personalize sleep hygiene for better sleep by avoiding work projects, arguments, and screens before bed. Try calming alternatives like white noise or specific TV shows. In the inpatient setting, avoid exercise before bedtime. Ensure a dark and dim sleep environment and set timers for devices.
Establishing healthy sleep habits, or sleep hygiene, is crucial for improving sleep quality. Sleep associations, such as using a phone or watching TV before bed, can be hard to break due to their familiarity. Instead, consider calming alternatives like background white noise. Eliminating work projects or arguments in bed are also recommended. Interestingly, some people may find that certain sleep associations, like watching specific TV shows, can actually help them fall asleep. In the inpatient setting, avoiding exercise before bedtime is important, as it increases sympathetic activity and can keep you awake. For those who need to exercise, aerobic exercise is beneficial but should not be done right before bed. Additionally, ensuring a dark and dim sleep environment, and setting a timer for TV shows or other devices, can help minimize disruptive elements. Overall, personalizing sleep hygiene to individual needs and preferences can lead to better sleep.
Minimizing medication disruptions to improve sleep in hospitals: Consider alternative methods for managing patients' conditions and use sedatives or anxiolytics for the shortest duration possible to minimize sleep disruptions and potential increased mortality risk.
While pharmaceutical options are often necessary in healthcare, there are ways to minimize their use, particularly when it comes to medications that disrupt sleep. These disruptions can occur due to frequent vital checks in the middle of the night or medications that are given at inconvenient times. Hospitals can improve the sleep environment by adjusting lighting and noise levels, but this may not be feasible in all units, such as ICUs. Chronic use of sedatives or anxiolytics, including Benzodiazepines and the Z drugs, has been associated with increased mortality rates. Therefore, it's essential to consider alternative methods for managing patients' conditions and use these medications for the shortest duration possible. A large UK study found that people taking sedatives or anxiolytics for extended periods had a higher all-cause mortality rate than those not taking these medications. While these patients may have had other health issues, the study suggests that the drugs themselves may contribute to the increased risk.
Comparing Sedatives and Anxiolytics for Insomnia: A Large-Scale Study: The study found that Benzodiazepines, while effective for short-term insomnia treatment, have high misuse rates, particularly among younger adults. CBT-I is more effective in the long term but is underutilized. Providers can consider short-term use of sedatives for transient insomnia and effective interventions for circadian disturbances.
A large-scale study was conducted to compare the effects of sedatives and anxiolytics on insomnia, as smaller studies had produced mixed results due to varying illnesses and drug lengths. The study found that 12.6% of adults reported past-year Benzodiazepine use, with misuse accounting for nearly 20%. The highest misuse was in the younger population, while the highest number of prescriptions was in adults over 50. However, Benzodiazepines are only effective for short-term insomnia treatment, as individuals become tolerant to their sedative effects within weeks. Instead, Cognitive Behavioral Therapy for Insomnia (CBT-I) is more effective in the long term, but it's challenging to get patients into this treatment. As providers, short-term use of sedatives, particularly the z drugs, can be helpful for those with transient or acute insomnia. Additionally, there are effective interventions for treating circadian disturbances.
Melatonin and its analogs for treating circadian disturbances: Melatonin and its synthetic forms can help manage insomnia from shift work or jet lag. Optimal dosage is 3-5mg, taken an hour before bedtime. Ramelteon, specifically, improves sleep onset and early stage sleep, and may be covered by insurance for certain conditions.
Melatonin and its synthetic analogs, such as Ramelteon and Tasamelteon, can be effective treatments for circadian disturbances, including insomnia caused by shift work or jet lag. The optimal dose for most adults is between 3-5 milligrams, taken about an hour before bedtime. While higher doses can make the user drowsy, they may also cause impairment of alertness and cognition the following day. Melatonin's short half-life means that it goes away quickly when taken as a pill, unlike the natural melatonin produced by the pineal gland. Ramelteon, specifically, has a poor bioavailability and primarily helps with sleep onset and early stage sleep. Its use may be covered by insurance for certain conditions, such as phase advance of the sleep-wake cycle, which can help older adults adjust to social obligations. Overall, these medications can be useful for managing circadian disturbances, but it's important to consult a healthcare professional for dosage and specific application.
Benzodiazepines impact on sleep and dementia: Benzodiazepines, while helping sleep initiation, can cause daytime impairment depending on their half-life. Long-term use increases dementia risk, but the calming effect might reduce it. Gradual tapering is crucial to avoid relapse or withdrawal symptoms.
While melatonin and its analogs have minimal effect on sleep regardless of the time of day, benzodiazepines, which are commonly used for sleep and anxiety, can have significant daytime impairment depending on their half-life. Chronic use of benzodiazepines is associated with an increased risk of dementia, although it's unclear if the drug is the cause. The calming effect of benzodiazepines may reduce the risk of dementia, but the increased risk of depression and mortality might offset this benefit. If tapering a patient off benzodiazepines, it's crucial to do so very gradually due to the risk of relapse or withdrawal symptoms. In elderly patients, it's best to avoid chronic benzodiazepine use for sleep.
Gradual tapering off Benzodiazepines is essential: Slowly decrease Benzodiazepine dosages over 6-12 months to prevent relapses or catatonia. Use antihistamines like hydroxyzine as alternatives for sedatives and consider trazodone for sleep, but recognize its limited effectiveness compared to placebo.
When it comes to tapering patients off Benzodiazepines, a slow and gradual approach is crucial to prevent relapses or the development of catatonia. While some physicians may be in a hurry to reduce dosages, the brain is more tolerant of gradual change. A decrease in dosage should ideally be spread over 6 months to 12 months. Benzodiazepines are best used as short-term rescue medications, recognizing that some clinical circumstances may require long-term use. They can be compared to high-potency steroids, excellent for rescue but miserable long-term medications. For sedatives, antihistamines like hydroxyzine are a preferred option due to their minimal side effects. Trazodone, while commonly used for sleep, may not be as effective as placebo in helping patients fall asleep faster or return to sleep quicker. Its popularity may be due to the historical concern of tolerance and dependency with Benzodiazepines, leading to an increase in trazodone prescriptions during that time.
Considering the Risks and Benefits of Sedatives for Insomnia: Antihistamines like hydroxyzine and trazodone can help with insomnia but come with risks and considerations. Trazodone can worsen bipolar disorder and cause disrupted sleep, while hydroxyzine lacks anticholinergic side effects. Mirtazapine and magnesium also have potential benefits and risks.
While antihistamines like hydroxyzine and trazodone can be effective sedatives, they come with risks and considerations. Trazodone, being an antidepressant, can worsen conditions like bipolar disorder if given to someone experiencing hypomania or mania. Additionally, trazodone can cause sedation with a second dip, leading to disrupted sleep. Hydroxyzine, on the other hand, lacks the undesirable side effects of anticholinergic drugs like diphenhydramine. Mirtazapine, another option, acts primarily as an antihistamine at low doses and can be effective for some patients, but carries the risk of discontinuation syndromes. Magnesium, which some people report helps with insomnia, has a theoretical mechanism for calming effects but lacks substantial evidence from well-controlled studies. It's important for healthcare professionals to carefully consider the risks and benefits of each option when prescribing sedatives for their patients.
Be Aware of Sleep Medications' Side Effects: Antihistamine OTC meds can impair memory and cause side effects. Herbal sedatives like Valerian have inconsistent quality. Prescription meds like Seroquel have concerning side effects. For sleep apnea, consider quieter machines, surgical revisions, or weight loss. Z drugs and Benzodiazepines are not effective or dangerous respectively.
When it comes to over-the-counter sleeping medications, people should be cautious as many contain antihistamines, like Diphenhydramine (Benadryl), which have anticholinergic side effects leading to memory impairment, blurred vision, dry mouth, constipation, and urinary retention. Valerian, a commonly used herbal sedative, has sedative effects but the quality of products can be inconsistent. Prescription medications like Seroquel, which is sometimes used off-label for sleep due to its antihistamine properties, can have concerning side effects such as hypotension. For those with sleep apnea not responding to CPAP machines, options include trying quieter machines, surgical revisions, and weight loss. However, z drugs like Azopetine and zolpidem have not been found to be effective for sleep apnea and Benzodiazepines are dangerous due to the risk of causing both obstructive and central apnea.
Maintaining Comfort with CPAP Machines: Addressing discomfort and noise with CPAP machines is essential for effective use. Melatonin can help patients fall asleep, while eszopiclone is often used for acute insomnia in bipolar patients, but individual responses should guide dosage.
Ensuring a good fit and comfort level with Continuous Positive Airway Pressure (CPAP) machines is crucial for effective use. These machines help maintain airways during sleep, but their discomfort and noise can lead to resistance. It's essential to address any issues promptly, such as adjusting the mask or using earplugs for noise reduction. Melatonin is a safe option for patients to help them fall asleep while wearing CPAP machines. For acute treatment of insomnia in bipolar patients, eszopiclone is often the first choice, with doses sometimes increased during manic episodes to maintain sleep. However, it's important to note that these higher doses are not necessary during non-manic periods. As always, individual patient needs and responses should guide treatment decisions.
Combining Antidepressants and Sleep Aids for Insomnia: For terminal insomnia, treating underlying depression is key. Antidepressant fluoxetine with esopiclone is effective in reducing depressive symptoms and improving sleep quality.
While zopiclone and zolpidem are effective in treating insomnia, they come with potential side effects such as dry mouth, unpleasant taste, and in higher doses, dissociative episodes. Zolpidem is particularly prone to causing dissociative mental states when combined with alcohol or cannabis. For terminal insomnia, treating the underlying depression is the primary approach, and sedatives with short half-lives like zopiclone and zolpidem may not be effective. A study from 2006 found that combining fluoxetine and esopiclone led to greater reductions in depressive symptoms and improvements in sleep quality for patients with major depressive disorder and persistent insomnia. Esopiclone has been the most effective z drug in this context. It's important to note that alcohol and cannabis use can significantly increase the risk of dissociative states when taking these medications.
Considering Factors Beyond Medication for Insomnia: When treating insomnia, consider factors beyond medication, such as patient's unique needs, lifestyle, and underlying causes like trauma. Esopiclone is a better option for terminal insomnia, while sedative drugs with shortest half-lives are recommended for vertigo. Always ask questions and consider lifestyle factors for effective treatment.
When dealing with insomnia, it's crucial to consider various factors beyond just prescribing medication. Zolpidem and zalopline may not be effective for terminal insomnia due to their short half-lives. Esopiclone is a better option. When treating dizziness, it's essential to avoid drugs with alpha adrenergic antagonist properties if the patient has orthostatic hypotension. For vertigo, sedative drugs generally don't worsen symptoms, but some patients may experience exquisite sensitiveness to mild ataxia. In such cases, using chronobiologic drugs like melatonin or sedative drugs with the shortest half-lives, such as xalepol, is recommended. Remember, every patient is unique, and lifestyle factors like exercise and personal preferences should also be considered. Always ask questions before choosing an intervention and keep in mind that not everyone responds the same way to treatments. Additionally, trauma can contribute to insomnia, and addressing it may be necessary for effective treatment.
Emphasizing the importance of addressing trauma in mental health: Continuing education through CME and mentorship plays a crucial role in understanding and effectively addressing the underlying trauma in mental health issues.
Importance of addressing the underlying trauma in mental health issues. The speaker, who has a strong belief in the role of trauma, emphasized the significance of going back to the roots of mental health concerns. She expressed her gratitude for the opportunity to share this information for free, but encouraged those interested in continuing education to sign up for CME. She acknowledged the contributions of doctors Tomatsu and Krishnan, and looked forward to a future episode featuring her mentor, Dr. Cummings, who has written a book on psychotic disorders. Overall, the speaker emphasized the importance of ongoing learning and the role of mentorship in the field of mental health. If you're interested in continuing your education, consider signing up for CME or checking out Dr. Cummings' book.