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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by fachad on April 14, 2002, at 19:57:47
Quite a bit is made here of the fact that benzos disturb sleep architecture.
Another less talked about item is that SSRIs wreck havoc on sleep architecture. This does not abate, but rather it continues for the duration of SSRI therapy.
I'm wondering if the BZD disrupted sleep architecture is still better and closer to natural sleep architecture than the SSRI induced sleep disturbances.
To me, it seems like there is a continuum from natural, perfect sleep to horrifically disrupted sleep, and that it goes something like this, from best to worse:
1. Natural sleep (best)
2. Benzo disturbed sleep (better than #3)
3. SSRI wrecked sleep + benzos (better than #4)
4. SSRI wrecked sleep (worst)Of course the only way to verify this would be to do a PSG sleep study, but it's how it seems subjectiely to me.
Posted by alan on April 14, 2002, at 23:26:44
In reply to BZD Improved Sleep Architecture w/SSRI Treatment?, posted by fachad on April 14, 2002, at 19:57:47
> Quite a bit is made here of the fact that benzos disturb sleep architecture.
>
> Another less talked about item is that SSRIs wreck havoc on sleep architecture. This does not abate, but rather it continues for the duration of SSRI therapy.
>
> I'm wondering if the BZD disrupted sleep architecture is still better and closer to natural sleep architecture than the SSRI induced sleep disturbances.
>
> To me, it seems like there is a continuum from natural, perfect sleep to horrifically disrupted sleep, and that it goes something like this, from best to worse:
>
> 1. Natural sleep (best)
> 2. Benzo disturbed sleep (better than #3)
> 3. SSRI wrecked sleep + benzos (better than #4)
> 4. SSRI wrecked sleep (worst)
>
> Of course the only way to verify this would be to do a PSG sleep study, but it's how it seems subjectiely to me.
**********************************************
Yours and my experience line up exactly. I was not aware until elizabeth's post that ssri's and other AD's disrupted or changed sleep architecture. Perhaps for some, it's the opposite - it just may depend on what change from "natural" is the least disruptive for any given individual. The sleep study would only confirm, scientifically speaking, what elizabeth described.
Individual responses to the different architechtures would be what really mattered it seems.My experience has been that anything in the newer AD class, regardless of whether the med had a "sedating" quality attributed to it (serzone, luvox, remeron) or not, the feeling I always got from all of them was that I was overstimulated and felt the wrong kind of sedation - both at the same time. Almost all of them inspired start-up agitation and sometimes downright panic unless taken with a bzd simultaneously. Sleeplessness and sexual side effects were always a problem and it was the main reason I stopped the many that I tried.
I tried different mood stabilsers in augmentation with these ssri's, etc, and in any number of combinations for 7 years - at my protest by the way. I finally concluded that after 3 pdocs, two of whom insisted that it was my stubborn disorder not the medication that was the problem (they even tried fitting my diagnosis around the medicine calling it "listening to the drug" - see Dr. Peter Kramer's "Listening to Prozac"), that the way to go was bzd's. Nothing in the stimulant or activating class of drugs would fundamentally get me past that artificially induced hyperaroused feeling. I fired two docs because of their anti-bzd bias. I essentially wasted 7 years at a very important time in my life because of that bias.
Anyway, if you want to know my opinion, AD's are indicated when depression is primary and anxiolytics when anxiety is primary. I'm a purist I guess because I sincerely believe that the many more anxiety sufferers are helped by them then the ssri types. The use of ssri's for anxiety disorders IMO - even though many are helped with their anxiety using them - are much less effective and complete - many times acheiving exactly the opposite effect from what is needed. Anxiety patients go through life thinking that that's just the best meds have to offer without having been given the freedom of choice to try bzd's on equal footing with ssri's and similiar drugs.
Maybe it just goes back to my disbelief at how the medical professionals have fallen so far for the promotion of these newer drugs in the treatment of anxiety for profit and political reasons - reasons you've expertly outlined here on this bboard before.
Alan
Posted by Ritch on April 15, 2002, at 10:48:28
In reply to BZD Improved Sleep Architecture w/SSRI Treatment?, posted by fachad on April 14, 2002, at 19:57:47
> Quite a bit is made here of the fact that benzos disturb sleep architecture.
>
> Another less talked about item is that SSRIs wreck havoc on sleep architecture. This does not abate, but rather it continues for the duration of SSRI therapy.
>
> I'm wondering if the BZD disrupted sleep architecture is still better and closer to natural sleep architecture than the SSRI induced sleep disturbances.
>
> To me, it seems like there is a continuum from natural, perfect sleep to horrifically disrupted sleep, and that it goes something like this, from best to worse:
>
> 1. Natural sleep (best)
> 2. Benzo disturbed sleep (better than #3)
> 3. SSRI wrecked sleep + benzos (better than #4)
> 4. SSRI wrecked sleep (worst)
>
> Of course the only way to verify this would be to do a PSG sleep study, but it's how it seems subjectiely to me.
Fachad,The sleep disruption with SSRI's can vary greatly depending on the SSRI used. From personal experience I found Zoloft to be the worst-primarily from restless legs syndrome during sleep. Prozac could do it pretty bad as well-but it has a long-half life. Haven't had much experience with Luvox, but Paxil seemed to not disturb my sleep and Celexa seems to not goof it up too bad.
Mitch
Posted by fachad on April 15, 2002, at 15:59:21
In reply to Re: BZD Improved Sleep Architecture w/SSRI Treatment?, posted by alan on April 14, 2002, at 23:26:44
>I was not aware until elizabeth's post that ssri's and other AD's disrupted or changed sleep architecture.
I think I might have missed that post. Was it recent?
>The sleep study would only confirm, scientifically speaking, what elizabeth described.
I don't know what was in the post, but sleep studies have been done, and SSRIs have been shown to invariably cause severe disruption of the sleep architecture. The makers of Serzone and Remeron funded the studies, and SSRIs were used as "controls" i.e., it was a setup to make their drugs look good because they already knew how badly SSRIs would perform on the sleep architecture parameters.
>I fired two docs because of their anti-bzd bias. I essentially wasted 7 years at a very important time in my life because of that bias.
Yeah, I wasted a number of years trying ADs when stimulants were really the best for me. I used the SSRI vs. benzos for anxiety as an example of drug company marketing hype because it's so obvious to me and I have no personal stake in the matter because I don't have any clinically significant anxiety.
>Anyway, if you want to know my opinion, AD's are indicated when depression is primary and anxiolytics when anxiety is primary.
I'm somewhat skeptical about the validity of DSM-IV diagnosis. I think they are a convenient way to group symptoms and present something “scientific” sounding to third party payers, but I don't think they are as valid as medical diagnosis like streptococcus caused strep throat.
The one thing I absolutely don't buy into at all is medication treatment specificity in psych disorders. By that I mean I don't think one class of meds is always indicated in one class of disorders.
Benzo's probably help some depression patients. Mood stabilizers help some anxiety patients. ADs help some OCD sufferers. Stimulants help some depression patients, and that does not necessarily mean those patients "really had" undiagnosed ADD all along.
The diagnosis are somewhat questionable, but the specificity of treatment concept is a carryover from the germ / antibiotic medical model and it just does not hold water in psych disorders.
It's a real shame in that it limits the possible treatments that are tried and also results in a diagnosis in the event of response. "Oh, I guess you really had (whatever) disorder, because you responed to (whatever class) of meds. Now expect these symptoms too, because they go along with your disorder."
>Anxiety patients go through life thinking that that's just the best meds have to offer without having been given the freedom of choice to try bzd's on equal footing with ssri's and similiar drugs.
Yes, and they have to PAY more for those less effective SSRIs, too. And depression patients go on from one ineffective, side effect laden AD to another, without trying stimulants, unless there is some indication of ADHD, or without trying benzos, unless there is evidence of GAD, or whatever...
Well, this has turned into another rant. I just need to do that once in awhile.
-fachad
Posted by jay on April 15, 2002, at 21:52:44
In reply to Marketing Hype and Specificity of Drug Treatments » alan, posted by fachad on April 15, 2002, at 15:59:21
I just wanted to add a "me too" to your comments. Another area I think that really is scarry is the rationale for use of anti-psychotics for anxiety. (Doc's seem to think anxiety=mania. Can't sleep?..hhmm..must be manic!) So, they are not only putting people at risk for TD and EPS, but at a great financial cost, rather than using *the only 100 percent proven* cure for anxiety, which is benzos, and which are WAY cheaper...about the cost of a bottle of aspirin.Okay.../rant
Jay
> >I was not aware until elizabeth's post that ssri's and other AD's disrupted or changed sleep architecture.
>
> I think I might have missed that post. Was it recent?
>
> >The sleep study would only confirm, scientifically speaking, what elizabeth described.
>
> I don't know what was in the post, but sleep studies have been done, and SSRIs have been shown to invariably cause severe disruption of the sleep architecture. The makers of Serzone and Remeron funded the studies, and SSRIs were used as "controls" i.e., it was a setup to make their drugs look good because they already knew how badly SSRIs would perform on the sleep architecture parameters.
>
> >I fired two docs because of their anti-bzd bias. I essentially wasted 7 years at a very important time in my life because of that bias.
>
> Yeah, I wasted a number of years trying ADs when stimulants were really the best for me. I used the SSRI vs. benzos for anxiety as an example of drug company marketing hype because it's so obvious to me and I have no personal stake in the matter because I don't have any clinically significant anxiety.
>
> >Anyway, if you want to know my opinion, AD's are indicated when depression is primary and anxiolytics when anxiety is primary.
>
> I'm somewhat skeptical about the validity of DSM-IV diagnosis. I think they are a convenient way to group symptoms and present something “scientific” sounding to third party payers, but I don't think they are as valid as medical diagnosis like streptococcus caused strep throat.
>
> The one thing I absolutely don't buy into at all is medication treatment specificity in psych disorders. By that I mean I don't think one class of meds is always indicated in one class of disorders.
>
> Benzo's probably help some depression patients. Mood stabilizers help some anxiety patients. ADs help some OCD sufferers. Stimulants help some depression patients, and that does not necessarily mean those patients "really had" undiagnosed ADD all along.
>
> The diagnosis are somewhat questionable, but the specificity of treatment concept is a carryover from the germ / antibiotic medical model and it just does not hold water in psych disorders.
>
> It's a real shame in that it limits the possible treatments that are tried and also results in a diagnosis in the event of response. "Oh, I guess you really had (whatever) disorder, because you responed to (whatever class) of meds. Now expect these symptoms too, because they go along with your disorder."
>
> >Anxiety patients go through life thinking that that's just the best meds have to offer without having been given the freedom of choice to try bzd's on equal footing with ssri's and similiar drugs.
>
> Yes, and they have to PAY more for those less effective SSRIs, too. And depression patients go on from one ineffective, side effect laden AD to another, without trying stimulants, unless there is some indication of ADHD, or without trying benzos, unless there is evidence of GAD, or whatever...
>
> Well, this has turned into another rant. I just need to do that once in awhile.
>
> -fachad
Posted by IsoM on April 16, 2002, at 1:14:05
In reply to Marketing Hype and Specificity of Drug Treatments » alan, posted by fachad on April 15, 2002, at 15:59:21
Posted by Elizabeth on April 16, 2002, at 23:17:29
In reply to Marketing Hype and Specificity of Drug Treatments » alan, posted by fachad on April 15, 2002, at 15:59:21
> I don't know what was in the post, but sleep studies have been done, and SSRIs have been shown to invariably cause severe disruption of the sleep architecture. The makers of Serzone and Remeron funded the studies, and SSRIs were used as "controls" i.e., it was a setup to make their drugs look good because they already knew how badly SSRIs would perform on the sleep architecture parameters.
Well, the effects of SSRIs on sleep architecture have been observed in studies that *weren't* funded by the makers of Serzone or Remeron, too!
> I'm somewhat skeptical about the validity of DSM-IV diagnosis.
You too, eh? :-]
> Yes, and they have to PAY more for those less effective SSRIs, too. And depression patients go on from one ineffective, side effect laden AD to another, without trying stimulants, unless there is some indication of ADHD, or without trying benzos, unless there is evidence of GAD, or whatever...
I think in both of these cases, the fact that SSRIs aren't controlled substances has a lot to do with it. Even when there are some symptoms that might suggest that stimulants or benzos would be worth a try after SSRIs fail, most pdocs would probably prefer to prescribe anticonvulsants and antipsychotics.
> Well, this has turned into another rant. I just need to do that once in awhile.
I can identify with that.
-elizabeth
Posted by alan on April 17, 2002, at 21:08:15
In reply to Re: Marketing Hype and Specificity of Drug Treatments » fachad, posted by Elizabeth on April 16, 2002, at 23:17:29
> I think in both of these cases, the fact that SSRIs aren't controlled substances has a lot to do with it. Even when there are some symptoms that might suggest that stimulants or benzos would be worth a try after SSRIs fail, most pdocs would probably prefer to prescribe anticonvulsants and antipsychotics.
> -elizabeth
______________________________________________Case in point...a discussion I had with one of my inlaws who is a GP. This what I learned.
Bottom line about ANY controlled substance (and unfortunately bzd's are not distinguished from narcotics, etc. most of the time with docs and pdocs alike who don't know any better or are just plain lazy):
1)Can't be bothered with the SLIGHT RISK of a patient going behind their back selling them, endangering their prescribing privileges.
2)Can't be bothered with the AMOUNT OF TIME of keeping track of managing a patient when they call in saying they "lost" or "accidentally flushed" their prescription and need more (keeping track of paperwork, records, etc.).
3)Can't be bothered with the SLIGHTEST AMOUNT OF RISK of being viewed by their peers as the one in town who had prescribed a drug to an "addict". Doctor comes before the patient (Ego).
"Send em to the local psych say non pdocs if nothing else works and bzd's might be needed" was what I heard.
What about the risk of withdrawl syndromes and high incidence of sexual side effects of the ssri's that docs - including many pdocs - deny are possible straight to their complaining patient's faces? That's what I read here just about more than any other subject - side effects of ssri's and their equivalents. But are you kidding? BZD'S? You can just forget about it! Even if they DO end up working better than something else for chronic anxiety.
What about the risk of TD or the euphemistically referred to "movement disorders" with antipsychotics - even in small doses?
Meanwhile, all of those unused free samples of the latest AD's are crying for a home in the freebie cabinet. The same freebies that work at BEST 50% of the time (who knows ultimately if as well as a bzd) when a bzd tried on equal footing has proven - and continues to look more and more as we learn about the side effects of ssri's - at least as safe as any ssri.
Lazy, egotistical, misinformed, or overworked docs are the culprit re: this discriminitory attitude towards bzd's looks like to me. And it's a problem that's rampant from what I read here and on other bboards.
How's that for getting of on a rant? Maybe even Dennis Miller would be envious.
Alan
Posted by Elizabeth on April 19, 2002, at 0:57:38
In reply to Re: Marketing Hype and Specificity of Drug Treatments » Elizabeth, posted by alan on April 17, 2002, at 21:08:15
Funny (in a creepy way) thing I heard: you know how in New York doctors have to use a special triplicate form in order to prescribe benzos? (Well, they do. Maybe in other states too, but NY is the only one I know of.) I heard that doctors there took to writing scripts for things like Placidyl and Miltown (two of the widespread downers that people used in the '70s if they couldn't get Quaalude) so they wouldn't have to bother with the paperwork!
> 2)Can't be bothered with the AMOUNT OF TIME of keeping track of managing a patient when they call in saying they "lost" or "accidentally flushed" their prescription and need more (keeping track of paperwork, records, etc.).
Being more than a little bit disorganized, I'm constantly losing things. My pdoc in Cambridge didn't give me a hard time when this happened (he'd known me for years and is pretty mellow in general), but the pdoc I've been seeing since I moved is not so easy-going.
> What about the risk of withdrawl syndromes and high incidence of sexual side effects of the ssri's that docs - including many pdocs - deny are possible straight to their complaining patient's faces?
I've never had a pdoc tell me that I could stop taking ADs abruptly (except Prozac). Tapering off antidepressants is one thing; tapering off benzos is *much* harder. Getting off benzos after you've become addicted is a major undertaking.
> That's what I read here just about more than any other subject - side effects of ssri's and their equivalents.
SSRIs are very common, and that probably accounts at least in part for the amount of discussion. But yeah, people with anxiety disorders usually tolerate benzos much better than SSRIs.
> What about the risk of TD or the euphemistically referred to "movement disorders" with antipsychotics - even in small doses?
I think that it's really rare (EPS from low-dose APs). But still, antipsychotic drugs are *not* a substitute for benzos, and they aren't a very effective treatment for classic anxiety disorders. To be fair, some specific types of (nonpsychotic) anxiety or agitation seem to be particularly responsive to low-dose APs; and people with certain disorders are at increased risk for potentially harmful disinhibition if they take benzos. But these are specific situations; they don't justify using APs as a general substitute for benzos!
> How's that for getting of on a rant? Maybe even Dennis Miller would be envious.
<g>
-elizabeth
Posted by alan on April 19, 2002, at 22:54:40
In reply to Re: Marketing Hype and Specificity of Drug Treatments » alan, posted by Elizabeth on April 19, 2002, at 0:57:38
> > What about the risk of withdrawl syndromes and high incidence of sexual side effects of the ssri's that docs - including many pdocs - deny are possible straight to their complaining patient's faces?
>
> I've never had a pdoc tell me that I could stop taking ADs abruptly (except Prozac). Tapering off antidepressants is one thing; tapering off benzos is *much* harder. Getting off benzos after you've become addicted is a major undertaking.I see the complaint over and over that docs look at them quizzically as they describe the adverse effects of stopping paxil by tapering and the like. The doc says that there is nothing in the prescribing information that says anything about your symptoms (blaming the patient, not the medicine).
What ever happened to medical dependence and tolerance instead of "addicted"? You wrote an entire essay on it here about a year ago. I just don't see it to be the case with bzd's relative to the "discontinuation syndrome" so common amongst more and more reported cases of ssri users, even if they do taper. It isn't a tolerance/withdrawl issue in the classic sense in those cases either.
Many, including myself, may take a time to taper a bzd with very little side effect while someone stopping paxil turns out to be a major undertaking NO MATTER how slow they go. Plus if there is a problem tapering bzd's, a longer acting bzd or calcium channel blocker or antiepileptic like neurontin commonly eases things well if the doc knows of such things. No such drug for the "brain zaps" and other awful discontinuation effects of ssri's and the like.
>
> > That's what I read here just about more than any other subject - side effects of ssri's and their equivalents.
>
> SSRIs are very common, and that probably accounts at least in part for the amount of discussion. But yeah, people with anxiety disorders usually tolerate benzos much better than SSRIs.Yes, too common - that IS the problem.
> -elizabeth
Alan
This is the end of the thread.
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