Psychopharmacology: Expert Tips for Insomnia

   

Psychopharmacology: Expert Tips for Insomnia

Insomnia is one of the most common symptoms patients report to their doctors. Up to fifty per cent of patients in a general medical practice complain of insomnia. Treating insomnia improves patient satisfaction, compliance, and medical care. Insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven’t found relief from their insomnia from previous treatment. 

Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person’s life including:  

- Decreased job performance

- Impaired focus and concentration

- More frequent car accidents

- Increased risk of suicide

- Worsening health condition

- Poor medication compliance  

Addressing and treating a person’s insomnia can make a great impact on an individual’s overall quality of life. A thorough assessment is essential in determining the potential underlying causes. 

Some of the most frequent causes of insomnia include:

- Depression, anxiety, and work stress

- Medical illnesses including reflux and asthma

- Restless leg syndrome

- Substance abuse including alcohol abuse

- Medication side effects e.g. antidepressants, stimulants, or steroids 

- Primary insomnia, insomnia without a known underlying cause

During an assessment of insomnia, it is critical to obtain a thorough medical and psychiatric history to discover potential underlying causes.  

Here are ten essential questions:

When did your sleeping problems start?

Have you had any changes at work or home?

Are you taking any new medications or supplements?

How late do you exercise?

Do you snore or kick your partner?

Have you struggled with insomnia in the past?

What treatments or solutions have your tried?

What medical problems do you have?

Do you have a history of depression, anxiety or ADHD?

Do you have a family history of insomnia, depression, or anxiety?

How much do you drink and how often? Do you use marijuana or any other drugs? How much caffeine do you get and how late in the day?

Many times, the underlying cause of the insomnia is discovered and treated; however, more often than not, a specific root cause of the insomnia is unclear. At this point, it is imperative to explore various treatment plans that include addressing any underlying medical or psychiatric causes of the insomnia, non-medication treatments such as evidenced-based cognitive behavioral therapy for insomnia (CBT-I), behavioral modifications, practicing good sleep hygiene, and the possible short-term use of medications. 

There are numerous treatments available for insomnia. Here are some of the major medical treatments for insomnia: 

Benzodiazepines

One of the most commonly prescribed medications for sleep include the benzodiazepines, e.g. Ativan, Klonopin, and Temazepam. These medications 

It is important for these medications to be monitored by the physician and therapist due to their abuse potential. In addition, these medications are typically recommended for only short term use due to the risk of dependence. However, in certain situations, a doctor or psychiatrist may determine a patient requires the medication for longer periods of time because the risk of the chronic insomnia outweighs the risk of dependence. In these situations, the dosing, monitoring and side effects should be closely monitored. 

Nonbenzodiazepines

The three main sleeping medications in the “nonbenzodiazepine” class include Ambien, Sonata, and Lunesta. When these medications were introduced to the market, many felt that they were different than the benzodiazepines and thus would not have the risk of dependence. However, they work in a similar fashion and can be habit forming. 

Ambien is an intermediate-acting sleeping medication. Its effect lasts for 6-8 hours, and it should be taken on an empty stomach. Many patients are not aware of this fact, and thus may report that the medication is ineffective. It is recommended to use for only two weeks, but often patients may require longer periods of use. 

Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake too early and need an additional 2-3 hours of sleep without a drug-induced hangover. This medication also should be taken on an empty stomach. 

Lunesta is another medication in this class. Many doctors find this medication to be less useful because of the high risk of side effects including a metallic taste that occurs in forty percent of patients. 

Antidepressants

Often, non-serotonin antidepressants have sedating properties. They are used “off-label” for insomnia, meaning they are being prescribed for reasons other than originally approved by the FDA. The doses for these medications when they are used for insomnia are typically lower than used for depression. 

One of these medications is Trazodone. There is a risk of hypotension and thus a risk of falls; thus, patients should be cautious of this side effect when they start the treatment. Also, in men, there is a risk of priapism, a prolonged erection, which must be discussed withs. 

Atypical Antipsychotics

Many atypical antipsychotics such as Zyprexa and Seroquel have sedating properties and can assist with sleep, especially if there is a co-occuring psychiatric disorder such as schizophrenia, bipolar disorder, or depression. There is significant concern about the side effects of these medications including diabetes, metabolic syndrome and other serious side effects. Thus, it is important for the doctor and patient to collaboratively discuss different treatment options, the risks and benefits in order to make an informed, collaborative decision. 

Melatonin Medications

Melatonin is a hormone that occurs naturally in the body, and signals the body to sleep. It peaks around four to six hours prior to sleep and is influenced by many factors, including exposure to light. 

Melatonin is an over-the-counter medication that has been shown to be helpful for jet lag and insomnia. Some studies have shown that smaller doses are more effective than larger doses. In addition, some psychiatrists recommended taking the medication when the natural melatonin level peaks in the early evening, rather than at bedtime. 

Rozerem is a prescription medication that increases the body’s melatonin and has been shown to help treat insomnia.

Other Sedating Medications

Clonidine, originally an anti-hypertensive medication, can be an effective off-label, treatment for insomnia. In Adult ADHD, it may address impulsivity and in PTSD it can help with nightmares.  

Neurontin is a seizure medication that can be sedating. In small doses, it is prescribed off-label for insomnia. Some sleep specialists feel that it helps with a syndrome called delayed sleep phase, a body clock disorder that makes it difficult to go to sleep prior to 2 or 3 am and challenging to wake for work or school. 

Conclusion

Insomnia is a very common symptom that presents in patients and can create significant impairment in functioning and quality of life. A comprehensive and thorough assessment along with careful consideration of effective and evidenced-based interventions, judicious, short term use of medication and non-medication treatments can help people have a better quality of life and to improve their general psychological and medical well-being.

If you have any questions about insomnia, please feel free to contact me at 212-631-8010 or scott@scottshapiromd.com. 

In the next quarterly Psychopharmacology Newsletter, I will be discussing updates on antidepressants. 

Bibliography

Weich S, Pearce HL, Croft P, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ 2014

Schatzberg, Alan, et al. Manual of Clinical Psychopharmacology. 7th ed. American Psychiatric Association. Arlington, Virginia. 2010.

Disclaimer: The author of the material has consulted sources believed to be reliable in his efforts to provide information that is in accord with the standards accepted at the time of posting. However, in view of the possibility of error by the author contained in this newsletter, the author does not guarantee that the information contained is in every respect accurate or complete, and the author is not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers reading articles posted in this newsletter and/or website should review the information carefully with their professional healthcare provider. The information is not intended to replace medical advice offered by the physicians. 

About Scott Shapiro, MD
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Scott Shapiro, MD is a psychiatrist in private practice who sees patients struggling with depression, anxiety, bipolar disorder and attention deficit and hyperactivity disorder (ADHD). He uses evidenced based treatments including psychopharmacology, cognitive behavioral therapy (CBT), and schema therapy.

Are We Afraid of Adderall?

Introduction

I sometimes wonder if the treatment of ADD/ADHD didn’t involve stimulants if there would there be such a fear of diagnosing Adult ADD/ADHD. Effective screening and treatment for Adult ADD/ADHD is essential to provide the highest level of care to your clients.

Many people question whether or not Adult ADHD exists as a legitimate diagnosis. Indeed, many claim that ADD is over diagnosed and that stimulants are overprescribed. Psychiatrists are afraid of becoming one of these doctors who “overprescribe”. Despite the fact that stimulants are the standard of treatment for Adult ADD, whether or not someone has ADD should not hinge on the treatment, but instead on the proper assessment and diagnosis.

Are some people misdiagnosed as having ADD but in fact have another condition? Sure. And many people, notoriously college students, use stimulants to improve their performance or energy.

However, more often than not, Adult ADD is under-diagnosed and under-treated. Adult ADD affects at least 5% of the population and it is estimated that nearly 75% of Adults with ADD never receive an accurate diagnosis or effective treatment. An estimated 3 percent to 5 percent of U.S. adults have ADHD, but only 15 percent are aware they have the disorder, according to Rafael Klorman, a professor of psychology and director of clinical training at the University of Rochester in New York and one of the briefing’s speakers. (Steven Reinberg, Healthday, Internet, Sept 9)

Dr. David L. Katz, the director of the Prevention Research Center at Yale University’s Schools of Public Health and Medicine, said, “Available data indicate we are concomitantly under-diagnosing and over-diagnosing ADHD, under- and over-treating it.”

Costs of Missing the Diagnosis

ADD causes significant lifelong impairment in those it affects. Left untreated, it affects financial status, educational achievements, relationships and even health.

“Overall, people with ADHD have less annual income,” Biederman said. “This was true for males and females. Those with ADHD had income approximately $10,791 lower per year among high school graduates, and about $4,334 lower for college graduates than their counterparts without ADHD.”

The estimated yearly income loss for adults with ADHD in the United States is $77 billion, Biederman said. The numbers for drug abuse are $58 billion, for alcohol abuse $85 billion, and depression $43 billion, he said. “You can see that ADHD is one of the costliest medical conditions we have,” he said.

I have seen hundreds of patients over the years who have suffered for decades with ADHD. Some of them have may have suspected that something wasn’t quite right or that school and life was more difficult for them than their peers. When they start to learn more about ADHD, realize that their challenges are due to ADHD and discover that there are effective treatments, they are often left wondering why their teachers, parents, and previous therapists or psychiatrists didn’t pick up on the ADHD.

For example, the other day, I saw a 26 year-old* who had been referred by his law school advisor for anxiety and depression. This client never suspected that he had ADHD. He had performed well in high school and college and had even been accepted into a leading law school. However, it wasn’t done without a huge price to pay. He was extremely anxious and fearful of failing. Hence, he would spend an inordinate number of hours studying, worrying and preparing. Other therapists and psychiatrists had diagnosed him with depression, OCD, or generalized anxiety disorder and attempting to treat his symptoms with antidepressants and benzodiazepines. These medications would make him feel depressed, lethargic, and foggy.

As I explored his history, he told me that he was always well behaved as a child but would often daydream in class. He had difficulty socializing with his peers and felt like “the other kids were playing by rules that he was never taught”. People often call him space cadet, and his parents had him tested several times for his hearing because he seemed not to listen. He was always losing his school supplies and had a messy desk and room. He did not do well in elementary school and his parents often yelled at him about his poor grades and not doing his homework. They hired tutors for him and set a very rigorous and regimented schedule of studying that continued throughout junior high and high school. He started earning good grades and was proud of his performance, but he still couldn’t understand why it seemed to take him 2-3 times more time to do his work than it took his peers.
He often had difficulty going to sleep at a regular hour and waking on time was nearly impossible. He was chronically a few minutes late to school, which almost lead to his dismissal.
Since he was very forgetful, he took copious notes in class and would keep lists of all of his “to do” items. Since he kept so many to-do lists and reviewed information on a regular basis to “keep from forgetting”, one psychiatrist had diagnosed and treated him with OCD.

When he went off to college and struggled a without the rigid structure that his parents and school had imposed on him, he enlisted tutors to help him with his classes and went to the writing center for assistance. He didn’t have much time to participate in collegiate social life because he was constantly studying. Yet his grades were mediocre and he suffered from bouts of anxiety and depression.
He said that he always had difficulty organizing and with time management. He was chronically late to all of his classes and appointments saying “he just didn’t have a good sense of time”.

My client was determined to go to law school and had difficulty with application process and keeping up with all of the details. He did get accepted to a lower-ranked law school and decided to go. With the new demands of law school, his previous coping strategies were starting to fail. He was getting further behind when he was finally referred to me for an assessment.

As it turned out, he did not have depression, anxiety or OCD, but he had ADHD. Interestingly, he had a cousin, a brother, and an aunt who all had been diagnosed with ADHD and were on treatment. They all had had the hyperactive type of ADHD and also had alcohol abuse problems. His parents were shocked that their son had ADHD because he always seemed to be so well behaved and fastidious about his schoolwork.

In addition he related to me how he walked around in a fog most of the day and felt that he had cobwebs in his brain, the way that someone might when they first wake up in the morning or when they have the flu. However, this was how he had felt his entire life and assumed this was how other people also felt. He didn’t realize that some people are able to focus, concentrate and stay on task without the need to rely on an excessive amount of effort and anxiety.

I started him on Adderall. All of a sudden, a light bulb went off, the cobwebs cleared, and he saw the world the way that most people do. In addition, his anxiety greatly diminished and finally had the hope to pursue his passions and life goals. Did he continue to keep copious notes, make lists and experience some anxiety? Did he still have trouble with forgetfulness and organization? Absolutely. Medications are not a total cure. However, as he continued to use the coping strategies that had painfully served him throughout his life, he also worked with an ADHD coach to help prioritize, learn additional strategies, and develop realistic expectations. In addition, he worked with a therapist who addressed with him other sources of his anxiety and developed realistic goals and expectations, taking into account his strengths and weaknesses.

How do you diagnose Adult ADD/ADHD?

Adult ADD/ADHD is a clinical diagnosis made by a therapist, neuropsychologist, psychiatrist, or other health care provider. It is important that whoever makes the diagnosis has experience with Adult ADD/ADHD. Many clinicians were taught that if someone presents with depression and ADHD, first treat the depression THEN treat the ADHD. Very often, the patient relates feeling depressed and frustrated; often this is because he has experienced one failure after another or jumped from one job to the next. In our experience at The Hallowell Center, when you treat the ADHD, the client or patient develops the ability to achieve his or her goals, improve relationships, meet deadlines, remember to pick up the children, avoid accidents on the road, remember the passport before driving to the airport and generally feel more competent, confident and happy.

Unfortunately, when patients are treated for depression with antidepressants, or worse, treated with atypical antipsychotics for bipolar disorder and kept on these medications for months or years, their symptoms often do not improve and indeed may worsen. I have never actually seen this data in the professional literature, but during my training at Massachusetts General Hospital, I was taught a VERY important lesson. Never, never, never take away a patient’s dopamine. Dopamine gives us zest for life, motivation, and enables us to pay attention. It is the piece of the puzzle people with ADHD may be missing that inhibits and often blocks them from their full potential. Antidepressants and antipsychotics, through a feedback loop, can decrease the function of dopamine in the frontal lobes and limbic system, exacerbating ADD symptoms.

In some instances, neuropsychiatric testing can be useful, especially when there is a suspicion of a learning disorder, such as dyslexia. However, testing is not always indicated nor is it always accurate. It is generally time consuming, very costly, and may miss the diagnosis. Testing may show that a person’s executive functioning, focus and distractibility are normal, but testing is performed over a short period of time. A key feature of adult ADD is that the symptoms are consistently inconsistent! The challenge that ADD presents is lack of sustained attention, focus and executive skills both throughout the day and over prolonged periods of time. Thus, one may function fairly well during neuropsychiatric testing over a brief period of time and with prompting from the tester, but may not be able to do this for extended periods of time. Neuropsychiatric testing is useful in complex cases or where the diagnosis is equivocal. However, it is important to recognize that someone may have clinical ADD even though testing was negative, much in the same way that someone may clinically have seizure disorder, despite a negative EEG.

How to Help Our Clients with Adult ADD/ADHD-Five Key Tips

1. Screen All Clients

So, how can we help our clients who have Adult ADD/ADHD? First, it is important to understand the impact that ADD/ADHD has on someone’s life and that it is frequently misdiagnosed or under-diagnosed. It is important to understand that ADD/ADHD does exist and that the stigma of ADD/ADHD and the anxiety about using stimulants keeps people from getting diagnosed and treated.
It is important to screen all clients for Adult ADD/ADHD by using a simple five minute screening tool in the office or waiting room.
Here is a site that can be utilized as a screening tool:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many of our clients also feel that Adult ADD/ADHD is not a “real diagnosis” and thus don’t get evaluated or treated. However, by explaining to the patients that SPECT and PET scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a real issue.

2. Refer For An Assessment and Treatment

With a client where there is a high suspicion of Adult ADD/ADHD, refer to a psychiatrist or psychologist who specializes in ADD/ADHD for assessment and treatment. Medications are a cornerstone of treatment and can be life changing for many patients who have been suffering for decades with an inaccurate diagnosis and without effective treatments.

3. Cognitive Behavioral Therapy

Another cornerstone of treatment is developing specific strategies to address the specific challenges with the individual case. “Cognitive behaviour therapy has been successfully applied to this client group even with minimal contact (Stevenson et al., 2002; Wilens et al., 1999). “Individuals with ADHD require structure in terms of personal organization, social boundaries, and practical help to cope with everyday problems” (Susan Young, 2007, pp 50)

By using CBT in session with your client, you can help them address their most important challenges. Often, these challenges include difficulties with time management, prioritizing, strategizing, planning, mood regulation, social skills, organization, focus and motivation.
It is very helpful to encourage your clients to purchase a weekly calendar and to use it on a regular basis instead of relying on post-it notes or on smart phone. Many ADHD patients do better when they see things visually.

Another behavioral intervention for your clients is to teach them to develop a to-do list with a way to prioritize each item. Then, have them place the items on a specific time on the calendar. More structure can facilitate better outcomes.

If you do not specialize in CBT or the client is having significant career challenges, hiring a coach to help the client overcome these specific challenges, develop strategies and increase accountability can help to increase success in work and personal life. Coaching can be an essential piece of treatment but it can be difficult to find an effective coach. Ideally, the coach should have extensive experience with working with clients who have Adult ADD/ADHD.

4. Address the Shame and Instill Hope

Growing up with diagnosed or undiagnosed ADD/ADHD can create significant shame for your client. There is often significant shortfall in academics, career history and relationships as well as frequent criticism or ridicule from parents, teachers, and peers.

Help the ADHD client to see that they have many strengths and that ADHD is just one aspect of who they are. In addition, they have compensated for it most of their lives. Validate that it may have been a difficult struggle and that their lives can improve significantly.

5. Minimize the Potential Fallout from ADD/ADHD

Even when a client understands some of the challenges that ADD/ADHD has created, it is often not clear how it has impacted other areas of their life. Help the client understand that many of their behaviors such as underperforming at work, engaging in high risk sexual activity, or facing struggles in their personal relationships are very common in patients with ADHD. Reassure them that this can improve over time with treatment, medications, behavioral treatments, or a combination.

Conclusion

ADD/ADHD is a serious disorder that affects all aspects of a client’s life. Many of your current or future clients may not have received an accurate diagnosis or treatment for ADD/ADHD. Understanding that ADD/ADHD does not necessarily equal Adderall is imperative. Overcoming the stigma that implies ADD/ADHD is not a “real diagnosis” and understanding the significant impact that it has on a client’s life and course of their therapy can make a substantial difference to your client. In addition, screening for Adult ADD/ADHD in each of your clients, referring them for assessment and treatment, and utilizing cognitive behavioral therapy can make a significant impact on their lives.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.
References:
Reinberg, Steven. Adult ADHD Costs Billions in Lost Income. HealthDay Reporter at HealingWell.Com. 2004. Retrieved from http://www.news.healingwell.com/indesx.php?p=news1&id=521145
Young, Susan et al.: ADHD in Adults; A Psychological Guide to Practice. John Wiley and Sons, Ltd. 2007
Wilens,T.E. Cognitive therapy in the treatment of adults with ADHD: a systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: an International Quarterly, 13, 215-226.

7 TIPS TO IMPROVE PRODUCTIVITY

Being more productive doesn't necessarily mean working longer hours or working faster. To me, it means working more efficiently and effectively. Below are 7 tips that I teach my patients to help them be more productive.

1. Create Your Schedule The Night Before

Many people start their work day spending a lot of time trying to figure out where to start, surfing the Internet, or chatting with colleagues. A great way to start your day with a bang is to write out a schedule the night before. This is not your calendar, but may include some of those items. Focus on your top priorities and anticipate any obstacles.

2. Under-promise and Over-Deliver 

Many of us are overly optimistic about what we can accomplish in a day. Thus, we promise our managers, families, and ourselves that we will get "just one more thing" done. This can create constant pressure and take the "wind out of our sails" when we don't deliver. I recommend that people promise or commit less and then as they are working, to over-deliver. This allows for more success and improved productivity.

3. Cluster Tasks

Answering phone calls, checking emails, and surfing the Internet are huge time sinks in our days. Thus, cluster certain tasks to specific times of day. For example, you might decide to check your emails only once in the morning and once in the afternoon. This allows your to focus on your key priorities without constant interruptions.

4. Reward Yourself

Research shows that rewarding yourself improves productivity and consistency. No matter how small the task is, say to yourself "Good Job" after you have started a business proposal, returned a phone call, or completed filing a pile. When it is a larger project or goal, you might reward yourself with a walk around the park, going out to lunch with a friend to a special restaurant, or going for a massage. It is more important to acknowledge your "wins" than the actual reward.

5. Write Out the Steps

There are many tasks or projects we avoid because they seem daunting or confusing. An effective way to overcome this is to take out a sheet of paper and start writing out the steps. The exact order doesn't matter. If you don't know how to do a particular step, write out "find out how to....". You might also work with a colleague or friend to discuss what the steps are. REMEMBER: Write it out. Don't just discuss the great ideas. Then, decide what the first steps are. After you have some momentum, you can organize the steps and add any additional items.

6. Create Goals

Create goals for different time periods including the year, quarter, and month. The most effective goals are specific and have a deadline. Also, by writing them in the present tense, it sends the message to yourself that you are going to complete it. For example, "I am reaching my sales goal of $500,000 by December 31st."

7. Develop Protocols

For tasks or projects that are repeated, develop a protocol. If there are ten steps for a specific task, write out a protocol that includes each of these steps. This improves the motivation to do a certain task and also ensures that nothing slips through the cracks. It also allows the task to be accomplished more quickly.