Bipolar Medication Spotlight: Sleep Aids

By Candida Fink MD
November 6, 2009

With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. This week, we focus the spotlight on medications that can help you sleep.

Before we crack open the medicine cabinet, I’d like to say a few words about bipolar disorder and sleep. Sleep is a biggie. Too much could trigger or be symptomatic of depression. Too little could trigger or be symptomatic of a manic episode. At least one study shows that changes in sleep patterns can be an early predictor of a manic episode. Sleep plays a major role in mood disorders and recovery, so if you’re having trouble sleeping, you and your doctor need to do something about it.

That something could consist of many strategies, ranging from very simple (such as going to bed the same time every night) to more involved – medication, avoiding caffeine and other stimulants, maintaining a strict sleep schedule, and convincing other family members to stop banging around in the kitchen till two in the morning. In stubborn cases, you may benefit from a sleep study to identify factors that may be contributing to the sleep disturbances.

Assuming your doctor and you decide that sleep medication is necessary, your doctor may prescribe one or both of the following:

A mood stabilizer, atypical antipsychotic, anxiolytic (anti-anxiety agent), or other medication that’s not primarily used for sleep but will hopefully help your sleep if it treats underlying mood or anxiety symptoms. Occasionally these medications are used just for the sedating side effects for sleep, but this is not so common.
A bona-fide sleeping pill (sedative), which brings us to the main point of this post.

A little-known fact is that the active ingredient in many over-the-counter sleeping pills is diphenhydramine – the generic form of Benadryl!

Prescription Sedatives

Several effective sleeping pills are available, which vary in terms of safety, side effects, and other considerations. The following list provides a quick rundown of some of the more common prescription sleep medications currently in use:

Ambien (zolpidem): Ambien is available in two forms – Ambien (and its generic), which help you fall asleep, and Ambien CR (no generic), approved to help you fall asleep fast and stay asleep. Ambien may not be safe for those who have a history of depression, liver or kidney disease, or respiratory conditions. Ambien may lose its effectiveness if taken longer than two weeks, while Ambien CR can be taken for a longer period of time. Ambien can trigger unusual side effects such as sleep walking, sleep eating, and even sleep driving. Ambien should not be mixed with alcohol – the combination increases the risk of these types of side effects. For more about Ambien CR, visit http://www.ambiencr.com/.
Lunesta (eszopiclone): Lunesta is approved to help you get to sleep and stay asleep, so you wake up feeling rested. It has a low-risk for developing a dependency, so you can use it short- or long-term, and rebound insomnia (increasing severity of insomnia after stopping the medication) is rare. Lunesta may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; liver disease; or are pregnant, planning to become pregnant, or breast feeding. Lunesta should not be combined with alcohol. For additional information, visit http://www.lunesta.com/.
Sonata (zaleplon): Sonata is approved to help you get to sleep. Its particular niche is that it is short acting, so is less likely to produce a hangover effect in the morning. It is so short acting that you can take it a second time if you awaken in the middle of night. Sonata can be habit forming and may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; severe liver impairment; or are pregnant, planning to become pregnant, or breast feeding. Sonata should not be combined with alcohol.
Rozerem (ramelteon): Rozerem works differently from other sleep medications and is designed to work in conjunction with your body’s internal clock. It’s non-habit-forming, won’t make you feel groggy the next day, and is safe to use with many prescribed medications. (It’s not a controlled substance like most other prescription sleep medications.) Although Rozerem is generally considered safer and gentler than other prescription sleep medications, it may not be safe for those who have a history of kidney or respiratory problems, sleep apnea, or depression, or are pregnant or breast feeding. It may interact with alcohol, and high-fat meals may slow absorption of the drug. For more about Rozerem, visit http://www.rozerem.com.

Some older sleep aids include Restoril (temazepam), Halcion (triazolam), and ProSom or Eurodin (estazolam). These are not used frequently anymore – and have a history of being addicting and causing a number of side effects. Halcion has been withdrawn form the market in several countries. If your doctor recommends one of these medications, question the reasoning for using an older drug.

Atypical Sleep Aids

Some medications that are not bona fide sedatives are often used for this purpose. Following are a few of the more common and effective medications in this group:

Trazodone: This is an old fashioned antidepressant, rarely used for depression anymore, but, because it is so sedating, has become popular as a non-habit-forming sleep aid. Its use is limited to women for the most part though, because of a risk in priapism for men – an erection that will not go away. This seems like it might be fun but it is actually a medical emergency.
Remeron: Another antidepressant used for sleep because it is so sedating, Remeron is pretty effective, but causes weight gain.
Clonidine: This medication was primarily used for high blood pressure, but is quite sedating, is often used in children with ADHD, and is a good sleep aid that’s not habit forming. It can sometimes cause a drop in blood pressure or rebound high blood pressure. In high doses, it can cause liver problems.

What about melatonin?

Melatonin is a natural hormone, released by the brain when it gets dark. It is available over the counter. It is an effective sleep aid and is well studied even in children. The safety profile is quite good. Doses range from 1-5 mg per night, and it comes in pills and spray forms.

Common Possible Side Effects

All medications have side effects. Prior to taking any prescription or over-the-counter sleep aid, consult your doctor let her know all the medications you are currently taking, including over-the-counter medications and “all natural” or herbal remedies. In addition, be aware that any sleep aid can cause drowsiness, so avoid driving or operating machinery while taking these medications, especially when you first start taking them and are unsure of the effect they may have on you. Additional side effects may include the following:

Dizziness
Allergic reaction, possibly severe
Facial swelling
Headache
Prolonged drowsiness (especially the sleep aids designed to help you stay asleep)
Sleep behaviors, such as sleep-driving and sleep-eating or a combination of the two, like if you sleep drive to McDonald’s

Sleep Aids in My Practice

I recommend or provide sleep aids frequently, because sleep problems are so commonly associated with mood disorders and other psychiatric conditions. I encourage people to practice good “sleep hygiene” as a primary intervention:

Regular bed time and wake up times
No stimulants after 12 noon
No vigorous exercise in the evening
Turn off screens and phones and work one hour before bedtime
Try to keep the bed for only sleeping and sex – no work or other activities
No TV in the bedroom… it’s bad for sleep

If we do need to use a sleep aid, I will often start with melatonin before proceeding to prescription interventions. We try hard to use medications for brief periods of time. Getting enough sleep is important in recovery from mood disorders, so treating aggressively is important.

If you have bipolar and accompanying sleep-related issues, please share your experiences and insights and any helpful suggestions. This goes for you doctors and therapists out there, too!

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Links to This Article

Stress Depression Link | My Blog (November 8, 2009)

Bipolar Disorder Sleep Medication | Depression Sleep Medication … « Problem Sleeping (November 9, 2009)

Medical Consultation In Bangkok (November 9, 2009)

5 Comments to
“Bipolar Medication Spotlight: Sleep Aids”

Becky at 7:45 pm on November 6th, 2009

I have bipolar with sleep issues. I have been seesawing back and forth between Ambien CR and Lunesta, mostly due to which one insurance will cover on any given year. For example, I just had to switch from Lunesta to Ambien CR last month.
I don’t really notice a difference. Usually, they help, but if I’m too revved, I still have trouble. Too much stimulation can be due to a late movie or dinner, or anxiety producing situations during the day or evening. So this stuff is not fool-proof. I have had trouble sleeping for many years even before I was diagnosed.
On rare occasions (thankfully) I have been up all night despite being on 3 psych. meds, one of which is very sedative. I do wish that science could unravel this serious problem . Why do people like me have insomnia and others don’t.? I can’t even nap anymore.

lisa at 12:16 am on November 8th, 2009

this is such a big deal for me i cannot tell you how happy i was to find it. why? it’s just so overlooked i think. people do not realize how horrible it is when you don’t sleep well. it’s beyond just a bad night here and there. i can count on one hand the times i’ve enjoyed REAL sleep in the past 3 years. i am so used to it i joke that i won’t know what to do if i ever wake up feeling rested! I’ve tried most meds you mentioned. nothing works! nothing! OTC stuff is total crapola. i tried trazodone but it does NOT sedate at all so i’m sick of people saying it’s just oh so sedative. HOGWASH! for me it didn’t help at all. i got laidoff 7-31. i still have no job. i have no insurance so ihave to go to a clinic where the psych doc tries but just keeps trying stuff on me which makes me feel like a guinea pig. then she wonders why i am so tired and angry and manic. DUH! i have tried Rozeram too but the only good thing about it is the cute TV commercials with the man and the talking Abe Lincoln and talking chipmunk thing. nothing’s hurt me but it doesn’t help either. i am DESPERATE for help with a sleep study. i’m willing to be a case study if needed but someone has GOT to help me get into a sleep study program. i am a lost cause at this point. and it’s horrible not being able to sleep well. also, to make it worse, we battled bedbugs for over a year so we have been sleeping on airbeds for a year. not good either for sleep quality. so anyone feel my pain? i am not a bad person. i am usually very energetic and happy but really, this lack of good sleep is getting chronic to say the least. something has to give. i now feel cynical when i read any warning on a bottle that “this product may cause drowsiness” i wanna scream OH YEAH? I DARE YA!

Waco at 11:33 am on November 8th, 2009

I had insomnia off and on my entire life, prior to starting on medications with a sedative side-effect about 10 years ago. I don’t recall thinking of the insomnia as such a terrible thing (except for the nights I couldn’t get my brain to slow down), but it certainly contributed to pushing me in to mania and depression.

I tried Ambien, Lunesta, Sonata, Klonopin, and Trazadone, over the years. I developed a nasty dependency on Ambien and abused as my tolerance levels increased (this was prior to accepting treatment for bipolar disorder). The only thing that’s worked well for me has been Seroquel, which I’ve taken for about 8 years, now. I don’t seem to build up any tolerance to it, and it reliably knocks me out every night.

The flip side of this is that I haven’t been able to sleep without it since I started taking it.

I’m surprised you didn’t include Seroquel in your article. In low dosages, it has begun to be commonly prescribed as a sleep aid, even for people without a diagnosed mental illness. It’s been a Godsend for me.

Waco

Joe at 12:59 pm on November 8th, 2009

Hi, Waco–

As Dr. Fink mentions near the beginning of her post, atypical antipsychotics and anxiolytics are sometimes used to help with sleep issues related to mood disorders, but this post focuses on meds designed specifically to act as sedatives.

You’re right about Seroquel (an atypical antipsychotic). A Dr. I met in Slovenia told me she often prescribes Klonipin (an anxiolytic) to help with sleep issues, because she finds that it’s not prone to be abused. According to her, at high doses, Klonopin causes the tongue to swell, which isn’t a very pleasant side effect.

Kazz at 9:37 am on November 10th, 2009

Im starting to get a little desperate I can be dead tired but unable to sleep and if I do sleep its a broken nights sleep where I wake up several times per night - I take 400mg SR Seroquel, 2 Alodorm (sleeping tablet) and if that doesnt work I add 2 Valium and still I wake through the night when I finally get to sleep - I then wake in the morning feeling hung over and I might be able to sleep an hour or so during the day but thats it I have bipolar and the Seroquel seems to be helping all the mania etc but not the sleep side of things my psych recently told me to take 800mg of Seroquel for a few days to try to set off a sleeping pattern but it didnt work - well its 1.35am I took 400mg Seroquel and 2 Alodorm at 9pm Im about to take a couple of Valium as I am tired but cant fall to sleep - Im wondering where I go to from here??