Insomnia meds for psych patients?

stephva1008 · May 27, 2009

working with kids, we have a "pathway" of sorts that we use. First, Benadryl. if not effective, Trazodone. If still not effective (after having increased dosage of Trazodone), then Seroquel. We will skip Benadryl and Trazodone if pt needs more mood stability or decrease in aggression and go straight for the Seroquel.

Noticing more psych kids coming in on Melatonin. We usually keep them on that unless it's not working.

SweetLemon · May 28, 2009

I am a firm believer in Benadryl.... and when my patients feel they NEED something a little stronger sometimes I even give them a Diphenhydramine... :rotfl: We also have Temazepam available to most of our patients to help with AAI but I try to start with benadryl just because getting them hooked on temazepam will only make their transition out of the hospital a little harder as we never write prescriptions for these once we send them home. With that said if a patient is really having trouble sleeping and needs the extra support I have no problem giving them a benzo (that has been prescribed) nothing is going to make you become psychotic faster then going days and days without sleep!

Another one I am seeing more and more of is Trazadone at HS, seems to be a little more subtle then the benzos as far as knocking a patient out but I am finding out it is also a lot more hit and miss for who it will actually work for.

Orca, ADN, ASN, RN · May 28, 2009

I worked with one psychiatrist who was in love with chloral hydrate for sleep. Others used Restoril.

George_MSN · Jun 2, 2009

Fairly recent news stories about Ambien use in England: Many front desk workers at hotels were instructed to keep towels on hand because of the high rate of nude sleepwalkers in the lobby (British men apparently have the tendency to sleep in the nude).

Ambien sleeping pills linked to bizarre sleep walking behavior , including unconscious driving of vehicles and wild hallucinations. :yawn:

New York Times article, "Some Sleeping Pill Users Range Far Beyond Bed," reporter Stephanie Saul tells the story of a registered nurse who took Ambien before going to sleep one night in January 2003. Sometime after falling asleep, she went out into the Denver winter night wearing only a thin nightshirt, even though the temperature was only 20 degrees. She got into her car, caused an accident, urinated in the middle of the intersection and then got into a violent altercation with the police officers who came to arrest her. In the matter of one night and one sleeping pill, her traffic record went from exemplary to tarnished with a reduced charge of careless driving. Interestingly enough, she says she remembers nothing of what happened during that Ambien-influenced night.

Also, there have been other instances of DUI for "sleep driving" while on Ambien. As if sleep-walking wasn't bad enough.... :eek:

http://www.naturalnews.com/019413.html

aloevera · Jun 2, 2009

Ambien can have a side effect of vivid dreams and sleepwalking. A drug rep who worked for the company that makes Ambien said they have heard of a lady who woke up with open cans of cat food in her bed, and a man who painted his wife's toenails. Personally, I know of a lady who got out of bed and tried to eat a quarter (her husband stopped her).

How can that drug rep sleep at night knowing he is pushing Ambien?????

Guess he is on it, too.........

These posts are so frightening !!!!!!! 1/2 the nurses I work with take Ambien due to the fact "they can't sleep the night before coming to work"...............OH, MY...............!!!!

aloevera · Jun 2, 2009

SWEETLEMON.............I LIKE BENODRYL ALSO...............PLEASE DON'T GIVE ME A POST RE: crazy side effects of that, too !!!!!!

We use Benodryl, trazodone and more commonly....Seroquel... Seems everyone is on Seroquel these days.................

jjohnnym65 · Jun 4, 2009

As an RRT, RPSGT (Registered Polysomnographic Technologist) and psych patient (depression) I think I can weigh in/rant on this issue.

I have been in an "intensive" and only slightly bearable outpatient therapy program for 2 months following 5 days of inpatient tx for suicidal ideation hours after losing my job. This was the first time I've been fired from anything and came two weeks after I had liberated myself from a financially and emotionally abusive girlfriend (BPD pt) of 2.5 years. Needless to say my coping skills were suboptimal. During my standard intake interview with the outpatient nurse practitioner I made the mistake of being honest about some collegiate chemical experimentation. I also admitted to drinking 4 beers (gasp!) while watching a NASCAR race with my old man--I tip the scales at almost 300 so if I wanted to get drunk 4 beers would be an appetizer. It had been 14 months since I had last been intoxicated at a friend's bachelor party.

I've been a night shift worker since college and have always had difficulty with sleep and have made my provider aware of this. I was on trazodone initially at 100 then 200 mg. It was ok for the first two weeks. Then I self-medicated with 300mg and was able to sleep after that lovely vertigo feeling resolved. I got sick of this vertigo feeling and told the advanced practice nurse it wasn't cutting it. After two weeks of this crap I finally got through to her and she switched me to Rozerem which worked initially but flamed out after a week. I asked for some samples of Ambien CR or Sonata and got the following reply: "Oh, we have to be careful with controlled drugs in people with a history of substance use." It took everything I had to keep myself from exploding considering what little respect I had for her as a clinician was now evaporated. My "substance use" was not relevant; it was not why I was seeking tx. I have never been to rehab or detox and have no criminal record of any sort let alone drug related. The only reason she knew anything was because I was honest with her. My reward? A label as a junkie.

Rozerem works on the melatonin system (I will give her credit for at least knowing that) and is highly specific to 2 of the 3 melatonin receptors (MT1 and MT2). Melatonin is a hormone released by the pineal gland in the brain and is responsible for our sleep/wake cycle or circadian rhythm. The release of melatonin is highly dependent on light as there are paracrine melatonin receptors on the retina of the eye. Even low levels of light (mainly in the blue light spectrum) are capable of inhibiting melatonin production. Chronic exposure to light throughout the 24 hour cycle can result in disruption that can be tough to reverse. Here is the link to the Rozerem website: http://www.rozerem.com Click on prescribing information and read the section under controlled clinical trials. The efficacy of the drug was evaluated using polysomnography in a sleep lab. Now, there's nothing wrong with that inherently; however, sleep labs (at least accredited ones) are built to be the ideal environment for promoting sleep; the walls are well insulated to seal outside noise and the room is pitch black with the lights out. Now I've worked nights for 6 years and my bedroom is not exactly optimal for sleep. Do ya think my melatonin release system may be a bit screwed up? My blinds do not shut out any light at all and my lease prohibits replacing them. In other words I'm likely producing very little melatonin at all when I need to be. Now giving me a drug that stimulates the melatonin receptors isn't a bad idea if I worked a normal schedule and was able to sleep in total darkness, but with the lifestyle I have to lead it's like kicking a horse with a broken leg to get it to run faster. Oh yeah and Rozerem costs 135.00 for 30 doses at Walgreen's. https://www.changehealthcare.com/rx_brands/13020

Enter my family doc, my savior. He has prescribed both ambien and valium for me in the past in reasonable amounts with 1 or no refills. I don't bang down his door begging for dosage increases or refills. He trusts me and I refuse to betray his trust by taking advantage of his generosity. However he has understandably stated that since I am now seeing a psych provider on a regular basis he doesn't feel comfortable treating problems that they are supposedly more "qualified" to address. Oh yeah and the cost of 30 5mg tabs of valium? 22 bucks.

Mr Ian · Jun 7, 2009

jjohnny - informative post; thx

As for the general debate:

I've long had a problem with the sledgehammer approach to sleep issues. My local medics (non-psych rural hospital) have a standard practice to prescribe Temazepam to everyone with a sleep problem - doesn't matter what the problem is; onset insomnia, early wakening, broken sleep... Temazepam 10-20mg PRN.

What would be better is to have an increasing pathway like childpsych said - and a thought about what jjohnny said on environment - rather than just giving a major tranq/hypnotic.

And I'd start with warm milk and cookies.

Whispera, MSN, RN · Jun 7, 2009

...also, if you have a turkey sandwich before bed...turkey has tryptophan in it. Tryptophan converts to melatonin and melatonin makes you sleepy.....

EarthChild1130 · Jun 7, 2009

Which of these meds have you seen work best for agitated patients who don't sleep for more than a couple of hours at a time AFTER being given insomnia meds?

When I worked inpatient we had big success with Seroquel and Benadryl. We didn't use a lot of Ambien when I was working on the unit.

In answer to another poster, we are having equal outpatient success with Lunesta and Ambien. We're having fair success with Rozerem.

We do quite a bit of education on non-pharmacologic relief for insomnia. We pretty much cured one lady's insomnia when we suggested she remove her TV from her bedroom.

aloevera · Jun 7, 2009

MrIan......No cookies, too much sugar...would get the kids rockin n rollin.....

maybe warm milk and an apple ????