What we’ve said about Insomnia

“it's not describing an entity, is it? It's describing a symptom. And it's saying that if you can't find the cause for this symptom, it's primary insomnia, which is meaningless”

“I think that having a night or two of insomnia is a normal, inevitable part of life. So almost inevitably, you're going to have something stressful occur, death of a loved one, divorce, family issues, being hospitalized, and you're not going to be able to sleep as a result of it”

“I think chronic insomnia is the people that have this short-term insomnia and then start to develop beliefs and behaviors that create a feedback loop that worsens the insomnia”

“Sleep is fundamental to your ability to function during the daytime. Sorry to say. Right. It's a basic thing of how the brain works, how the brain clears out. uh metabolites that are not good for its functioning”

“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 a.m. for a few nights in a row”

“People are depressed. They get decreased deep sleep, uh, increased light sleep, increased REM percentage”

“my approach is somewhat tailored to the cause of the sleep disruption. I try to isolate determine the causes of sleep disruption? Is it really psychological? Is it from a primary anxiety disorder like ruminations”

“You'll hear all the time like, oh, no, my sleep's good. I sleep five hours a night. Trust your heart. Yes, there are some people who can sleep five hours and function great. Those are rare, rare, rare, rare exceptions”

“Another major mimic that I think you really want to make sure you're not inappropriately treating is severe insomnia related to a trauma disorder. OK, people with a severe trauma disorder can be in such a hypervigilant state that they won't sleep for even a couple of days in a row”

“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”

“The if you're on your phone, you can't be asleep. So, yes, they might report request a sleep med”

“We have to understand that personality disorders can come with a lot of maladaptive coping or emotional dysregulation that will then disrupt sleep considerably”

“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”

“I go off the clinical history, though. I'm not sending everyone to a sleep study. If I hear something that sounds at least suspicious for sleep apnea, like multiple nighttime awakenings”

“It basically, it's nothing too fancy, but it screens for insomnia disorders, circadian disorders, obstructive sleep apnea, restless leg syndrome, narcolepsy, or parasomnias”

“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”

“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”

“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”

“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”

“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 a.m., can't fall asleep, so they go back on their phone”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“lots and lots of our patients are staying up late on purpose. There's a reason for it. And when we tell them to go to bed at a regular time like earlier, we're inviting them to do something that is dysphoric for them”

“Whoa, when I put these things on at 8, I fall asleep like almost an hour earlier and I fall asleep more quickly and I stay asleep better. So there are some people who are going to come back with their amber lenses and go, yeah, darn it, this really works”

“if you stabilize sleep for a patient, they're going to get a lot of their mental health better on their own because there's a lot you can't do in terms of the other activities we just talked about if you're not sleeping correctly”

“I don't think they're going to be able to engage appropriately with the psychological and behavioral changes in their lives to treat that anxiety disorder if they're just not sleeping right”

“Why am I on the augment team? Because I find that one medication usually doesn't immediately treat all the ill effects of depression right away. Most people have sleep problems. Obviously, those sleep problems tend to improve when you've gotten someone to an adequate dose of SSRI”

“there's a directional effect where if you disrupt the sleep of someone with a bipolar disorder, they're more likely to cycle, right? So if that's the case, then I also want to stabilize the sleep”

“So you really, really need to treat the sleep first, in my opinion, for the trauma disorder. And now you could wait several weeks sometimes or longer and try to rely solely on your SSRI. I think that's less effective and you don't need to do that”

“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”

“someone who seems to have neurodevelopmental but not adhd uh like autistic traits uh often you see dysregulation the sleep-wake cycle i'm going to give something not habit forming”

“SSRIs in people without major depressive disorder are actually disruptive to sleep. Same thing with low-dose BuSpar. Basically, the serotonin mechanism will suppress REM sleep and also cause more nighttime awakenings”

“If I'm seeing more insomnia lasting than that from an SSRI, I'm pulling them off of the SSRI. Okay. Again, I want the sleep to be stable first”

“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”

“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”

“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”

“the Benzodiazepines can help as a short-term, one-week prescription to get over that crisis, which is partially depression”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“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”

“do not use any technology invented after 1980 after 10 p.m. or maybe even 9 p.m. depends on your schedule”

“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”

“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”

“I just described like it's 4am um I've been sleeping for six hours and it actually worked really well. It helped me calm down, which is not the purpose of it, but it did work”

“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”

“If you actually go out and look for an algorithm for sleep, there's none guiding psychiatrists. Exactly. The American Sleep ASAM recommends against all the medications we use for insomnia”