Welcome to the Psychofarm podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality. Good morning, Dr. Malzberg.
Good morning. How are you doing? Well, you know, unfortunately, I'm in tiers again. And by that, I mean I've been strong-armed into making another tier list. I gotta give you credit. You did more tier lists than I expected you to do. Well, people seem to like them. I don't think they're the worst thing, but honestly, I don't love it. And also, did I already do that pun?
Did I already do that bit? You did the tiers. Oh, jeez.
The tiers. Yeah. Yeah.
So the topic today for another tier list, as people will know, because it's right there on the title every time, is sleep. Sleep. Okay, so regarding sleep, and you know, somebody in a comment said, what's the criteria here for the tier list? I tried talking about that with Dr. Malzberg on the first tier list, and he refused to give me a defined criteria. So there is no criteria for how the tier list works.
It's purely subjective and chaotic, and I think the audience is just going to have to accept that. Okay.
The points don't matter and the rules are all made up.
That's right. It's Calvin Ball tier list, so just keep that one in mind. Okay. What is... I'm going to try to pick from this broad list of things that we have an S tier and the best one I can think of. And honestly... Oh, actually, I always do this. Before I actually pick anything, there is one thing I want to emphasize. What do we mean when we talk about the treatment of sleep?
For us, this has to be the treatment of sleep specifically in people with psychiatric conditions of any kind. Okay. A lot of people out there, including psychiatrists on the internet and off of the internet, they really love evidence. Okay. They love to talk about the evidence and the studies, but evidence and studies is no substitute for your clinical decision making and your ability to think rationally. Okay.
A study is very constrained. And so when we look at sleep society guidelines, they are based on studies and selected studies. And if you look at those studies, They almost universally exclude psychiatric patients. If you can meet DSM criteria for a psychiatric disorder, you are excluded from the sleep medication studies. So in my opinion, those guidelines are nearly worthless when it comes to the treatment of psychiatric conditions.
So in terms of, I guess, a little bit of context where you're saying the American Sleep Association has recommendations for sleep medications and the medications that they push are mostly, I think, the Z drugs. Doxepin gets a big sign off from them, which we'll talk about Doxepin later. But the recommendations from the American Sleep Association versus what we see in actual practice are wildly different. And I think to your point, it's not because people aren't reading the guidelines or that people are doing bad medicine.
There's a good reason that we're not following these guidelines. And following these guidelines, if you start using Z-drugs first line for insomnia, you're going to get into a whole host of problems.
Well, maybe you're not. Your patients are going to love you. I think you can send them to the next person who has to fix the Z-drug dependence. But anyway. Okay. Enough about that. What is my number one pick out of this wide list for top ones? It doesn't mean it's the only thing that you have to do to treat sleep. Okay. But my number one pick is strict waking time.
Let's go and put that one into the S tier. You have it on the second row. It's in orange. There it is. Okay. Strict waking time. You'll find that this is a core component of CBT for insomnia. Okay. And I want to single it out because you can, in theory, if the axis one psychiatric condition is not so severe, anyone can theoretically do this one. In some fashion, even if they don't carry through with the rest of CVTI.
But everyone wants to regulate the sleep onset. And there are good reasons for that. There's a lot of distress, psychiatric distress and symptoms associated with the sleep onset period at the beginning of the night. But then they don't regulate the sleep offset, the waking time. But if you can regularly do waking time, You can really regulate your sleep, including sleep-wake cycle disorders. And so with that, I think we should put CBTI up there.
Awesome. My comments on that is the way I think about it is in terms of strict waking time. Your circadian rhythm is the most important thing with regards to sleep drive and with regards to wake drive. And I think of it as life is about rhythms. And when you get into the rhythm of life, the sleep drive will increase at the appropriate time. The wake drive will increase at the appropriate time.
Modern life is disastrous for all these things. Going out and partying on the weekends is disastrous for these things. Not exercising is disastrous for these things. Waking up, going to your computer, staying in a locked room. My one friend's a programmer and he sits and programs all day in an office with no windows. These things are terrible for our circadian rhythm. So that means that the normal hormones that help regulate being awake and being asleep get all out of whack.
Now, when you say strict waking time, the reason why that one's so important is because when you wake up at 11 and then 7 and then 6 and then 8 and then over the weekend you're up at noon and 1, you're destroying that circadian rhythm. You're destroying that night. The waking time is the easiest one to keep consistent. Now, this is also the hardest one compared to like, you know, when you say trying to go to bed at the same time or waking at the same time.
It's the hardest one in the short term. Because a lot of people are like, no, I need to catch up on the weekends. But the truth is, once you kind of get over that hump, waking up at the same time becomes like a staple that you can kind of build around. And what you'll see is it's actually easier to go to bed at the same time when you're waking up at the same time.
So that's my general impressions. Now, my thoughts on CBTI. I'll finish out real quick. For CBTI, it's first line for all insomnia treatment. I've never seen a good CBTI therapist who takes insurance. It's almost impossible to get. You can distill a lot of the principles. The big ones that I use is bed. Think of your bed as an association machine. If you're playing video games, working on your computer, watching television, your brain no longer associates the bed with sleep.
And you want to protect that association so that when you're in the bed, the only thing your brain knows is sleep. So I say to patients, you should only be using it for sleep and sex. If you're working, if you're stressing out, if you're doing any other thing that builds associations of your bed and other things, that's a problem. That's probably the most helpful in medication management sessions.
There's also when you're supposed to like if you haven't fallen asleep for longer than 15 minutes, you're supposed to get out of bed. That's a little bit harder to implement in medication management sessions. But you can kind of review the basic principles there. Ideally, you get your patient into gold standard CBTI. I've never actually seen it done.
Yeah, it's one of those things where it's like DBT program, like an actual DBT program. You know how many of those are existing right now out in the community and what they cost? It's not feasible. So you got to use workbooks instead. Same thing with CBTI. You probably have to use an app or you have to teach it piecemeal within your sessions to really get it there.
But it's actually not that complicated. What's complicated is getting it done, just like CBT. The complicated part is not the skills. The complicated part is convincing people And getting patients' buy-in and regularity into doing their skills. That's a different story. Let's go ahead and throw a sleep hygiene up there because you basically just discussed it. One thing you mentioned. For example, the programmer guy in the dark room.
We have to consider that strict waking time CBT-I and sleep hygiene may have variable efficacy for people who do have some kind of a reasonably endogenous disruption of their circadian rhythm, sleep-wake cycle. And speaking to programmers, you may see this with autism, autism spectrum, other neurodevelopmental disorders. And then that also makes us wonder about bipolar disorder. Is it harmful to ask for a strict waking time in a bipolar disorder?
Could severe sleep deprivation cause mania or hypomania? In theory, possibly. I think if you're doing appropriate medical treatment, it's not a concern. And frankly, the majority of sleep disruption you do see in a lot of mania, hypomania is If you're a fan of the
Just to comment on your sleep hygiene being up there. I actually wish I put one of the tabs in here. For S tier, what I recommend is the sleep book by Guy Meadows, which is using ACT principles for... It's spectacular. It's like a six-hour audiobook. He actually talks about taking sleep hygiene too far in that when patients become so preoccupied with having the absolute perfect sleep environment, it can backfire.
And with that said, that's not applicable to the majority of patients who have awful sleep hygiene. So what are the big things for sleep hygiene? I recommend getting blackout curtains. I recommend not using phone, not using laptop instruments. I have moved phone charger here. I'm putting this in S tier. I have cured insomnia by forcing a patient to move their phone charger out of the room. And now people are wake, go to bed, swiping on TikTok, Instagram.
Then wake up at 3 , can't fall asleep, so they go back on their phone. It keeps them up. It's such a problem. It's not insomnia. That's, to me, more of a phone addiction. Move your charger outside of your bed. It's the smallest intervention that makes the biggest difference. Now, I also have the metal system, which is a part of sleep hygiene.
What is the metal system? But before you talk about, I don't even know what that is. Before you talk about the metal system, I just want to emphasize the smartphone is like the perfect anti-sleep device. Okay. It is the perfect anti-sleep device. You are blasting even at the lowest settings. Even with all the blue light adjusting settings on the phone, you're blasting blue light directly into your eyeballs together usually with the most agitating social media snippets picked by the algorithm to make you engage mentally.
It is anti-sleep. So what I actually tell people is do not use any technology invented after 1980 after 10 m. or maybe even 9 m. depends on your schedule.
I like that. I'll talk a little bit about the mental system. This is discussed in the sleep book. The gist is that insomnia is exacerbated beliefs about sleep. And when we have beliefs like I'm going to be screwed for tomorrow, BTI. It's very detrimental in that we wake up at 3 m. and then we think I'm going to I'm not going to be able to fall asleep tomorrow.
I'm absolutely screwed. And then that makes it so that you're more anxious and that keeps you up and that you have worse thoughts. The metal system is obviously it's gold silver. So gold is you're falling asleep and you're asleep in your bed. That's the best thing you can be doing. Now, silver medal is the fact that just laying in bed calmly is a restful state. So teaching patients that when they're in their bed fighting insomnia, fighting like, oh, God, I'm screwed.
I'm not this. This is a terrible I'm screwed for tomorrow. I'm not going to get my work done. That's no metal at all. And so we what I recommend is trying for silver metal where you're in your bed, your eyes are closed. You're not asleep, but you're in a restful state, which is productive. So shoot for silver. Don't shoot for gold and fail and just fight sleep.
Now, the paradoxical thing is that when you shoot for silver, you're more likely to actually fall asleep. So that's my little like teaching with regards to the metal system.
I like that quite a lot, and it really outlines that core fundamental psychological principle of metacognitive distress and anxiety. Yes, part of CBTI and part of the treatment of sleep is to try to reduce or stop the level of metacognitive anxiety about the sleep itself, that sleep process. Having distress about your distress certainly does not help your distress. Hard to break out of that cycle, especially alone, but that's why this is part of the clinical process.
You have daytime activity and exercise in there. Let's throw that in along with red light, blue light management. I want you to put daytime activity and exercise right behind straight waking time. Boop. Okay. Oh, that's fine. Where it is. Does red light and blue light management really belong to Est here though? Oh man.
We're running out of space.
It's not about running out of space. Yes, it's important, but it's not like an end-all, be-all. It seems that the psychological and behavioral components are much more useful. And regarding daytime activity and exercise, again, these seem like basic things that people are going to recommend to everyone. But there is a reason why. If you have not expended your energy... By the end of the day, that energy will be spent on ruminations, thoughts, or just simply not being able to fall asleep.
You've got too much energy. Okay. I've heard from so many patients over the years. Oh, you know, I actually, you know, went on a hike this one time or I had to move. And let me tell you, the sleep was the best I had in years. Well, yeah, you know, you gotta have the daytime activity and exercise, spend that energy or that energy will be used on something else at night.
Absolutely. So I have a seven-month-old puppy now. I've had so many psychological insights from having a puppy. Exactly what you're saying. If we tire her out, if we give her the proper exercises, she completely zonks out. We have an easy, simple dog. When we don't do the proper daytime activity and exercise, she's a complete nightmare. I have learned so much by learning what dogs need, which is dogs need structure.
They need exercise. All these things, I'm like, oh, if this works for dogs, obviously this works for humans. This kind of goes back to what we were saying of sleep drive, wake drive. You need to get energy out. And if you don't have those nice rhythms in your body, that may help you fall asleep.
Yeah. Okay. So this is supposed to be a medication tier list. I think that's enough grandstanding for now on the things that actually work on sleep. And now we need pharmacology. We can throw it in later. Let's give people some medications here.
Hold on. No, no, no. I need one more. The treatment of sleep disorder. Where is it? Treatment of primary sleep disorders. It's too rare.
It's too rare. I mean, is it S tier?
I would put an A tier. They're an A tier. Why?
The actual likelihood of a primary sleep disorder is actually on the lower side, in my experience. Because even when it's treated, it does not solve the other issues. In most cases, or the psychiatric patients, at least my psychiatric patients, gotten many a patient onto their CPAP for sleep. And it's a minority that get them, what are you doing? Put that back in A. I thought I had control of the board.
This is BS. A, A, A. A is still good. A is still good. It's just, it's not always the fundamental answer, right? And I'm also a little concerned, honestly speaking, about some sleep doctors' tendency All right.
The reason why I call it STR is because if you're treating an underlying disorder, you're missing it, you're going to cause a lot of problems in that person's life. Now, what are the things I'm looking for that make me worry? I'm going to recommend, hopefully we can see it on our screen. If you have any concerns, com. Is a nice simple assessment that the patient answers a few questions and then it tells their risk of the primary sleep disorders.
Strongly recommend for any patients that you're concerned kind of going through that. Yeah. Now the things that you worry about I ask every patient that I start a sleep medication, do you snore at night? Does your partner say you're snoring at night? If you have an aura ring, do you have a lot of sleep disturbances or movement in your aura ring? Any patient with... Cardiovascular risk factors, obesity, any sort of metabolic syndrome.
Any patient who has like that, I would recommend doing the full screening. And if you're very worried, if you see major fatigue, if you see a lot of snoring, refer to a sleep specialist before you start your insomnia medications.
Yeah. So I hope we're ready to move on to medication now. I'm not, but I'll let you come back to the other ones later. We got to give the people what they want. So with regard to medication, maybe five years ago, I would have easily been able to pick my top number one and call it an S here. But I feel like after, you know, more and more experience with the medications, what I have begun to feel is that They all have drawbacks.
They honestly just all have their drawbacks, and they're either low risk, low benefit, or high apparent efficacy, high risk, all that kind of thing. I've got two picks for my top two. I'm going to pick my top two, going to tell you the caveats, and then I'm going to pick my bottom two. I want to do it at the same time. I'm going to put Doxepin in S tier.
Let's go. That's my number one S tier.
Nice. That's over on the top row right there in red. And then I'm going to put Trazodone in A tier. Okay. Ooh. Trazodone is blue next to treatment of primary disorder. It's on the top row. There you go. Okay. Why? Well, okay. So for those of you who don't know this story, I think it was like the 90s or something when Stephen Stahl had a series of short articles about psychopharmacology.
And in one of them, he reviewed the various antihistamines, the so-called antihistamines, because antihistamines as a class are actually pretty heterogeneous and have a lot of different effects. And in that article, he notes Doxepin, by the way, at doses of eight milligrams or below is almost a pure antihistamine. Okay. Unlike the other TCAs and other antihistamines. And being a pure antihistamine, in theory, it's perfect for people who want to sleep but also need to wake up in the middle the night and do things like a medical resident.
That stuck out to me. And I think it was the same year I read it that they came out with Silanor, which is just Doxepin, but eight or four milligrams. Okay. No surprise that the most on-patent drugs tend to be most recommended by sleep societies because they have the best quality studies. But doxepin's good. It works well. You know, you can probably say the same of a lot of the TCAs.
But again, most of the TCAs dosed at the typical levels have so many actions, including anticholinergic, that the side effect profile is not fantastic. Right. Low dose Doxepin. And yes, you can just give a 10 milligram capsule. You don't have to be all cute and get to four and eight milligrams. It's not going to be more effective like that. You know, you can give Doxepin at a low dose here or even using a liquid form if you want to titrate down if they can get that filled.
And it's going to be pretty effective if it's just a simple sleep problem.
So Doxepin is by far my favorite sleep medication to use. It is FDA approved for sleep maintenance. I think it's the only one. It does help with sleep onset as well. In terms of how I think about it, so you mentioned there's the Silenor, which is three to six, you're saying four to eight, just a small correction. And so it is a spectacular medication. Now, when I prescribe it with patients, this is kind of my spiel.
I say it's got, and this is what I see, very variable insurance coverages. I see some insurances cover it with absolutely no issue. I'm able to get the three and six milligrams. Silenor, no problem. But a lot of patients for some reason have difficulties or the insurances don't cover it. Now the liquid is always covered or is at least much, much cheaper. It's just a little bit harder to use because you have to draw it up with a little syringe.
Yeah, I think you have to dilute it too. So just order like a little micro liter Amazon, draw up three milligrams, squirt it in your mouth. Not that big a deal. Now, you can also get five milligram tablets, which are not Xilador, which you'll never have problems getting those. Ten. For some reason, I haven't had the same. That's weird.
I don't feel like I have those around my area. Five milligrams. You know what?
Maybe it's ten. Oh, sorry. It's ten milligrams. And I told the patient to cut it in half. Yeah. Yeah. It doesn't work as well. The patients don't have the same experience. What's nice is that after they failed that, I was able to win the prior off and get them this silenor. So you might have to do that. But the three to six, I feel like I haven't been having issues getting it covered recently.
I typically say, let's start at three milligrams. If you're having issues, go up to six. I see variable, like for some patients, three milligrams totally knock them out. For some patients, they need the six milligrams. But overall, to me, it is the best sleep medication. It's the most consistent. It's not strong enough for a few patients, but it is my go-to sleep medication.
Yeah. That stock's been great med. Doesn't work for everybody. When it works, it works. Trazodone, kind of a mixed bag. Why isn't it S tier? Well, because it's S tier for the people that it works in. And then it's like C, D, or even F tier. How come we don't have F tier today, by the way?
Oh, I'm not sure.
Uh-oh. Well, anyway. Hold on. For the people where it doesn't work, you want me to wait? F tier. Okay. There we go. For the people where it doesn't work, Trazodone is an F tier, okay? And we have to make a note of that. And why is there so much variability? At first, I had no idea. I was like, is this just psychosomatic? But later on in my practice, I realized, I learned, that Trazodone has an active metabolite.
Called MCPP. Okay. Metachlorophenylpipirazine, which is apparently like a designer drug that causes agitation and dysphoria, but also may have antidepressant effects. Very unusual. So what it seems like it's plausible to me is that people probably have different levels of sensitivity to MCPP. It's an active metabolite of Frazinone. So even at low doses, this can explain why some patients experience agitation rather than help with their sleep and their mood.
With Trazodone. Why is it good though? That was why it's bad. Why is it good? It's long lasting. Good for sleep maintenance. Now the time to onset isn't great. So you do have to take it on like a timer, you know, one or two hours before your desired bedtime. And then some people do get overly sedated even on a 25 milligram half tablet dose. Okay. Not everyone's going to respond to Trazodone, but for the ones that do effective, gives you deep sleep and also non-habit forming.
Really good.
Yeah. With Trazodone, that's funny, for the MCPP, I always, in terms of, because I see what you see, I'd say, you know, a small percentage of patients have an awful experience where it's like, Doc, what the heck did you do to me? You kept me up all night. I always thought it was, I guess, I just say like different patients have different, I thought it was a metabolism thing.
It might be a sensitivity. God only knows. That's probably both. Yeah, I agree with everything you say. I think it's really effective. Now, both these medications, if a patient has something underlying that needs to be fixed, like sleep hygiene, whatnot, all sleep medications impact sleep architecture. Now, I think of trazodone and doxepin as the most preserving medications for sleep architecture. So I bring this up in that if someone's sleeping five hours and getting terrible sleep and hates going to bed and It has all these negative associations.
These, Trasmodel and Doxepin are spectacular because it helps them build their confidence in the ability to sleep. Eight hours of a slightly modified sleep architecture is better than five hours of a terrible sleep architecture. But that said, if a patient could be getting nine hours, but they're staying up because they're on their phone, then why should we mess with their sleep architecture? That's sort of like the overall principles of how I think about when sleep medications are indicated.
And I think if I recall correctly, Traston is one of the few medications we use for sleep support that actually may increase stage three deep sleep. So yeah, you know, it's pretty good. It's not the worst thing at all. By the way, for more on sleep medication theory, there's a very old episode we have of this podcast on sleep. You can go and watch that. But today's just tier list.
Yeah. And the way I think about sleep is to me, there's no free lunch. Like there's no, there's no way you can, some people are like, oh, I want more REM sleep or, oh, I want more deep sleep. It's not like that. It's not like more REM is good or more deep is good. You're really trying to get a balance So for people who have their aura rings and are tracking all these things, you shouldn't be focusing on just one variable.
To me, the deep sleep is really important for the deep sleep. Body rest for your mind working well. REM is really good for... REM is probably even more of your mind. I think of it as clearing out the junk in your brain. Would Freud use the chimney sweeping for your mind metaphor? I kind of picture that with sleep.
That wasn't for the dreaming.
No, of course not. No, no, of course not. It was for psychoanalysis. But that analogy I think of for sleep. I think of REM sleep as cleaning out the chimney.
Yeah, I mean, we have theories about sleep and it gets very interesting. We all know a lot about it, but I pretty much agree with your take on it. Now, for our worst ones, if you've watched the other tier lists, it should not surprise you at this point. For stands of benzos and Z drugs, you're not going to like my practice style. The F tier is benzos and Z drugs.
Why? Why are these down here when people love them so much and the sleep societies recommend them and they're FDA approved? Well, don't get me wrong. If you turn the brain off, the brain will turn off. If you hit the off switch on your neurons, you're going to be off. Is that a good thing? Well, I would say in select severe brain conditions, you got to use these, okay?
It's not like I don't use these. But during the minority of patients, because as we've discussed in the other episodes, too many drawbacks, memory issues, learning problems, slows your progress. Progress in psychotherapy and healing from psychiatric disorders. Addictive. Did I already say addictive? Withdrawal problems. Tolerance, too. It may work in the beginning. They only test these for like 48 weeks. But in the long run, you're just back to square one.
And now you're dependent on these medications. So with Benzos and Z drugs, those are really effed here. And then together, we might as well throw in alcohol. Okay. But alcohol is worse than F tier. If there was like a hell level of these, it would be alcohol. Because people... Eighth circle of hell. Yes, exactly. People feel... Experientially, that alcohol helps with sleep. This can be a big reason why people can develop dependency on alcohol when they have a sleep problem.
But actually, if you look at what it does to sleep, alcohol messes up your sleep quality. And usually the body will metabolize through it partway through the night. And then that will cause the paradoxical effect of awakening in the middle of the night and having trouble falling back asleep because now you're feeling agitated from the alcohol withdrawal.
100%. And in terms of talking about this with patients, I think it's super important that when we talk with patients, we don't say things. Is it okay if I throw cannabis in an F-T or two?
Yeah, let's do it. It's not as bad as alcohol, but it's just not very good.
When patients say like, oh, alcohol or cannabis really helps me sleep. Important for me not to lose therapeutic alliance by being like, you're wrong. They're terrible for sleep. I explained to them, it's like, you're right. So it does help you fall asleep. Now, the issue is it completely distracts. So, subjectively, yes, you fall asleep. And that's a benefit that you experience. But the truth is you're getting terrible quality sleep.
Now, I've talked about this a lot on the podcast. I have aura rings and I used to have like a little sleep. Sleep mat and drink does a lot of damage sleep architecture. It's different for different people. I know I'm a little bit more sensitive than other people, but even if I have one drink, my sleep score every single time is 20 points lower with alcohol. But yes, to your point, when you're drinking five drinks or you're going out on the weekends, that sleep is awful quality sleep.
It completely suppresses the deep sleep, which is the most important part in the beginning stages of sleep. Now, with cannabis, same kind of situation. People say they use cannabis to help them fall asleep. Yes, but cannabis also is very destructive to sleep architecture. It really suppresses REM sleep. And so another big psychoad piece, when people stop I let them know that there's going to be an adjustment period.
There's going to be two or three weeks while your brain is read sometimes much longer. Yeah, that your brain is going to be readjusting. You're going to be more tired than normal. You're going to have a tough time. I see almost every single time you see this crazy REM rebound that they're having these crazy dreams that are causing them to wake up. I tell them that their brain has had dream sleep suppressed for a really long time and their brain is now exploding with dreams.
So there's going to be an adjustment period. It's going to be unfun. You're going to say my sleep's terrible. But if I could take you right now, have you stop marijuana and give a time machine and give you in a month, you're going to feel so well rested. I give that little psycho ad, as you mentioned, sometimes it's a little bit longer.
Yeah, I do think the subjective experience of cannabis and alcohol being effective is generally more about treating symptoms, not treating, suppressing symptoms that are interfering with sleep rather than helping the sleep itself. OK, I think it's because they both have this intoxicating effect that can help suppress or at least turn the volume down on things like ruminations and bad feelings. Right. And those are the things that are interfering with people's sleep.
And then so to that end, let's put into the S tier treatment of primary disorder, which we should have labeled treatment of primary mental or psychiatric disorder. It didn't fit in the box. Yeah. Well, those of you looking at this treatment of primary disorder is about primary, you know, mental health or DSM or psychiatric disorder. Okay. Almost every psychiatric disorder that we consider a psychiatric disorder comes with some level of sleep disruption.
Okay. That comes together with that pathology. Another reason why you can't rely on sleep society recommendations who don't treat psychiatric conditions. But you have to treat the primary disorder. Think of SSRIs. SSRIs in people without major depressive disorder are actually disruptive to sleep. Same thing with low-dose Buspro. Basically, the serotonin mechanism will suppress REM sleep and also cause more nighttime awakenings. Okay. But... If you give that same medication to someone who has a true major depressive disorder, their already messed up sleep from the major depressive disorder will improve because it has that treatment effect.
This is, again, the importance of proper diagnosis. You can't just be throwing an SSRI at everyone who says they have depression or scores behind a PHQ-9. You have to make a proper diagnosis and see this is somebody who would probably genuinely benefit from this medication. And then you have to follow up and see if they actually benefit.
Yeah. And I'm going to think of a particular example. So for treatment of primary disorder, whenever there's depression, early morning awakening, I forget what I read, but I think it's like the most specific symptom for depression. When a patient wakes up at 3 m. for a few nights in a row. When I hear that, and then the other symptoms of depression, typically I'm going through the Madras and hearing how the other screen and the other symptoms for the Madras, the SSRI helps with the sleep dysfunction so much better than if Because there are a lot of patients who come and say, I just need help with the sleep.
The sleep is the problem that I'm struggling with. And then if you get a full history, and then you give a really strong formulation to a patient, there have been so many patients who are like, I'm so opposed to SSRIs. I really just need a medication. Now, I'm not 100% opposed to starting an SSRI and a sleeper at the same time. But when I hear all the other symptoms of depression, and I feel like the sleep is really secondary, On my psychoeducation for the patient really emphasize that I expect a lot of this will improve as a result once we treat the depression.
And if not, then we can add a sleep medication. So formulation is so important for patients. And as you do this more and more, you get a feel for what's primary insomnia, what's depression. There's little nuances that you hear in the history that make it very clear what it is.
Yeah. On my end, I'm always willing to give a sleeper on the first visit. And the reason is because I never really ever prescribe addictive potential withdrawal potential sleepers on the first visit or the second visit or the third or whatever. Right. So I'm much more willing to do that. But, you know, I leave that to the values of the patient. Some patients want that. And I think you can get faster recovery from, let's say, major depressive disorder if you treat the sleep simultaneously.
But, you know, some people want to minimize the medications and that's fine too. We can just stick with the Prozac or the Zoloft, for example, if it's indicated. In addition of antidepressant treatment, I think a very high ranking sleep medication must be mirtazapine. And I will put that one in the A class. Why do I not put it into S class? Sorry, not S class, A class.
Okay. Why not S? Well, it's again the problem of weight gain and appetite increase, substantial. We cannot just ignore side effects and say this medication is super effective. Simply prescribing based on efficacy. Efficacy is crazy. Okay. Sorry to use the word crazy, but that's not good medicine. All right. You're supposed to weigh both the risks and the benefits, physicians and clinicians. Do not go off of the efficacy as seen only in studies.
You need to weigh clinical risks and benefits, but it's really good, mirtazapine. You know, if you don't want to be doing antidepressant effect, you can be treating at the very low doses, you know, seven and a half range. And it can work for sleep, onset, and maintenance. It's really quite good.
So I think of it as Traz and Taz. I'm actually team Taz more than team Traz. I love mirtazapine. I think it's a great sleep medication. As you mentioned, In terms of the negative side effects, the weight gain is a serious thing. Even at the lower doses, you see patients tend to gain significant amount of weight that is just absolutely a part of the medication. I've seen patients stop seven and a half mirtazapine and then lose.
Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack, Substack. I call it a hangover because it's just easier. So I say expect a hangover. What I usually see is three to four days of feeling like a little bit of a zombie. I do not recommend starting this medication the night before you have a big work meeting the night before.
You have your kids' graduation. Wait for a time when you can afford to be a little bit slower than normal. It's going to be tough. You're going to have three to four days of feeling like you're slogging around. If you push through it, I typically see that go away. And what's left over is just the superb ability to fall asleep.
Yeah, there's definitely decreasing daytime sedation, at least on most of the sleep support medications once the body gets used to it. But that also requires nightly dosing, you know. As needed dosing as people who have listened to the other episodes know, I'm not really a fan of that. If it's worth taking a medication, it's worth taking it every night. If it's not worth taking every night, then maybe it can be addressed with psychotherapy or other skills.
Yes. And you're going to disappoint a lot of patients when you provide that psycho ad and hold your line. I say I've repeated multiple times, you know, I'm a provider who thinks long term. I do think sometimes it depends on the patient. Of course, there are patients who benefit from from. But for your average patient, I say, I'm not going to prescribe something knowing that I think it's going to hurt you long term.
And as you said, if it can be used PRN, there are a lot of other treatments, other therapies that will work much, much better.
Yeah. Along the lines of effective but causes weight gain, let's throw paroxetine into C. And Quetiapine into C. I have a B, but... Yeah, you'd want B, I know. Why am I doing this? Again, you can see that I am very much against giving side effects. Quetiapine is really effective. It works awesome. And the fact that it works so well and is so subjectively loved is another reason why I want to rank it lower.
Because then it's hard to get people off of it. They're afraid to stop it. And that's why it gets prescribed to so many people who shouldn't be on an antipsychotic. It is an antipsychotic. I don't care how much you want to tell me, oh, you know, based on reception. It's not until a XYZ dose. Not every clinician is going to follow or know the reasonable cutoffs. And we can't say for certain that you're not going to cause tardive dyskinesia just because you're dosing it below 100 milligrams.
Am I going to bet money that tardive dyskinesia is going to develop under 100 milligrams? No. But am I going to bet that it's not? No, I'm not going to bet that either. It is an antipsychotic. Please use it only when there's an indication for an antipsychotic. That's my opinion on quetiapine. Paroxetine is in C tier for different reasons. Again, both anticholinergic with the side effects and weight gain effects are really pushing it down there.
There is not a whole lot of reason to be using this one instead of mirtazapine, so I put it in C tier.
I actually agree with everything you said about quetiapine. I don't think I've ever started it for sleep. I have had patients who mentioned they tried all the prior medications, they got the quetiapine. It's the only thing that works. I'm not opposed to keeping it. Whereas with the Z drugs or benzos, I'll probably do a little bit more digging and a little bit more of an attempt to pull them off probably sooner.
I'm not saying automatically if a patient's on a Z drug or I instantly pull them off. But my degree of pushing to pull off is much higher than if nothing worked in the past and they like their low-dose quetiapine.
So let's just round out the rest of the so-called antihistamines and anticholinergics as well, I think. Hydroxyzine, I'm going to put that one into B tier. The Zequil and NyQuil goes into F tier. Diphenhydramine goes into C tier for me. That's the pink one right there. Doxalamine in the same tier as well. Benadryl. Doxalamine right there. And am I missing anything? Oh, other TCAs, especially amitriptyline. B tier.
B tier for me. Yeah, really, really. Oh, really? I'll explain why in a moment here.
Okay.
Hydroxyzine. It's low risk, but it's low efficacy, unfortunately. It works, but it doesn't work all that well. Shouldn't be too afraid to push it to 100 milligrams. Seems to be well tolerated in those who are well tolerated. Beware of dosing it in the daytime for anxiety because it can cause cognitive slowing. But, you know, it doesn't seem to have as much anticholinergic as a lot of the other antihistamines that we use, and it's fine.
It's just really middle-of-the-road hydroxyzine. It's not going to work for some people, pointless for some people. It helps some others. The TCX... They're effective. They're effective because they're dirty medications. They work on a lot of different things. If you have another indication for them and it's safe to use in that particular patient for cardiac reasons or they don't have constipation, for example, they'll help the sleep and you'll be able to treat the primary disorder via a migraine disorder or a depressive disorder or anxiety disorder.
So I think they're pretty good. But they came into some problem as peroxidine and quatypine. There's a lot of weight gain. But I think the risks Are a little bit the same as quetiapine and peroxidine, and the benefits are higher, so it makes it to be. Phenidramine and doxalamine, they work. They're very anticholinergic as well, which is also part of why they work, and I don't like that for patients, so they go into the C tier.
But they're not horrible if you need anticholinergic, for example, treatment of schizophrenia, some of that is EPS.
Yeah, I just wanted to comment on amitriptyline. I think it's first line for fibromyalgia pain. Now, we have other TCAs on there. I almost wish we just put amitriptyline because you're really going to want a tertiary TCA. Tertiary TCAs hit more of the other receptors, whereas the secondary TCAs have a lot more neuroanergic activity. So I think amitriptyline is reasonable as it be. All the other TCAs, I'd probably put C and F tier for sleep.
I don't know.
Let's do melatonin and sleep cycle stuff next. Melatonin to me is a... Question mark. C tier. C tier for me. I always want to put it in like, it's almost its own thing. It's like not... Yeah, it's its own category because It's actually a niche medication. Melatonin has a hypnotic effect. It makes you sleepy, but it also has a sleep-wake cycle regulating effect. And I mostly use it for sleep-wake cycle regulation.
For example, shift work, international travel, and people who have a bad circadian rhythm for either endogenous or behavioral reasons, basically. And when you dose it for that, you generally want to dose it more hours before the desired bedtime. In order to get that effect, then you want to If you're taking it as needed for sleep. So it's not great as needed for sleep. So that's what lands it in C tier.
This is kind of a mixed bag. And in the same way to Remelition, which is a melatonin receptor agonist, I believe it's basically about the same efficacy, but some patients then want to pay out of pocket. It's a little bit more controlled. It only really comes in one milligram dose. It's fine. It's well tolerated, not really problematic.
Oh, I got to go. My few comments on melatonin. Oh, yeah. Yeah, totally agree. Sleep-wake cycle disturbances is where it should be used. Not necessarily like sleep onslaught or sleep maintenance. Yeah. Oftentimes patients use it at way higher doses than they should be. I think studies have shown like 3 to 1 milligrams is the ideal dose. Just be careful when you hear, because I have heard patients on insane doses of melatonin.
Was it here that we discussed? I forget. Someone told me some story of someone taking like a thousand milligrams of melatonin, which is like, yeah, just give PsychoEd that usually you need much lower doses than what people use and don't have escalating doses for sleep.
Okay. The caveat there is that melatonin in the United States at least is unregulated. So I actually have no idea what the proper doses of melatonin actually are because it's unregulated. All the ones that my patients use are unregulated. That's not the case outside the United States. So outside the United States, if you have a regulated melatonin, then you're going to know what the proper milligrams are.
You're going to have to find that out for yourself because I don't know it. What do I do? Well, I just ask patients to use ones that have been Approved by like that pharmaceutical testing board at least. So that's basically nature made or like Costco brand is usually the easiest to find. And then on those, I do think dosing three to six milligrams is appropriate, but they've done studies of over-the-counter melatonin and it can have like over a thousand times or like under a thousand times or something, the actual listed amount milligrams in each dose compared to what's on the bottle.
And whenever it's Chris Aiken's website, I think it might just be Chris Aiken MD. Just Google Chris Aiken. He has wonderful resources. A-I-K-E-N. He's got wonderful resources with regards to the recommended supplements, supplements that are somewhat vouched for. So whenever I prescribe a supplement, I always check out Chris Aiken's site.
Yeah. Speaking of regulating sleep-wake cycle, we forgot to put limiting and timing stimulants onto the board. That's an S tier for sure. Go ahead and throw it on there. Stimulants, including caffeine, basically anything That produces wakefulness physiologically or suppresses sleep physiologically. We can consider a stimulant in this particular case. Super important for anyone on prescription or non-prescription. Stimulants, including caffeine, energy drinks, and methamphetamine. Obviously, if you are having sleep problems, using those are messing up your sleep.
If you're taking a prescription, work with your doctor to not take them too late in the day. By the way, we can get into this whole thing about the afternoon coop out or reduced efficacy of stimulants. But the short version is it is probably the natural sleep-wake cycle circadian rhythm to get more sluggish and less effective in the afternoon after lunch, whether or not you eat anything, number one.
Number two, it's probably no SIBO effect. Your expectation of wanting to be as good as you were in the morning is creating a more pronounced effect because yes, they were able to find a signal for this that was real in older studies where they were using immediate release forms, but that's why modern extended release stimulants are made to have a rising level Of the stimulant serum level in the afternoon period.
So if you're getting a long-acting stimulant, XR, IR, XR, or whatever you call them, and you're feeling that, that's probably just what you're supposed to be feeling. Do not just stim yourself all the way into the nighttime.
Another important psych way about this is, listen, I believe all patients. I'm not saying that I minimize patients' experiences. But for stimulants, it's really, really hard to subjectively know how a stimulant affects your sleep. Trust your gut. If a patient is drinking three espresso shots, please talk to them about the impact of five espresso shots before starting a sleep medication, before starting any host of medications. These medications, stimulants have a big impact on our sleep-wake cycle.
Also, it's not intuitive that a stimulant taken super early, like for example, I've had a lot of patients that We stop their stimulant that they're taking at 7 m. And I see an improvement in sleep. So it's not the sort of thing where you can actually notice it or sometimes even feel it. But the stimulant by itself has unknown impacts with regards to our sleep system and wake system.
And any sort of stimulant can have an impact on ability to fall asleep. Now, I also set rules. I talk to patients. If someone's complaining about not sleeping and they're drinking any sort of stimulant afternoon, you need to have them pull back when they're drinking their coffee, when they're taking their stimulant. There are a lot of patients who say like, no, no, no, coffee doesn't impact me.
I can drink coffee and then fall right asleep. It doesn't matter. It's still impacting all those different neurochemicals and hormones that are connected to the circadian rhythm. Use your common sense. Don't... Talk with a patient, but don't always take what they say at face value. If someone says, yeah, I have five espresso shots, but it doesn't impact my sleep, but I need something to help my sleep, trust your gut on common sense.
Yeah. For patients, this is a difficult thing because it's basically true that your subjective experiences in sleep may not reflect your physiological sleep reality. And that's a tough nut to crack because we're so used to Understanding reality through a subjective experience. But let's just take the extreme example of paradoxical insomnia. There is such a condition where people think that they literally do not sleep overnight. Yet, if you look at them objectively, they are sleeping and they have quality sleep.
That's called paradoxical insomnia. With the whole caffeine thing, it is interesting. Some people do report getting sleepier after they drink caffeine. I agree, nonetheless, that their sleep architecture and physiology is probably being disrupted. But why might they get sleepy? Well, in theory, it is possible that it could be competitive use. I believe of cytochrome 1A2 because both caffeine and melatonin are metabolized by 1A2. And I think there've been some small studies showing that a dose of caffeine in some people can basically result in accumulation of melatonin, which you don't want during the daytime beyond a level that's supposed to be there, right?
You want to suppress that. So that's why caffeine can mess people up. And as an avid caffeine user, I understand the difficulty. And yes, it is true that I take Red Bulls during these podcasts.
Yeah, someone commented, is it true Dr. Fu drinks Rebels? It is true sometimes.
I don't know why that was hard to believe. Is it like not congruent with my image somehow? It's a Red Bull. Red Bull gives you wings. Why not? They should send me some money for mentioning them.
I have a small anecdote related to things from earlier. I had mentioned that I have my seven month old puppy that I'm learning a lot about, Zoltov. We got them neutered a few months ago and we gave them Trazodone and Gabapentin and she's a very high energy puppy.
It went awfully.
I don't know if... I searched. Dogs also have that same paradoxical reaction with the trazodone. They also have a paradoxical reaction with gabapentin. The best way... She was like a drunk animal. We were given tons of trazodone, tons of gabapentin, and she was getting even more and more hyped up, but just running into the walls. I wondered...
The best formulation I had was... Did you play some EDM at the same time?
Yeah, seriously. I think my best theory was the paradoxical benzo reaction where I suspect that maybe we disinhibited her without hitting the sleep. So it's just like basically just having a drunk dog.
I think it's just MCPP. I just think it's MCPP, probably, because the gabapentin just does not have a direct GABA effect. So let's get on to that, gabapentin. Gabapentin's effect is actually more like a mood stabilizer, but you can see that it does have impact on sleep and may even improve deep sleep in some cases. I think it's a solid B. B tier, it's not amazing. It's not gonna work for everybody, but the fact is it does have some beneficial effects for a lot of people.
Some people get benefit for sleep itself, some people for anxiety. Helps with RLS, it's first line I believe for that. It can reduce the risk of migraines. It's kind of like the serical of neurology. It's like not that good, but kind of works on everything. And yes, again, in some countries where they don't have access to hard drugs easily the way they do in the United States, it's real habit-forming potential withdrawal, etc.
But again, in the United States where you can walk down the corner and get a much better drug, most people are not abusing Gabapentin. Not that it doesn't happen. So pre-Gabalin, Lyrica, then goes into... I do C tier. I do C tier. I'm tempted to put an F tier, but it's just simply not as harmful as, you know, alcohol, benzos and Z drugs. And there's some efficacy.
And if someone, let's say, has a genuine chronic pain, neuropathic pain, reason to be taking pregabalin and you dose it at night, it can be a nice synergistic thing because chronic pain can really cause a lot of problems with sleep, obviously.
Yeah, so gabapentin, I agree. I've never had someone come back and been like, I love it. With Trazodone, with Doxepin, with Mirtazapine, I've had so many patients come back being like, oh, I finally got some sleep. This is wonderful. Gabapentin always just helps a little bit. I've never had that really appreciative patient who's like, oh, you really helped me out, doc. So I agree. I tend to reserve it for when there's comorbidities, like you mentioned, like bipolarity or if neuropathic pain, anxiety...
Those are the patients that I tend to reach for it.
Buspirone is on here and I want to talk about Buspirone. Buspirone is not really a sleep medication per se. I would put it in B tier nonetheless, but I would want to edit it if I could and say high dose Buspirone. Why? Low-dose buspirone, as I mentioned, like an SSRI, is more serotonin agonism and seems to cause sleep disruption. Sleep disruption. This is at total daily doses below 20 milligrams.
It's one of the reasons why I usually try to start at total daily dose of 30 milligrams, 15 and 15. Higher doses of buspirone, if you kind of look at the... You know, receptor profile, a little bit more antipsychotic and therefore can support sleep to some degree. So it can be considered in people who have other indications for buspirone, but not exactly sleep medication. And, you know, as I talk about it, maybe we should even put it in C tier.
It's honestly between B and C tier, but it's low risk, so I don't really want to put it in C tier of the rest. Let's put it back. No, you know, melatonin or melatonin are there. We'll leave it in C tier. Buspirone's in C tier.
Yeah. Now, I've said this before. Every world-class expert has their little baby medication that they think treats absolutely everything. For Nasir Gami, everything is a temperament and everything needs lithium. There's providers who think amphetamines treat everything. Buspirone is Dr. Fu's baby. I don't know how to say that.
It's my favorite for the last couple of years. Okay. I switch around. I am promiscuous with...
Whether anxiety, Buspirone. Depression, Buspirone. Personality disorders, Buspirone. Trauma, Buspirone. Insomnia, Buspirone. Psychosis.
Okay. It's Buspirone. So, but it's not like, you know, panacea. It's just that you can use it on a lot of stuff. It's not bad.
I've said multiple times, since we've talked, I've used it a lot more, and it's infinitely better than I ever...
It's better than I thought it used to be. So speaking of second-generation antipsychotic profile, let's talk about the actual second-generation antipsychotics other than quetiapine. Unfortunately, there are more people than you would like out there, internationally and locally, using olanzapine and risperidone for sleep problems and depression. Okay, I don't like that. I'm going to put an F tier. Okay. It's not that they don't work. It's that you should not be using them primarily for sleep.
If someone is having sleep problems together with the schizophrenia or schizoaffective disorder, go ahead and use them. If someone is having them together with a refractory bipolar one and you've already exhausted the mood stabilizers, go ahead and use them. But you shouldn't be using them first line. It's really clear tardive dyskinesia risk and, of course, weight gain, avidite increase, sedation, and neurolepsis. These are big guns. You should not be using them just for sleep.
Totally agree. Using Risperidone for sleep is absolutely wild. Olanzapine also wild, but in my opinion, I understand it at least somewhat. Totally agree that it's excellent if you need it and it's also getting to sleep, but never use it just for the sleep.
Yeah. And where you're probably going to see it being used for that the most, in my opinion, is going to be nursing home medicine in the United States. These poor abandoned people who are hardly being looked at and often maltreated, obviously for You know, dementia associated agitation. People will call it psychosis or agitation and give a second generation antipsychotic because it does work even if it increases the risk of death.
But really, if you control the sleep wake cycle, In the ICU or nursing home patient using something else like a trazodone, mirtazapine, or even a melatonin or ramelteon, you may get a lot of the same effect without the same problems. Now, of course, really severe agitation, you are going to have to use one of the bigger guns. And Risperdal does come in a small tablet form and in a melting form as low as
25. Not bad in the short term, but as a long term medication, please don't.
Awesome. What's our next?
Doros. Unfortunately, as a safety net clinic psychiatrist, I don't have a lot of experience with the Doros. But my impression from reading and talking to colleagues is that it's probably in the A class. It may even be S-Class. I don't know. Okay. But what keeps it from S-Class probably is cost. So once it all gets off patent and is easy to get for people on Medicaid, I'll be able to say more about it.
Do you have any thoughts on the Doris?
No, I have the same thing. I have a little bit of experience, but not enough to generalize anything important. I have the same. I probably put it in A-class. I've heard wonderful things. You do read. It essentially being a much stronger medication than the trazodones and the doxepin, but I just don't have enough experience to speak.
Yeah, like mechanistically, not habit forming, not much risk, relatively speaking, seems to be effective. Good set of meds, but on personal experience, so I can't say too much about it.
Yeah, some cool studies that taking people off benzos, it was really productive and patients' quality of life improved when switching to Dora's. So definitely a great option there.
Yeah. Okay. Finally, let's talk about some weird stuff. Valerian Root. Over-the-counter stuff that a lot of people will take without consulting with a psychiatrist or a physician. Valerian Root is an F. Why would Valerian Root work at all? Seems to be more serotonergic. I think where Valerian Root works is where there is somebody who would actually benefit from SSRI, but they're afraid to take it. And that's what Valerian Root is for.
So why spend your money? On this untested, unregulated product. When you can get basically the same effect from some kind of low dose SSRI. Sleepy time tea or herbal teas are also F. Okay. For me, I do not see these as efficacious. It's probably the ritual of doing something. Again, going to daytime activity and exercise. Even nighttime activity of some kind is good. Not effective, not meaningfully effective to me.
And there's a adverse effect. Drinking a bunch of tea. Right before bedtime is going to make you need to urinate in the middle of the night. And if you already have existing sleep problems, you may have trouble falling back asleep as a result. So I also advise patients in the whole daytime activity thing to limit their liquid intake after 6pm if they're getting a lot of nighttime sleep interruptions from urination.
I agree with the sleepy time teas. Just be careful about the ones purporting to have special effects for insomnia. That said, I have less of a problem with the herbal teas. I think something like a little chamomile ritual, something that I don't think the tea... So I don't have herbal teas. Herbal teas is a category of things, but I don't have all herbal teas in the F tier.
I don't think it's going to be massively helpful for insomnia, but I think rituals, wind-down routines are wonderful, and I'm not going to tell a patient to stop any sort of herbal tea.
Yeah, I don't really tell people to stop. I just say I'm not sure that's so helpful. Here's how it can be not helpful. And, you know, any kind of wind down or relaxation thing that you do in your bedtime is great. Yeah. Go ahead and focus on that. Tea or not tea. Of course, you have to advise people that they're herbal teas, not green tea. Green tea is still tea.
It still has a bunch of caffeine and other stimulating chemicals inside of it, though there is L-theanine. I probably should have added L-theanine to this list. Why aren't you pronouncing the H? What do you mean? It's pronounced T-A-N-E. T-A-N-E. Yeah, because it's from tea. Pretty sure. I don't know. Someone's got to look that up and see which one of us is right.
But L-T-A-N-E. No, it's T-A-N-E. T-A-N-I-N-E, I believe, is pronounced T-A-N-E because it's from green tea. No, no, no. It's L-T-A-N-E because it's a natural amino acid. You're totally out of your element here. T-A-N-E.
Anyway, I don't think it's very effective. I don't think it's very effective. I probably would have put it in F as well. But it's not harmful and maybe beneficial a little bit. I just looked at Valerian, by the way, and I think while it is proportional I think it's reported to have some GABA detected inside. I feel like it must be clinically insignificant, for example, given that they have tried it for restless leg and it's not effective.
And if I think of a real GABA that was clinically significant, it will probably be effective for that and more effective overall.
The Theanine. Yeah, it is. It is. Oh, so go back to the teas. All tea property has caffeine. So green, black, oolong, white tea, all things that use the property life definitionally. Herbal teas, tea is almost like a misnomer. Herbal teas is when you use flowers or things to infuse into a drink. Those don't necessarily have caffeine. So the chamomiles, the lavenders, is that a thing? Those won't have caffeine.
Okay. I think you're right about theanine, though I'm not inclined to change my pronunciation of it because it is again named after tea.
I'm going to say... I'm going to say it's kind of adorable.
I think it should be Tianan. It's from tea. Why wouldn't you call it that? Anyway.
Now I have another cute anecdote. I have dog anecdotes. My sister's dachshund had some sort of infection and got doxycycline. Sister thought it was antibiotic for dachshunds. I think that's a cute story.
Okay. The last one I'd put on here... Sodium Oxabate and GHB. Kind of a joke. Why did you put that on there? The reason why is because we're putting an F tier is because it's not for the treatment of primary sleep insomnia. It's for sleep disorders. Leave that to the professionals. Leave that to the sleep doctors who have diagnosed a narcolepsy or whatever condition that requires that level of the big gun for treatment.
That is not an appropriate medication to use for sleep.
Yeah, I'm upset that we even have, I feel like this is promoting, GHB should never be used for insomnia. I feel like that's like hearing, what was it, Michael Jackson getting ketamine for sleep or something?
Yeah, yeah, exactly. No anesthetics. That's basically why I mentioned it. Do not take anesthetics for sleep. Okay. And in the rare case that you have such a rare medical disorder that you should be taking it, it should be the adequate specialist with training experience that's recommending it in a very specific way.
Yeah. The fact that we have benzos and herbal tea with GHB, I feel like it needs the eighth tier of hell.
Yeah. Yeah. I mean, you can edit that in if you want, but yeah, there's basically circle of hell ones and that's definitely in there probably.
All right. I think we're, yeah.
I think that's enough time. Again, if you listened all the way here, please post on the forum about what kind of topics or things that you would like talked about. But of course, you can always just leave a comment, like, subscribe, et cetera, as they always say on the internet media.
Yeah, just, you know, be a friend. We're on there. Yeah. All right. Well, I'll see you next time. Until next time.