Getting Enough Zzzzzz’s

So what’s left to be said about what we’re likely to face throughout 2009? Most experts agree that we are facing the worst financial crisis in recent history. Extreme stock market swings, the collapse of the housing industry driving widespread foreclosures, failing banks, growing job losses and rising consumer prices are affecting the financial and emotional stability of many Americans.

sleep_deprivedA survey of 2,500 people by the American Psychological Association found that 80% of respondents say the economy is a significant source of stress and that it’s taking a toll on their health. Respondents alluded to experiencing a general sense of fear and concern, while nearly one in five reported suffering insomnia. One person surveyed said this: “I don’t sleep more than four hours a night. I get headaches. I worry that my kids can’t go to college, and my doctor now has me on anti-anxiety medication.”

So what about these anti-anxiety medications? Are they effective? Even more importantly, are they effective and at the same time SAFE? If you’re noticing an upswing in phone calls to your agency, clinic or private practice about these drugs as I have over the last few months, here’s some pertinent information about them along with some common sense, non-pharmacological tips for improving sleep hygiene to share with your clients:

Benzodiazepines can trigger addictive behavior in susceptible people. These medications are all essentially the same and prescriber decisions as to which benzodiazepine to use are typically based on the anxiety disorder being treated as well as the drug’s onset of action and rate of elimination from the body. Examples include: Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam) and Halcion (triazolam). For the most part, they are quite safe unless mixed with alcohol or other sedatives, but they can cause euphoria leading to habituation in vulnerable individuals. Also, prolonged use has an adverse effect on sleep architecture, particularly rapid eye movement (REM) sleep. Benzodiazepines can cause “foggy thinking syndrome” in that they are linked to cognitive dysfunction. Recommend intermittent short-term use of these drugs.

Non-benzodiazepines probably represent an improvement over the benzodiazepines, but there are other reasons to be wary. We’ve all seen the direct-to-consumer advertisements for Ambien CR (zolpidem CR) and Lunesta (eszopiclone). Some studies indicate that these agents are associated with less dependence and cognitive impairment than the benzodiazepines. Also there are less adverse effects on overall sleep architecture. But these drugs (Ambien in particular), are linked to the troubling side effects of possible sleepwalking, sleep-eating and even sleep-driving in vulnerable people. Make certain that your clients are aware of these adverse events and advise them to stop the drug immediately and notify their prescriber if they experience any of these effects.

A kicked-up melatonin subtype. Rozerem (ramelteon), a relatively new prescription sleep aid, is a non-controlled substance, unlike the benzodiazepines and non-benzodiazepines. As such, this medication is not linked to abuse or habituation. Melatonin is believed to be involved in the maintenance of the circadian rhythm associated with the sleep-wake cycle. Advise your clients that this drug is quite costly (up to $150 for a 30-day supply) and that it typically helps clients get to sleep but not STAY asleep.

The old fashioned antihistamines. Gosh, how long has Benadryl been around? Although not FDA approved for insomnia, antihistamines typically produce drowsiness through their sedative effects. Like Rozerem, antihistamines can help a patient fall asleep, but that’s about the extent of their usefulness. Remind clients that antihistamine use may produce a hangover effect or residual grogginess.

Antidepressants can adversely impact sleep quality. Inform your clients that most antidepressants are sleep disruptive, particularly first line agents such as the SSRIs (Prozac, Zoloft, Paxil, Celexa, Luvox, Lexapro) as well as the SNRIs (Effexor, Cymbalta, Pristiq). SSRIs and SNRIs also suppress REM sleep, particularly if withdrawn abruptly. Clients with depression accompanied by insomnia should discuss these issues with their prescriber so that appropriate options can be identified for managing their sleep difficulties.

The bottom line. There has been a veritable explosion of non-benzodiazepine use for managing insomnia over the last few years. This has been fueled by the fact that these agents represent an improvement when compared to the rest of the bunch and by direct-to-consumer advertising. But the hardest pill for us to swallow (no pun intended!) is that chronic sleep problems require us to investigate lifestyle changes that incorporate alternative remedies such as diet improvement, exercise, and establishing a regular sleep schedule – changes we are too often unwilling to make.

From the common sense department. If clients mention that their financial woes mark the “end of the world” for them, remind them that this is truly an event that will happen only once.

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Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, Psychopharmacology: Straight Talk on Mental Health Medications is available at www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at joe@thepharmatherapist.com.