You Are Not My Walrus

January 15, 2013 6:05 PM

But you might have some insight into my Ambien questions. Any suggestions on what antidepressants might work well for someone whose brain really likes Ambien? Do you find that certain activities/foods/supplements make Ambien work better? If you've tried both Ambien and another heavy-duty sleep aid, how do they compare?

Background on me: mid-30's female with a history of insomnia (both trouble going to sleep and staying asleep) for as long as I can remember. I'm well-versed in sleep hygiene and OTC supplements like Benadryl, melatonin, and valerian do nothing. Trazodone seems to help in getting back to sleep, but not going to sleep or frequent wakings. So I've been taking Ambien, 10mg a night, for several years, and for the most part, it's been a wonder drug. But here are a few questions that have eluded my Google-fu:

1. I also have a history of chronic depression (predating the Ambien use), mostly of the "never feel like doing anything, don't enjoy things or doing things, what's the point of it all" variety. My pattern seems to be a few okay days, where I feel like I can cope, do the work/housework that needs to be done, followed by a few days where everything is So Hard and I break down crying frequently over nothing. I have been listening to my depression's lies of "you just need to get a hobby, you're just lazy and need to get your butt off the couch" for far too long and something needs to be done. This is where the Ambien comes in: it makes me feel like myself. Some nights it only makes me sleepy, but most nights there's a substantial mood lift to the point where I feel like contacting my friends and making plans, I can see the point in doing the dishes and feel some satisfaction in accomplishing something, I look forward to the future. I don't feel high or euphoric, I just feel normal. Obviously I'm not unique in the Ambien-elevated-mood arena, but I haven't read any accounts quite like mine, where Ambien functions as an ideal antidepressant, at least for the 30 or so minutes from the time it kicks in until the time I pass out. So my question is, given my response to Ambien, which antidepressant would be best for me to try? I've taken a few Ativan recently, and while it takes the edge off the depression/anxiety, it's nowhere near as effective as Ambien, and it's not a long term solution anyway. What about other GABA drugs like Lyrica or Gabapentin? Would that be a good idea, or bad (would it make the Ambien less effective if I also hit up GABA pretty hard with a similar drug during the daytime)?

2. As much as I love Ambien, it doesn't always love me back. I go through phases, usually a couple nights in a row, where it just never seems to kick in, and I have to take another 1/4 pill to get to sleep. I've tried to make a connection between what I've had to eat, or lifestyle factors, that would cause it to work really well some nights and not so much other nights, but I haven't come up with anything. Surprisingly, the up/down times with Ambien don't seem to correlate with my up/down depression times. Have you used Ambien long-term and found that certain foods/behaviors make it more/less effective?

3. I plan to stay on Ambien indefinitely, as long as it continues to function at this level. But I'm concerned that over time it may become less effective, or my doctor my have a change of heart about continuing to prescribe it, or the FDA's new regulations may affect my ability to get it at this dose. What other sleep meds have you found to be as effective as Ambien? How does it compare to Lunesta, in your experience? Unfortunately, the aforementioned depression complicates matters for me; a night or two of bad sleep causes depression to spiral out of control, which of course exacerbates the insomnia, and so on and so forth.

tl;dr

Share your industrial-strength med experiences with a fellow depressive insomniac.

posted by storminator7 to health & fitness (9 answers total)

I'd stay away from Gabapentin. That drug has been thoroughly mis-marketed over the years.

Have a look at the Wiki article. It's effects are not understood.
posted by Mr. Yuck at 6:21 PM on January 15

Along with limiting your intake of caffeine and sugar, I suggest forgoing the sleep aids and instead going to a doctor about getting on some anti-depressants (or at least a blood test to see if you aren't anemic or have some other vitamin deficiency).

I used to not be able to sleep or stay asleep and was tired all of the time. I tried some sleep aids, but they made me feel worse (ambien made me feel like I was still half-asleep throughout the day, while melatonin would wear off in the middle of the night and I'd wake up suddenly). I finally went to a doctor and was prescribed a low dose of Lexapro and feel so. much. better. I can actually sleep and stay asleep at night and I have energy for the first time in years. Also, I don't feel like crying all the time - which is awesome :)
posted by littlesq at 6:28 PM on January 15 [1 favorite]

Seconding littlesq's experience with Lexapro. It sounds like you suffer from mild depression. I didn't want to admit it to myself, but once I started on Lexapro it was like the haze over my mind, which I had begun to think was just reality, suddenly lifted. Frustrating situations that would have overwhelmed me before became just, frustrating situations. No more crying jags!

Another suggestion is to avoid benzodiazepines. My doctor was worried about how frequently I used Ambien (every other night, approimately) and switched me to low-dose Xanax. I developed (what I am assuming was) dependence, and went through a long week of crazy, intense withdrawl symptoms when I decided to stop.
posted by BusyBusyBusy at 8:05 PM on January 15 [1 favorite]

I have had good success getting BACK to sleep with Melatonin, for when I wake at 2:42 and can't sleep. I just take a melatonin and then listen to the radio or a podcast and I'm asleep easily within 20 minutes. This surprised me since it's a 'natural' product...which don't in general help me...but it specifically is great used for what and when I use it...YMMV.
posted by mumstheword at 9:28 PM on January 15

Depression sometimes goes hand-in-hand with insomnia. Treating my depression treated my insomnia. True, sleepiness is a side-effect of my medication, but the doctor says that my new-found ability to stay asleep is in a large part because the depression has lifted.
posted by MuChao at 9:49 PM on January 15

since we're doing the amateur guess-a-prescription thing, try 100mg of doxepin, an old tricyclic antidepressant, to keep you asleep after the ambien wears off, then welbutrin for relief of depression and anxiety. that's the good stuff.
posted by facetious at 11:23 PM on January 15

Depressive insomniac here. Also a pharmacology nerd.

With zolpidem, it's not so much what you eat as how long it's been since you've eaten. Food can slow absorbance to the point where a therapeutic plasma level is never reached (e.g., the concentration/time curve becomes flattened). I would recommend not eating for at least two hours before dosing at night. The longer the better. Drinking liquids is fine.

The increase in mood and sociability that you're experiencing is dis-inhibition. Certain subtypes of GABA receptor are activated by zolpidem, and since GABA is an inhibitory receptor, this causes neuronal inhibition. But in some circuits of the brain, the neurons being inhibited by GABA receptors are themselves inhibitory, which produces a net excitation downstream. This effect lasts until global inhibition overwhelms the local excitation and you conk out. The mechanism is very similar to what happens with alcohol.

Unfortunately, this effect cannot readily be used for the treatment of depression because the relevant circuits develop tolerance quite rapidly. If it were somehow possible to eliminate the hypnotic effects of zolpidem while maintaining the mood elevating effects, you would find that the latter would gradually disappear with regular dosing over the course of days or weeks. I could go into much more detail, but the bottom line is that you cannot win using this pharmacological strategy.

Other GABAergic drugs are also not suitable options. Pregabilin and gabapentin will not give you the same affective kick as zolpidem. Some of the fast-acting benzodiazepines might, but they'll come with as many problems as zolpidem.

There are certainly antidepressants that are effective, but not in the same qualitative way that you know and love with zolpidem. The effects are far more subtle. That is the trade-off of having a long-term solution. Furthermore, most antidepressants do not produce the sort of acute sedation needed to put a hardened insomniac down for the night. The only drug that functions as both a powerful antidepressant and hypnotic is mirtazapine, but taking it is a bit of a Faustian bargain, as it tends to cause massive weight gain.

My suggestion is to treat the depression and insomnia separately. Keep taking zolpidem for insomnia as long as it works. Add an antidepressant to help with the daytime depression. Do NOT expect it to cause the same sort of mood elevation that you get from zolpidem—if it works, it won't be something you feel so much as something you don't feel; depressed moods will be less frequent and less severe.

Feel free to MeMail me if you have any questions.
posted by dephlogisticated at 1:38 AM on January 16 [2 favorites]

Not sure how helpful this will be, but... Ambien works well for my insomnia, and ambien plus baclofen (muscle relaxer) worked better. Ambien for initiation and baclofen for maintenance. When taking the combo I was able to take less ambien. But I have muscle cramping/pain issues which are part of my sleep issues (at least sleep maintenance).

Also, Wellbutrin worked very well for me when I was depressed a number of years ago. I very quickly just felt like me again, without the black cloud, and the only side effect was dry mouth. It was also easy for me to discontinue (no withdrawal). One caveat, this was back when Wellbutrin went out of patent and I was on the generic for one month, it was hell and I had a rapid decent into a worse depression than when I started, which cleared up when I went back to the brand name.

And speaking of generics, I also noticed that one type of generic ambien worked really well for me, but generics from two other sources didn't work for me. So I stick with the brand now, since I couldn't reliably get the one generic that worked.

I think if trying something new, it can be worth it to start with the brand name, and then if that works for you, try the generics to see if they have the same effect. These are the only two meds I've taken where I've noticed dramatic differences based on the manufacturer, but it's something to consider.

Also, as someone else mentioned, the ambien seems to work less well if I've eaten a meal too close to taking it or if I take my magnesium too close to bedtime (I'm guessing its bulk in the stomach, but don't really know). I seem ok with a light snack, a little fruit, a few almonds, at bed time.
posted by pennypiper at 8:27 AM on January 16

I've been on mirtazapine for probably 6 or 7 years. From day one until this day it gets me to sleep effectively about 98% of nights. In the beginning it worked pretty powerfully for me as an anti-depressant too, but my symptoms got stronger due to circumstances and anxiety has been since identified as the prime mover so now my doctor keeps me on it for sleep.

Sleep inducement wasn't a consideration when mirtazapine was chosen for me, but I've been awfully desperately thankful for it because I used to have a lot of trouble getting to sleep (though I still have a lot of anxiety in the hours before bedtime). I don't seem to have built up much of a tolerance to the sleep-inducing effects either, I have faith in it when I take it at night.

I also have a friend who has been on the drug, and neither of us experienced weight gain that wasn't attributable to beer or other bad habits. Weight gain can be countered or mitigated if you know it's coming and stand strong against it, anyway. That's my anecdata.
posted by My Famous Mistake at 12:25 PM on January 16