Dr. Bob's Psychopharmacology Tips

Refractory insomnia associated with depression

Date: Sun, 19 Nov 1995 13:10:58 -0500 (EST)
From: Bill Boyer <wboyer@emory.edu>
Subject: Refractory insomnia associated with depression

I need help with a 30 year old, male patient with major depression. After two years, he has finally responded to bupropion and fluoxetine. Despite great improvement in most of his presenting symptoms he continues to have a significant sleep disturbance (mostly difficulty falling asleep and some early morning awakening). He complains of not being able to "shut off" his mind when he tries to go to sleep.

--Andrea B. Stone, M.D.

1. "Not being able to shut off my mind" sounds a lot like a habit, which could be addressed by breaking up the time and/or routine prior to bed or prescribing something different to think about. He also probably believes he won't be able to sleep, that will be terrible, everything is useless, etc., which could be addressed directly.

2. Sometimes the problem is with dosing. Trazodone should be given up to 400-600 mg hs, if tolerated, antihistamines 200 mg hs, and trimipramine (Surmontil) often works very well (200-300 mg hs for tough cases).

3. There are other drugs we sometimes don't think about, such as low-potency antipsychotics, baribiturates and ethcholrvynol (Placidyl). However it seems to me that by the time everything else doesn't work, these won't either.

Date: Tue, 21 Nov 1995 06:48:15 -0600
From: crismonl@MAIL.utexas.edu (M. Lynn Crismon)
Subject: Refractory insomnia associated with depression

I just reviewed the literature on the use of trazodone as a hypnotic, as opposed to as an antidepressant. Among these reports, the highest dose of trazodone I could find was 200 mg nightly, and the dose in most reports was lower. This is obviously contrasted with doses in depression studies. Do you have references to substantiate the higer dose for hypnotic use?

All of the literature I have seen with diphenhydramine, the antihistamine best studied for insomnia, indicate that when one increases it above 50 mg nightly no superiority in hypnotic effect is achieved, but there is an increase in anticholinergic side effects. It is also important to note that studies have indicated that diphenhydramine only has a significant effect on sleep latency and does not significantly improve other sleep parameters.

Date: Tue, 21 Nov 1995 12:36:15 -0500 (EST)
From: Bill Boyer <wboyer@emory.edu>
Subject: Refractory insomnia associated with depression

I truly don't mean to be cavalier, but I have the "evidence" of experience.

About antihistamines, I have prescribed doses of 150-200 mg for quite a few patients, a number of whom unequivocally got better hypnotic effects and no marked anticholinergic effects.

I have rarely had to use trazodone in such high doses for sleep, but I will consider it if (1) lower doses had at least some beneficial effect (e.g. person felt tired) and (2) lower doses were well tolerated.

I suspect this discussion stems from the fact that published literature almost always deals with a numerical average (i.e. outliers are under-represented) derived from "normal" patients (i.e. not the highly refractory few).

Date: Tue, 21 Nov 1995 23:34:09 -0500 (EST)
From: Donald Franklin Klein <dfk2@columbia.edu>
Subject: Refractory insomnia associated with depression

I have found hs divalproex (Depakote) up to 1500 mg very useful for this picture.

Date: Sat, 25 Nov 1995 21:52:37 -0500 (EST)
From: Donald Franklin Klein <dfk2@columbia.edu>
Subject: Refractory insomnia associated with depression

On Fri, 24 Nov 1995, Bill Boyer wrote:

Is that 1500 mg hs or in split doses?

Date: Wed, 22 Nov 1995 09:54:10 -0800
From: jimstev@netcom.com (Dr. Jim Stevenson)
Subject: Refractory insomnia associated with depression

Some of these pts have phase delayed circadian rhythm. Rx:

1. morning bright light
2. morning exercise
3. melatonin.

Date: Thu, 23 Nov 1995 13:24:33 -0800 (PST)
From: "J. Wynn" <jdwynn@u.washington.edu>
Subject: Refractory insomnia associated with depression

I am very wary about using diphenhydramine for sleep, especially in the elderly. About half the delirious inpatients I see (C-L) are in anticholinergic trouble.

Isn't the sedating effect of trazodone just an antihistamine effect? It is interesting to note that trazodone was originally developed as a sleeper and only incidentally found to be an effective antidepressant.

Date: Thu, 4 Apr 1996 00:44:42 -0500 (EST)
From: Donald Franklin Klein <dfk2@columbia.edu>
Subject: Divalproex for refractory insomnia

On Wed, 3 Apr 1996, William Wilson wrote:

When using divalproex (Depakote) for intractable insomnia, what dose do you use?

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