Key moments, in order
If you meet DSM criteria for a psychiatric disorder, you are excluded from the sleep medication studies. So the primary insomnia research and the sleep guidelines are nearly worthless for almost every patient in a psychiatric clinic.
Wake time is the anchor. Once the patient gets over the hump, waking at the same time becomes a staple to build around, and going to bed at the same time gets easier.
Strict wake times, CBT-I and sleep hygiene may have variable efficacy when the circadian rhythm is disrupted for reasonably endogenous reasons.
Asking for a strict waking time is not a concern with appropriate medical treatment, though severe sleep deprivation could in theory trigger mania or hypomania.
Sleep hygiene can be taken too far: a patient preoccupied with the absolutely perfect sleep environment can backfire. That does not apply to most patients, who have awful sleep hygiene.
Move the phone charger out of the bedroom. People go to bed swiping, wake at 3 a.m., can't fall asleep and go back on the phone. That one change has cured insomnia and made drastic improvements in many other areas of patients' lives.
A simple rule: no technology invented after 1980 after 10 p.m., or maybe even 9 p.m., depending on your schedule.
Shoot for silver, not gold: in bed, eyes closed, not asleep but resting, which is productive. Going for gold and failing means fighting sleep.
In our experience the likelihood of a primary sleep disorder is on the lower side, and even when one is treated it does not solve the other issues.
Ask everyone you start on a sleep medication: do you snore? Does your partner say you snore? If you have an Oura ring, does it show a lot of disturbance or movement?
There is no free lunch: more REM or more deep sleep is not the goal. You are trying to get a balance.
Too many drawbacks: memory problems, learning problems, slower progress in psychotherapy and in healing, addiction, withdrawal and tolerance.
Do not lose the alliance by telling the patient they are wrong. Start with: you are right, it does help you fall asleep.
In people without major depressive disorder, SSRIs actually disrupt sleep: the serotonin mechanism suppresses REM and causes more nighttime awakenings.
Early morning awakening, waking at 3 a.m. for a few nights in a row, may be the most specific symptom of depression.
We are willing to give a sleeper on the first visit because the sleepers we start are never the habit-forming ones: trazodone, gabapentin or hydroxyzine, which support deep, healthy sleep.
For sleep without aiming for an antidepressant effect, very low doses around 7.5 mg work for sleep onset and maintenance. It is really quite good.
Incredibly sedating. Warn patients they will feel like a zombie: expect a hangover, usually three to four days of feeling a bit like a zombie the next day, which typically gets better after about a week. Do not start it the night before a big work meeting.
We are not fans of as-needed dosing. If a sleep medication is worth taking, it is worth taking every night.
For sleep, it is an antipsychotic. Arguments that it only acts like one above a certain dose depend on cutoffs that not every clinician knows or follows.
C tier for sleep: the anticholinergic side effects and weight gain push it down, and there is not much reason to use it instead of mirtazapine.
We have never started it for sleep. But when a patient has tried everything else and quetiapine is the only thing that works, we are not opposed to keeping it.
Low risk but low efficacy: it works, but it does not work all that well. Do not be too afraid to push it to 100 mg for sleep; it seems well tolerated.
For sleep: if you have another indication and the patient can take one safely (cardiac status, no constipation), a TCA will help the sleep while treating the primary disorder.
They are very anticholinergic, which is part of why they work, and we do not like that for patients, so they go in the C tier.
We think amitriptyline is first line for fibromyalgia pain. Of the tricyclics on our board, we almost wish we had put just amitriptyline, because you really want a tertiary tricyclic.
We mostly use it to regulate the sleep-wake cycle: shift work, international travel, and people with a bad circadian rhythm for endogenous or behavioral reasons. When the problem is circadian rather than insomnia, go for melatonin and a bright light regimen.
Ask patients to use a product approved by the pharmaceutical testing board. Nature Made or the Costco brand are usually the easiest to find.
Limiting and timing stimulants, including caffeine and anything else that produces wakefulness, is S tier for sleep.
Modern extended-release stimulants are built for a rising serum level in the afternoon, so what a patient feels then is probably what they are supposed to feel.
It is very hard to know subjectively how a stimulant affects your sleep. If a patient drinks several espresso shots, deal with that before starting a sleep medication.
In paradoxical insomnia, people believe they literally do not sleep, yet objectively they sleep, with good quality. A sleep study shows it.
Caffeine and melatonin are both metabolized by CYP1A2, so it is possible they compete.
For sleep: when someone has a genuine chronic pain or neuropathic pain reason to take pregabalin, dosing it at night can be a nice synergistic move, since chronic pain causes a lot of problems with sleep.
For sleep, gabapentin always just helps a little; we have never had the really appreciative patient. We tend to reserve it for when there are comorbidities.
Not for sleep alone. Use it for sleep when the sleep problem comes with schizophrenia or schizoaffective disorder, or with refractory bipolar I after the mood stabilizers are exhausted.
In the ICU or nursing home, controlling the sleep-wake cycle with trazodone, mirtazapine, melatonin or ramelteon may give a lot of the same effect without the same problems.
Mechanistically these are not habit forming, carry not much risk relatively speaking, and seem effective. A good set of meds, though personal experience is limited.
Where valerian root works, it is usually in someone who would benefit from an SSRI but is afraid to take one.
Lots of tea right before bed means getting up to urinate in the night, and someone with sleep problems may then have trouble falling back asleep.
Sodium oxybate is not for primary insomnia. Leave it to sleep doctors treating diagnosed disorders like narcolepsy.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.