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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Dave954 on October 4, 2009, at 16:39:08
I am in desperate need of help for my treatment resistant insomnia. For many years I was on an excellent combination of medications to treat my depression, mood and sleep. I was taking 10 mg of Lexapro with 80 mg of Strattera in the morning and 200 mg of Seroquel with 900 mg of Neurontin at bedtime. Then, about a year and a half ago I stopped sleeping well. My Seroquel was doubled to 400 mg and I began sleeping ok again. Then, my sleep became poor yet again. I have tried all of the benzos (Ativan, Klonopin, Valium and Xanax) in addition to Ambien and Lunesta. All of those medicines, while they helped my sleep to a degree, worsened my depression. I have also tried Risperdal, which used to help my insomnia, but it is no longer effective. I have also tried Remeron and Trazodone which also helped my insomnia to a degree but also worsened my depression. I tried a higher dosage of the Lexapro and my sleep remained unchanged. I have tried removing the Strattera from my current regimen and my sleep remained unchanged, while my depression and anxiety became worse, so I eventually resumed it. My psychiatrist had me undergo a sleep study, an MRI of my brain and an EEG as well as a physical. Everything came back normal. The neurologist that I went to recommended that my psychiatrist either increase the Neurontin or try me on Xyrem at this point. My psychiatrist seems too concerned about protecting his medical license as opposed to helping me with stronger medicines - although I have heard that Xyrem can worsen depression. I have tried supplements like Kava Kava, Valerian Root and Melatonin and they didn't work. I thought about asking to be put on Xyprexa but my understanding is that it isn't as sedating as Seroquel. I pay for my psychiatrist out of pocket as he doesn't accept insurance and I thought maybe he would be more helpful than a doctor under my plan (I am beginning to think this isn't the case). I really feel hopeless at this point and could use any expert advice. I live in the Washington DC area. Thanks.
Posted by Sunbath on October 4, 2009, at 17:15:51
In reply to Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 16:39:08
Hey,
sorry to hear that, insomnia is a really really bad problem :(
Did you already try Trazodone and amitriptyine?
Both drugs helped me a lot and although I'm taking trazodone since >2years, it's still very effective treating my sleep problems (but it's not for everyone!).. also amitriptyline seemed VERY effective when I tried it!Good luck!!
Posted by Phillipa on October 4, 2009, at 17:19:01
In reply to Re: Need advice for treatment resistant insomnia » Dave954, posted by Sunbath on October 4, 2009, at 17:15:51
Chloral hydrate with low doses of benzos seriously gave me great sleep. Now not on it. Phillipa
Posted by Larry Hoover on October 4, 2009, at 18:45:43
In reply to Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 16:39:08
You haven't tried all the hypnotic benzos, if your list is accurate. Three that are used almost exclusively as hypnotics are temazepam, nitrazepam and oxazepam. There's another, whose name escapes me, also.
There are three tricyclic antidepressants with powerful sleep-inducing potential. They are doxepin, trimipramine, and amitiptyline.
You might also benefit from oral melatonin, in combination with any of the above.
Lar
Posted by Dave954 on October 4, 2009, at 19:35:33
In reply to Re: Need advice for treatment resistant insomnia » Dave954, posted by Larry Hoover on October 4, 2009, at 18:45:43
I have actually been on Temazepam before (Restoril). I have a generally high tolerance to all benzos now. My neurologist felt that if medicines like Remeron and Trazodone exacerbated my depression, then so would the sedating tricyclics which share a somewhat similar mechanism of action on certain sites. Melatonin seems to worsen my mood during the daytime for some reason. Have any of you had experience with barbiturates? I assume there is probably cross-tolerance between them and benzos - and I realize they are rarely prescribed due to overdose potential. Also, is chloral hydrate known to worsen other conditions? Finally, do any of you have personal experience being on Xyrem (Sodium Oxybate)?
Posted by jasmineneroli on October 4, 2009, at 21:04:34
In reply to Re: Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 19:35:33
>Melatonin seems to worsen my mood during the daytime for some reason.
* I also suffer from chronic insomnia, and also found Melatonin to worsen my mood - irritated depression.
I haven't tried Xyrem, but I did take very high doses of L-Tryptophan (3000mg at night) for 6 months which worked very well, until it pooped-out. My L-tryptophan was prescribed, pharmaceutical grade.
My only other drug suggestion is to try some of the old anti-histamines and experiment with dose - Phenergan for instance might work.It seems that no sleep inducers work long-term.
Have you considered the possibility that you have a Circadian Rythmn problem? Blue Light Therapy works very well (I tried that too, worked beautifully until I had lens replacements in both eyes that I discovered filter blue light - after the fact!).
Good luck
J
Posted by desolationrower on October 4, 2009, at 21:07:45
In reply to Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 16:39:08
clonidine?
phenibut is awfully like xyrem
do you meditate?
sometimes less seroquel is better. its a hypnotic b/c its an antihistamine (mostly). once you start getting alpha2 antagonism at higher doses, it is more arousing.
dopamine agonists might be worth trying at some point, especially (though not exclusivly) if you ahve rls
-d/r
Posted by yxibow on October 5, 2009, at 1:10:59
In reply to Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 16:39:08
I hate to say it but your psychiatrist is right to be worried about his license with Xyrem.
The DEA has clamped down on licenses and people have had them yanked for appearing to distribute too many controlled substances.
A psychiatrist that has special training in "addiction medicine" is usually more open to substances that are normally red flags than a regular psychiatrist because of their training.
Xyrem, what ever people want to say or not about GHB, can be lethal.
Chloral hydrate, which is an incredibly old medication is also somewhat lethal.Barbiturates have to be carefully considered.
The thing is, its possible you've become somewhat resistant to GABA-nergic medication, in terms of their use for sleep.Its like trying to drive a nail through hardwood with a rubber mallet. The transmitter ignores it.
Maybe I'm projecting because I've become fairly resistant to GABA medications, although they still work, I don't really feel it... I have catch-22s with the Valium I still need to take, etc. No pseudobenzodiazepine or benzodiazepine hypnotic works for me.
But then I stand a good chance of having sleep apnea, and you went through a study, which I am going to have soon, and there was nothing found.
Unfortunately sometimes with treatment resistant insomnia, if it involves the GABA receptors, the best thing is a washout. Yes, sleepless nights really suck, I know. I've had signs of insomnia probably as early as 8.
An EEG will only show something significant if you aren't on too many benzodiazepines (or Neurontin). Its harder to see things through the fog -- I mean, a good neurologist probably can, I'm just pointing that out.
If you've been through all of those I would say that amitriptyline (10mg) is worth a try. It would have a longer period of usefulness.Otherwise doxylamine succinate (Unisom doxylamine formation) 25-75mg (less is better if you can).
I'd still say with the combination of medications you're on you need a psychiatrist or psychopharmacologist to manage them, but I appreciate that costs are a concern. I'm just concerned because GPs while they know about these medications havent gone through a psychiatric rotation.
Stronger medications don't necessarily mean better results -- just quick and dirty solutions, and ones that may have serious consequences.
I'd try the two I mentioned if you want to go through a few more trials.I'm not quite sure how fast these changes were made in all your medications -- that can affect things too.
I think there are other possibilities -- one, your circadian clock may be offset. And the only way really to change this unfortunately is to go through sometimes a good two weeks of changing it.Which means, avoiding naps at all cost, caffeine, etc, staying awake (not to a dangerous point) during the day and allowing your body to have a chance to reset itself.
I'm not saying that it may work for you (and I know that its really hard for me to avoid naps and the like), but it could be a longer term solution for some.
I would try first with the TCA I mentioned though. It might work -- who knows, it also might give a little antidepressant lift.
-- best wishes
Posted by X-ray on October 5, 2009, at 2:26:49
In reply to Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 16:39:08
Hi,
You could try Wellbutrin XL for depression and trazodone for insomnia.
I'm going to try this combo myself in the near future.
Best regards,
X-ray
Posted by Phillipa on October 5, 2009, at 19:02:15
In reply to Re: Need advice for treatment resistant insomnia, posted by X-ray on October 5, 2009, at 2:26:49
Seriously l0cc of liquid chloral hydrate slept like a baby. When came off it just reduced gradually over maybe two weeks. Took for about four years. Phillipa
Posted by yxibow on October 5, 2009, at 20:15:57
In reply to Re: Need advice for treatment resistant insomnia, posted by Phillipa on October 5, 2009, at 19:02:15
> Seriously l0cc of liquid chloral hydrate slept like a baby. When came off it just reduced gradually over maybe two weeks. Took for about four years. Phillipa
The fact that its liquid and you have to measure it like that.. it sounds extremely dangerous not to mention a very outdated sedative.
It's basically like drinking alcohol to sleep. (And of course if you combine these two....)
But different people may have different experiences...
-- tidings
Posted by zzzz7 on October 5, 2009, at 21:49:53
In reply to Re: Need advice for treatment resistant insomnia, posted by Dave954 on October 4, 2009, at 19:35:33
I think you should give the TCAs a shot. The mechanisms of actions between TCAs and mirtazapine/trazodone are sufficiently different (very different, in fact) to merit trial.
Posted by Dave954 on October 6, 2009, at 20:55:27
In reply to Re: Need advice for treatment resistant insomnia, posted by zzzz7 on October 5, 2009, at 21:49:53
Well, one of my concerns is that nothing is more sedating than Seroquel or Remeron (or the two combined which I have already tried) - my understanding is that the TCAs are actually less sedating comparatively speaking. I also understand that the TCAs have similar issues with daytime sedation and somnolence - which always aggravates my depression. I want to try something that has a high likelihood of working this time around. I fear that nothing may be sufficient enough to keep me asleep for 7 to 8 hours any longer. I am hoping Zyprexa might work or some special type of dosing schedule with a combination of things taken at bedtime and then again 4 hours later to keep me asleep (like I am currently doing with the Seroquel - I set my alarm clock to wake me 4 hours later to take more so that I can get barely enough sleep to function the next day - I have tried all the XR formulations with no success). I wish the medical community had a better understanding of neurology and insomnia treatments so that there were more options available for hard cases like me. There appears to be nothing of significance coming up in the pipeline - just more 'me too' drugs with similar mechanisms of action. I miss the days when just 200 mg of Seroquel gave me a guaranteed 8 hours of sleep a night...
Posted by zzzz7 on October 6, 2009, at 23:48:51
In reply to Re: Need advice for treatment resistant insomnia, posted by Dave954 on October 6, 2009, at 20:55:27
"Well, one of my concerns is that nothing is more sedating than Seroquel or Remeron (or the two combined which I have already tried) - my understanding is that the TCAs are actually less sedating comparatively speaking. "
It really depends. For some people, TCAs (and Amitriptyline in particular ) work better than anything else for sleep. Or else a combo might work. If you search these boards, you'll find at least one person who could sleep only on Amitriptyline and nothing else.
So I think TCAs are worth a shot. As to daytime sedation, that's tough, as you know. Dosing lower can help. So can modafinil or something speedy the next day.
Good luck.
Posted by desolationrower on October 16, 2009, at 5:12:51
In reply to Re: Need advice for treatment resistant insomnia, posted by zzzz7 on October 6, 2009, at 23:48:51
the main benefit of a tca vs mirtazapine is the alpha1 antagonism
-d/r
This is the end of the thread.
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