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The Role of Sleeping Medications in the Treatment of Sleep Disturbances

Good and not so good ways to use sleeping pills

Online Health Chat with Douglas Moul, MD

March 9, 2011


Introduction

Cleveland_Clinic_Host: Since the 1970s, our understanding of the physiology of sleep has increased dramatically. During this time, psychologists and sleep experts have developed non-medical treatments for insomnia that focus on thoughts and behaviors. While medication continues as a commonly used treatment approach for individuals with sleep disorders, psychology-based self-management techniques have also been shown to work for many people.

As our understanding of sleep mechanisms has grown, the quality and benefits of the “sleeping pill” have become more focused. Today’s sleep medications are generally more effective with fewer side effects and withdrawal symptoms than medicines used several decades ago. Still, as with all medications, sleep aids for the treatment of sleep disturbances must be used properly and with care.

Join Dr. Douglas Moul as he answers questions about sleep disturbances and the role of sleeping pills in their treatment. He also discusses non-medical, behavioral approaches for improving sleep.

Douglas Moul, MD, earned his medical degree from the University of Southern California Keck School of Medicine in Los Angeles in 1985. He completed a residency in psychiatry at Los Angeles County/USC Medical Center and a fellowship in seasonal affective disorders and circadian rhythms at the National Institutes of Health in Bethesda, MD. He also attended Johns Hopkins School of Hygiene & Public Health in Baltimore, where he obtained a Masters in Public Health. He completed a research fellowship in psychiatric epidemiology and services research at the National Institutes of Health in 1995, and another research fellowship in sleep medicine and psychiatric research at the University of Pittsburgh Medical Center in 2002. He is certified in both general psychiatry and sleep medicine. Among his special interests are insomnia, sleep psychiatry, and sleep disorders.

To make an appointment with Douglas Moul, MD or any of the other specialists in our name of the Sleep Disorders Center at Cleveland Clinic, please call 216. 636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/sleep.


Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Douglas Moul. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

george1958: I am a 53-year-old man. For the last 12 months, it seems like I lose sleep in the time period between 3 a.m. and 6 a.m. I am unable to sleep continuously from 10 p.m. through 6 a.m. I'll be able to sleep after 6 a.m. for two more hours. What does the loss of that sleep time zone mean? Could it be reinstated? Do I need sleeping pills?

Dr__Douglas_Moul: Before there were light bulbs, people had what was called early and late sleep. Your description reminds me of that pattern. A question to ask would be whether or not you get refreshed from the sleep pattern you now have. If so, and if your job permits it, there is nothing wrong with that sleep pattern.

If you want to change this sleep pattern, then my advice would be to get help from a sleep psychologist or physician to get the schedule of your sleep back to that others have. There may be ways to get more consolidated sleep through medication use, but my preference would be to look at behavioral measures first. It is conceivable that the use of a sleeping pill might help you, but it would have to be a medication with a longer half-life, and your doctor would have to make that choice. However, if it is a longer-lasting medication, it may give you a longer morning sedation that you may not want. A situation like yours should have an individual evaluation. If your problem is caused by anxiety or depression, that would also require individualized attention.

NeedSleep_: I have no problem falling asleep, but have a problem staying asleep for more than two hours at a time. My mind races at night, which wakes me up, usually thinking about my jobs when I do wake up. I do take over-the-counter sleeping pills (and have taken them longer than I should), which seems to help a little. I have been on prescriptions also, which helped a little more but were too costly to keep up. I have cut out all the things they tell you to cut out of your diet in order to sleep, but nothing seems to help. Any new suggestions? Like my screen name -- I Need Sleep!

Dr__Douglas_Moul: Your type of problem is common with people who have difficulty with sleep. For some people with this problem, sleeping pills provide a benefit. Other people find the benefit only temporary or minimal. The truth is that sometimes the activity of the mind can undo whatever help a medication provides. In the case of too much thinking or worrying in bed, sleep problems often happen, even though you do all the routine sleep hygiene things.

In situations like this, there should be a slow-down period before bed, when the sleeper recognizes the need to downplay or dis-attend to thoughts about the daytime. Bedtime can be a wonderful time when we are relaxed and we feel we can concentrate on things; but doing thinking in bed can cause problems with getting to sleep. It is really a skill to recognize when you are thinking too much and to de-focus from those thoughts. Sometimes, people can do this by figuring out this problem for themselves, and sometimes they need coaching from a sleep psychologist. But if you can figure out a way to not think about things in bed, the natural process of sleep will be there and will work. There are many stories about people who learn these skills and are able to sleep better or even normally.

george1958: Do afternoon naps for one hour or so help or disturb sleep later on at night?

Dr__Douglas_Moul: There are two processes in the brain that create sleep drive in general. The first is the body's clock. It creates sleepiness between 3 a.m. and 5 a.m. and a little bit also in the afternoon; and it paradoxically creates wakefulness at around 8 p.m., during a time called 'the forbidden zone of sleep.'

The second process relates more directly to your question. It is called “Process S”, where the “S” stands for 'sleep.' This is a process where the longer you stay awake, the more likely you are to go to the deeper stages of sleep when you go to sleep. We think it is driven by the build-up of adenosine in the brain over time. Caffeine antagonizes adenosine.

Now, if you take a nap, the brain gets rid of adenosine at its site of action rather quickly. So, if you take a nap, you are indeed less likely to be able to go to sleep as successfully at bedtime. However, this isn't the only thing driving you to sleep when you go to bed at night. We ask our insomnia patients not to nap because we want to keep as much of Process S going as we can. But we also have to think about the clock aspects of sleep. Both are involved in whether a person sleeps at a particular time.

CR.: I avoid caffeine, naps, chocolate, and all the things I should that would keep me from getting a good night’s sleep. I wake up on average five times a night and only sleep about two hours at a time. I take over-the-counter medications and have tried Lunesta® and Ambien®. Nothing seems to give me a full night’s sleep, and my mind wonders all night. Do you have any suggestions?

Dr__Douglas_Moul: In your situation, my hope would be that you could find a sleep behavioral specialist in your area and work closely with him or her. Medications can help some people in your situation, but the preferred treatment in your kind of situation involves carefully and closely looking at what you are doing and what you are thinking so that you can change how your brain habitually relates to the bed and sleeping. Cognitive and behavioral approaches are effective and do not involve any medications. In a good number of people, the effects of cognitive and behavioral approaches are longer term, and can persist in some patients indefinitely. It takes longer to make those interventions work, but they do work for many people.

hawkinr: My husband has gotten into a cycle of waking up in the middle of the night, and sometimes is unable to go back to sleep. Is there something over-the-counter he could try for a short time to break the cycle?

Dr__Douglas_Moul: Probably not. I know a lot of people try to find something from the drug store, but the truth seems to be that fixing this kind of problem will not involve taking a medicine.


Prescription Medications

slmoore:With regard to sleep disorders, I have been on sleeping pills (Lunesta® mostly and some Ambien®) for more than four years. Is it harmful to stay on these pills for an indefinite period of time? I also heard that those on Ambien® sleepwalk, and I don't know if this is a good medication for me, as I am a thyroid cancer survivor and I'm also on Prozac® and Wellbutrin XL®. Since I have been put on these two medications, I am not as fatigued, but I worry about the length of time I can stay on those also.

Dr__Douglas_Moul: The medical community used to believe that a person should not be on sleeping pills for a long period of time. So, there is still a lot of concern out there about being on these pills for a projected period of time. However, more recent evidence suggests that people can be on these pills for extended periods of time without problems. If a person is older or frail, there can be a concern about over-sedation and falls. However, this has become less of a concern, medically, as newer sleeping pills have slightly better side-effect profiles. In older patients particularly, greater care is needed in prescribing because many older patients are frail and on many medications that might cross-react. While over-sedation can a concern, the concern about these medications being “addictive” is overblown for patients who have no history of substance abuse. With regard to the other medications mentioned, there should be no major concern about those either.

The key question is whether other things not involving medications have been tried. It is clearly preferable for a person to sleep and not have anxiety or depression treated without medications. However, it is not wrong to be on these medications.

Grannyscott:I take Lunesta® when I really need a good night’s sleep, and it works for a couple of nights. However, I cannot take it every night for a week because it no longer works. I then wait a couple of weeks to try it again. Is there any medication for sleep that you will not build-up a tolerance to?

Dr__Douglas_Moul: Your pattern of getting benefit intermittently is quite common. It is probably more common for any medication that acts on the benzodiazepine receptor. However there are people for whom this is not an issue. It may be less of an issue for drugs not in this class. The truth is, it depends on the person. There are other medications that might give more stable benefit, but they might not work as well for other patients. Finding a stable medicine for nightly, regular use over a longer period of time is a trial-and-error process that should be discussed with your prescriber. There are no general answers to your question.

safekeeping: What drugs can you take that are not habit forming?

Dr__Douglas_Moul:Non-scheduled medications that are used for helping with insomnia include: ramelteon, melatonin, trazodone, doxepin, and amitriptyline in limited doses; and some people are using the antipsychotic medication Seroquel®. These are some common ones that are not considered habit forming.

nyst: Can't amitriptyline cause nightmares and adverse side effect?

Dr__Douglas_Moul:All medications have side effects. Common side effects to amitriptyline include dry mouth and possibly daytime sedation, along with dizziness when one stands up quickly. Your question is interesting because it relates to a class of medications that includes medications that affect the serotonin and noradrenaline receptors. These medications – such as SSRIs and SNRIs -- can have effects on dream life, either when you are starting, maintaining, or withdrawing these medications. Nightmares are thought to occur during REM sleep, and these medications are what are called REM suppressants. However, there are other causes of nightmares, one of which is the use of alcohol. So, before concluding that the problem has to do with one of these medications, also think about alcohol or other drugs that give rise to nightmares.

In addition, nightmares can be a part of post-traumatic stress disorder. Interestingly, if a person has repetitive nightmares replaying a trauma -- such as what occurs with combat veterans -- then a medication called prazosin helps in a good number of people.

nyst: Regarding sleeping aids in general, are there any general or common side effects that one should know about that are not considered 'good,' and therefore the prescribing physician should be consulted?

Dr__Douglas_Moul: When it comes to using medications that affect sleep, mood, or any other psychological functions, it is best to have a prescriber fully knowledgeable about how you are doing. Self-prescribing such medications is like a lawyer trying to defend himself in court. It is unwise.

ccima_1: I have been put on amitriptyline for EBS, but it helps me sleep. Is it dangerous to stay on it for extended periods of time?

Dr__Douglas_Moul: At doses given for sleep, usually not.

ccima_1: My dose of amitriptyline for IBS is 5mg at bedtime. Would this be safe to continue indefinitely for help with sleep and IBS?

Dr__Douglas_Moul: If it continues to work, most likely.


Non-prescription medications

LindaG: For non-prescription sleep aids, my psychiatrist recommended that I try Benadryl®, melatonin, and valerian root (in that order). Do you have any thoughts on these remedies?

Dr__Douglas_Moul: The literature on Benedryl® and related medications indicate that they work for a few nights; but for most people, they lose effectiveness thereafter. Taking more than about 50mg doesn't add anything.

When used as a sleeping pill, melatonin and a related compound, ramelteon, help a number of people get to sleep. My experience has been that there are some people for whom it is very helpful, but for most people with severe insomnia, it won't necessarily be that helpful. However, it is worth trying as they are non-addictive medications.

The data on valerian root isn't good enough for me to recommend it as a general approach, although I have had patients say that it has helped them. Valerian root is a little different because it is a mixture of chemicals, rather than a pure compound. Valerian from one provider may be different from another.

Parker3: I’ve recently had some bouts with insomnia, but am not quite ready to go to the doctor. I don’t feel it’s that bad, although it’s starting to get more frequent. My question is: is it OK to take over-the-counter medications or use Benedryl® or Nyquil® to try and get myself to sleep on the nights I have problems. Is Nyquil® safe to use regularly? Am I making the problem worse by possibly depending on these to get to sleep at night? Thanks for your opinion.

Dr__Douglas_Moul: If a problem like this gets worse, it probably has less to do with the medication than with how you get into the habit of coping that doesn’t serve you well in the long run. These medications are over-the-counter because they are thought to be safe for general use, when considered as pharmaceutical chemicals. That's different from dealing with a psychology of stress and coping as it affects sleep. If you can get into bad coping patterns; then, yes, use of these medicines can get quite crazy.


Natural Remedies

ccima_1: Does chamomile tea really help someone get to sleep?

Dr__Douglas_Moul: Some people think so. The test of an intervention like this is individual. The length of the test is about three weeks. So, try it for three weeks; and after three weeks, look at your data and make a conclusion about your experience. That would tell you on an individual basis whether it is helpful to you. I am not aware of any clinical trial data suggesting it works for most people.

ccima_1: I have a mitral valve with mild regurgitation. I tried valerian tea with 25mg of valerian in it, but felt that it gave me irregular heartbeats the next day. Is this possible?

Dr__Douglas_Moul: Yes.


Withdrawal

jester: Are there withdrawal symptom associated with stopping Lunesta®? How about other sleeping pills?

Dr__Douglas_Moul: The newer sleeping pills probably have less withdrawal effects than older agents. Sometimes when stopping sleeping pills, there can be several nights afterward when sleep is worse, but eventually you return to how sleep was before taking the sleeping pills. This is the most common withdrawal process. Withdrawal is different if a person was taking out-of-control high doses of these medications day and night. Older medications, such as Valium – common in the 1970’s -- caused some people to have distorted sensory problems for several months, but these tended to be people who were on higher doses day and night. In general, though, there shouldn't be anything medically dangerous about stopping these medications if the reason you are taking them is for sleep and you are taking them at normal doses.

ccima: Are there withdrawal symptoms when stopping amitriptyline?

Dr__Douglas_Moul: When stopping an antidepressant such as this, you may find some changes in your dream life as the chemical is leeched out of your brain. For SSRIs, you may get some head sensations that feel vaguely like dizziness. (There are some people that find that SSRIs help with insomnia.) In general, withdrawal from these medications is benign for most people who are using them for insomnia.

If you are using these medications for depression or anxiety, then you may go back to having the problems that the medications are being used to treat. In some cases, patients are given these medications to treat headaches. So, when stopping the medication, you may start having headaches again.

sweet_dreams:If you start taking sleeping pills and then stop, will the insomnia patterns start again?

Dr__Douglas_Moul: For a few days there may be a rebound effect. It is hard to say in general, but my suspicion would be that the insomnia pattern that the person had before the pills would return after stopping the pills, with some initial days of worsened sleep. This is one of the reasons I recommend behavior treatments; because with behavioral treatments, there is a better self-management process, and the insomnia is treated more definitively. If the insomnia is just brief in nature, then I would suspect that the person should go back to sleeping like he or she did when not under stress. Taking sleeping pills for short-term stress periods is entirely appropriate.


Stress>

c45:If anxiety or stress is the cause of my insomnia, which is better -- medication or non-medication remedies?

Dr__Douglas_Moul: This may not be a clear-cut choice. I often find that both are needed for the best treatment. It depends also on the person. There are some people for whom medications are fully effective. There are others for whom non-medication treatments might be curative. I recommend an in- person, individualized assessment.

caitlynn: I have tremendous stress in my life (dying mother - son with special needs) and can't turn my brain off when I wake up at 2 a.m. or 3 a.m. Is it a good idea to look at ways (natural supplements?) to reduce cortisol to help sleep?

Dr__Douglas_Moul: I am not aware of any ways to decrease cortisol in the way you hypothesize, and I am not sure that reducing cortisone will deal with the 'thinking too much' problem you describe. You might consider setting aside a period of time in the early evening that you can use to worry as best as you can. Then, when you find yourself worrying in the middle of the night, you can reassure yourself that you did your best worrying for the day, and can do your worrying again the next day at the scheduled time. This does work for some people, and I am recommending it as something to try.

monterey: I am going through menopause and frequently wake up during the night. Usually, I feel the start of a hot flash, and it feels like I am having an anxiety attack. Is this considered normal? Would sleeping pills be of any use?

Dr__Douglas_Moul: Hot flashes do give some women problems, but having a full-fledged panic attack is a little unusual. If you are having panic attacks, I would wonder a little if you are also having some sleep apnea that might need attention. Hot flashes, as you know, can be treated by hormone replacement, but that would be an option best discussed with your gynecologist. Sleeping pills might be a help, but increasingly, there is evidence to suspect that a medication called Neurotin, taken at bedtime, can address hot flashes during the night. You may want to discuss this with your doctor as an option. This medication has a favorable side effect profile.

LindaG: I had a recent bout with insomnia that lasted a week. Now, I fall asleep at night and wake up an hour or two later. I'm able to get back to sleep right away, but I never used to do this. Is there a reason for this change in my sleep pattern?

Dr__Douglas_Moul: Bouts of insomnia may set up habit patterns in the brain's responses that make it more likely to have insomnia in the future. You might think of this as a total lifetime stress build-up process. Normally, as we get older, our sleep becomes lighter and more fragmented anyway. The technology to give a more specific explanation is still unavailable to us.


Closing

Cleveland_Clinic_Host:I'm sorry to say that our time with Dr. Douglas Moul is now over. Thank you again, Dr. Moul, for taking the time to answer our questions about Sleep Disturbances & Sleeping Pills.

Dr__Douglas_Moul:Thanks for chatting with me today. Your questions were very good. I hope I was able to help.


More Information

  • To make an appointment with Douglas Moul, MD, or any of the other specialists in the Sleep Disorders Center at Cleveland Clinic, please call 216. 636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/sleep.
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