What type of drugs are best for treating insomnia?

January 12, 2012 8:40 AM

Are antidepressants as effective as sedatives/hypnotics for helping insomnia?

I travel Sunday-Thursday every week and when I'm on the road I just don't sleep.

I've talked everything over with my PCP and he initially prescribed doxepin 50mg. That had no effect on my sleep whatsoever. It only made me a little sluggish during the day and I felt kind of like Peter from Office Space.

He then switched me over to trazodone 100mg a few days ago. This doesn't help me fall asleep either. I still wake up a couple of times during the night but it does seem to help me fall back asleep quickly.

Are sedatives like Ambien CR and Lunesta better for sleep related issues than antidepressants?

Whatever ends up working for me will need to be something I can use long-term and hopefully won't be habit forming.

posted by jwfree to health & fitness (22 answers total)

Have you given Melatonin a shot before going on to the prescription-strength stuff? A lot of places don't stock in in higher than 3 or 5mg, but you can safely go as high as 10.
posted by griphus at 8:45 AM on January 12, 2012 [1 favorite]

Antidepressants have never helped me with my insomnia. Granted, my insomnia is due to my back and nerve pain primarily.

Ambien is great if it works for you. For me, it simply made me feel drunk. Didn't put me down, and it actually is an odd state of being if/when it doesn't put you down.

I find stronger hypnotics and benzodiazapams to be the most effective. They carry risks and shouldn't be used long term. Temazapam will put me down on most nights if I have trouble sleeping.
posted by handbanana at 8:46 AM on January 12, 2012

My experience is that antidepressants are not helpful at all for sleep. I did find trazodone helpful, but I had to take 250mg - 100 was not even close to enough. However, the issue for me was not falling asleep (that was never a problem), but staying asleep.

My understanding is that Ambien and Lunesta are not good for long-term, regular use because the are addictive and you build a tolerance. That's probably why you were prescribed trazodone to try first - my understanding is that it is non-addictive and can be used long term.
posted by insectosaurus at 8:46 AM on January 12, 2012

Trazodone did work for me. I take 50 mg. Most doctors want to start with something like trazodone because it has much milder side effects than the newer drugs. If it's not working for you, go back to the doctgor.
posted by something something at 8:47 AM on January 12, 2012

A note on melatonin, smaller doses have been shown to be more effective than larger doses.

The more you know!
posted by handbanana at 8:47 AM on January 12, 2012 [1 favorite]

Not a doctor here, but this sort of thing REALLY depends on the person, and on the reason for their insomnia. I've known people who've taken tricyclic antidepressants for sleep-related stuff and it's worked for them, and have even heard of people who sleep better when prescribed *stimulants* (because this can help stop ADD bouncy-brain from keeping them awake). But really this is the sort of thing where, if you're in a "troubleshooting" phase, you need to make sure your doctor will listen to you if you tell him or her that something isn't working for you. Be detailed in your descriptions of what is going on when you try to sleep, and make sure to get checked out for physical problems that could impact sleep (e.g., hyperthyroidism) if you haven't already.
posted by aecorwin at 9:01 AM on January 12, 2012

My neurologist gave me Pamelor (sp?) as it apparently has an off-label use for chronic migraines. It aided my mild insomnia by making me sleep about 16 hours a day whether I wanted to or not.

Very obvsly ymmv.
posted by elizardbits at 9:12 AM on January 12, 2012

Try melatonin first - and consider a drug for shift work-related sleep disturbances (I can't remember the name, but it's much closer to the kind of situation you're in.) Antidepressants have been, in my understanding, mostly helpful for people who can't sleep because they're depressed - they're up, anxious, worrying about tomorrow, unable to focus, most of the day for weeks or months at a time. Though some antidepressants do make people sleepy, it's often the sluggish kind of not-awakeness, rather than true (good) sleep.

You may also be having issues because of changing schedules back and forth. It stinks, but try going to bed and making yourself get up at the same times at home as on the road. My weekday insomnia was greatly helped by making myself get up earlier on weekends, weirdly.
posted by SMPA at 9:14 AM on January 12, 2012

ADs have always helped my insomnia more than sleep medication. Anti psychotics too. I develop a fast immunity to sleeping pills (work for one day and that is it). I am on trazadone but it took til 300 mg before it works. But it really varies for people. It may be worth a shot of upping the traz to see if you hit that sweet spot.
posted by kanata at 9:14 AM on January 12, 2012

I know people who say a sub-clinical dose of amitriptyline does wonders.
posted by pickypicky at 9:17 AM on January 12, 2012

If trazodone didn't help you sleep, I suspect that these less-intense alternatives won't be of much use. But they may be worth a shot:

benadryl (my shrink recommended this because trazodone knocked me out cold for nearly 2 days at a time.)

nthing melatonin, especially for maintaining sleep

After dealing with years of insomnia related to anxiety and depression, I've only found meaningful long-term improvement from being ridiculously strict about "sleep hygiene." I stick to the exact same bedtime 28-30 days per month, despite the lousy effect on my social life. I turn off screens 1 hour before bed, drink some peppermint tea, and read a print book in dim lighting.

Since you travel so frequently, perhaps you could create a 'bedtime ritual' of sorts. It sounds silly, but having something consistent may help your brain settle down a bit and let you sleep on a regular basis.
posted by brackish.line at 9:18 AM on January 12, 2012

I had to bump up to 300mg on trazodone before it really started to work. But when it does work--hoo! It puts me out within about 30-45 minutes.
posted by sperose at 9:22 AM on January 12, 2012

No drug recommendation but I'm seconding suggestion to develop a ritual for bedtime.

If your problem is falling asleep as opposed to staying asleep, I swear by an app (desktop and phone) called pzizz. It's new age-y with soothing voice ("You're feeling light and eyes getting heavy" sort of stuff) and light music in the background. But for some reason it works for me. I normally couldn't fall asleep in less than 30+ minutes but after this and some training, I can fall asleep within 5 (without the need for the app anymore) almost anytime and anywhere.
posted by 7life at 9:32 AM on January 12, 2012

Do you know why you're waking up several times a night? FWIW I actually find that a Xanax tab 30 minutes before bed actually helps me sleep restfully through the night instead of waking up with midnight and 2 am and 4 am and 6 am anxiety.
posted by DarlingBri at 9:46 AM on January 12, 2012

I use valerian, an herb for which there is a pretty good evidence base. It works as well for me as Ambien did. I was on Ambien and found it hell to quit. In my experience, it was not as innocuous as the ads suggest. BTW, trazodone is rather unique among antidepressants in its off-label use for insomnia.
posted by Wordwoman at 10:00 AM on January 12, 2012

There is a correlation with Ease of use/low side effects/physical addiction and efficacy when it comes to sleeping medicine. For example, xanax works beautifully, relaxes you, eases you, mellows you, and allows you to enjoy your sleep while wearing off by the morning. I would actually recommend it (if you can get a doc to trust you to prescribe it) if you don't need a pill more than once or twice a week and won't abuse it. If you need something nightly there are some anti-depressants that are used off label that work well.

You will always develop an addiction. Psychological dependence on these drugs is very real. I don't have trouble sleeping but I am prescribed xanax, klonopin, and lexapro. If you have questions on these drugs you can send me a message.
posted by jjmoney at 10:12 AM on January 12, 2012

For whatever it's worth, mirtzapine (Remeron) is the only antidepressant I've taken which made me sleep more instead of less, and that effect decreased significantly for me after a couple months. Melatonin and valerian were not effective for me either. From the answers here I'm quite an outlier, but maybe it's just a note that different people react very differently to this stuff.

I used to take diphenhydramine (Benadryl) in its sleep-aid form every night. It worked reasonably well at knocking me out most of the time, but if I didn't sleep for 8-9 hours the first few hours of wakefulness were very sluggish and groggy, and I almost never sleep for that long. Right now I have an Ambien prescription which I only take if I can't get to sleep by 4 am or so. I like Ambien, but it is definitely not a "take this every night" kind of drug, more of a "you need to go to sleep right now and nothing else has worked, and you shouldn't take it again within a couple days if you can help it" kind of drug. Ambien will also not really help you stay asleep, so it may not help with the intermittent waking.
posted by Errant at 12:58 PM on January 12, 2012

I've been taking antidepressants for years (though not trazodone, which I know is prescribed off-label for insomnia) and it never affected my insomnia.

Seconding DarlingBri's recommendation that you might talk about Xanax. Which lots of people take at a low dose every day for years without any negative side effects, but on the other hand some people experience it as very addictive, so that would certainly be something you wanted to talk about with your doctor.

I know that I recommend Cognitive Behavioral Therapy for just about everything, to the point where it is ludicrous, but one of the things that CBT does very very well is help people learn how to manage intrusive thoughts and anxiety. If those play a role in your not being able to sleep while traveling, you might want to look into that.

Good luck!
posted by Sidhedevil at 2:26 PM on January 12, 2012

What is your stimulant intake like when you travel versus at home?

What about your diet? If you aren't getting enough protein, you aren't getting enough tryptophan. Which means not enough serotonin, which gets converted into melatonin in the brain when the lights go out.
posted by gjc at 4:31 PM on January 12, 2012

I'm a crappy sleeper (wired that way, alas) and I use Ambien, Seroquel, Ativan, and melatonin (not all at once, I rotate them) and they seem to work. Sometimes benadryl works, and sometimes I can stay awake (though I don't dare drive) right through 100 mg which would normally fell an ox - but I'm exceptional.

A couple of non-drug sleep hacks have really, really helped me and enabled me to scale way back on the prescription drugs:

1) Comfy mattress. Forget the "extra firm" nonsense, I love my soft and squishy mattress. YMMV, definitely, because some people love extra firm. A comfortable mattress goes a long way toward making you fall asleep faster.

2) A light, protein-intensive snack about an hour before bed. Turns out one of the reasons I kept waking up was that my blood sugar was cratering overnight and my body was saying "Help, help, I'm starving, feed me!" I didn't wake up feeling hungry or anything - just kept waking up. A small snack - like a piece of turkey, a hard-boiled egg, a bit of yogurt - keeps my blood sugar from dropping overnight.

3) No coffee or tea past 11 AM. Some people are more sensitive to caffeine than others. My dad can swill coffee by the potful from morning to night and still sleep. I'm caffeine-sensitive and have to be pretty strict about not having coffee or tea past the late morning.

4) A bedside aromatherapy heater with jasmine and lavender essential oils, and pillow speakers attached to my iPod playing soft, soothing music or nature sounds.

5) A cool room and some super-wonderful "temperature-sensitive" sheets I got from the Vermont Country Store online so I'm not waking up in a sweat.

6) Nasal spray and Breathe-Right strips so I am not awakened by congestion.

For the record, Trazodone never, ever worked for me and gave me gnarly side effects (I couldn't breathe, I had nightmares, I was a zombie the next day). Restoril worked but I developed too much of a tolerance for it. My above hacks are helping me so, so much in tapering down my sleep meds.
posted by Rosie M. Banks at 5:54 PM on January 12, 2012

Lunesta. But people are still unclear why/how it works.
No groggy feeling.

Zolpidem isn't great but it works if you take it then get to bed or else your up doing things and going places and not remembering it.
Somewhat groggy.
posted by Bun Surnt at 8:45 PM on January 12, 2012

If other things don't work well for you, and you can tolerate benzodiazepines but maybe don't want to try Xanax, Restoril (temazepam) is prescribed for sleep and seems to help with both putting to and staying asleep. None of the new drugs ever worked for me, and anything based on antihistamine action (trazodone, TCAs, benadryl, seroquel) makes me into a somnolent zombie.

I'm a terrible insomniac, and have never found that any of my antidepressants helped me to sleep, unless I wanted to ONLY sleep. That being said, I am very prone to side effects and so un-addictive in nature that my doc finally gave me Tylenol 3, which is the only thing I can take more than one night in a row. I still haven't talked her around to letting me try Seconal... maybe in another few years.
posted by monopas at 12:28 AM on January 13, 2012