Many Children in Mental Health Treatment Medicated for Insomnia

Parents and their children are both increasingly turning to the medicine cabinet to meet their sleep needs. One specific population of school-aged kids and adolescents seems to be the most medicated for sleep. Nearly a third of children in therapy for psychiatric or behavioral disorders are treated for insomnia using prescription and over-the-counter medications, a new study suggests.

Nearly all of the 1,300 participating members of the American Academy of Child and Adolescent Psychiatry said they prescribed at least one sleep medication per month. About 88 percent said they recommended over-the-counter treatments for insomnia.

Recommended medications included antihistamines and the antidepressant trazadone, which is often prescribed off-label for insomnia. Clinicians surveyed in the study also prescribed drugs with psychiatric or behavioral effects such as antipsychotics and anticonvulsants for insomnia.

The principal author of the study notes that most often the sleep medications are used to manage the effects of sleep disruption on daytime functioning. The average participating psychiatrist reported seeing about 70 children per month. Older children were more frequently treated for insomnia.

While most insomnia patients were older than six years old, clinical psychiatrists reported more than 20 percent of preschool-aged patients were affected by insomnia.

The complete study will be published in the August 1st issue of Sleep Medicine.

“Ambien Zombies”, sleepwalking fears and facts

Last night, Fox News Boston aired the special report “Is Ambien creating a nation of zombies?” The segment called attention to dangerous or even deadly sleepwalking episodes linked to the prescription sleep drug Ambien.



While these incidents are a reminder that side effects can occur, millions of people regularly take Ambien and other prescription hypnotics without experiencing any problems.

You can minimize the risk if you take Ambien exactly as prescribed by your doctor, moments before bedtime. Never increase dosage or begin taking additional medications without consulting your doctor. And don’t use alcohol before or after taking Ambien. Allow for a full nights sleep when you take the drug.

The FDA warns in its Medication Guide for Ambien, “You may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night.”

The AASM recognizes Ambien as a safe short-term treatment for insomnia. For severe or chronic cases we recommend seeing a board-certified sleep specialist for further treatment options, such as cognitive behavioral therapy. To find a sleep specialist contact an AASM-accredited sleep center near you.

Find out more about Ambien and other sleep medications.

Or follow us on Twitter: twitter.com/aasmorg.

FDA Approves Silenor for Insomnia

The makers of sleeping pills such as Ambien, Lunesta and Rozerem will soon have new competition. On March 17 the FDA granted approval to Somaxon Pharmaceuticals for its drug Silenor. Somaxon reports that the insomnia medication should be available in the second half of 2010.

But Silenor isn’t for people who have trouble falling asleep. It takes about 3.5 hours for the drug to reach its peak concentration in the blood.

So the FDA approved Silenor to help people who struggle with “sleep maintenance.” It may benefit people who tend to wake up during the night or early in the morning and struggle to return to sleep.

The drug that Silenor contains is called “doxepin.” For years this histamine-blocking drug has been used at high doses as an antidepressant.

It has been known that doxepin also improves sleep. But at high doses it may cause severe side effects. This prevented the drug from being used as a common sleep aid.

Now studies have shown that doxepin can reduce the symptoms of insomnia at doses as low as 3mg or 6 mg. Side effects are minimal at these low doses. The FDA recommends that older adults start with the 3 mg dose.

One of these studies was published in the journal Sleep in 2007. It involved 66 adults with chronic primary insomnia. They had a mean age of 42 years, and 70 percent were women. Both 3 mg and 6 mg doses of doxepin were compared with a placebo.

Results show that doxepin reduced the time spent awake after falling asleep by about 22 to 23 minutes. It increased total sleep time by about 26 to 29 minutes. But it did not reduce the number of awakenings during the night.

Last year the Sleep Education Blog reported an increase in prescriptions for sleeping pills. The use of sleeping pills by young adults also rose dramatically.

The AASM offers these Guidelines for Taking Sleep Medications. Contact your doctor or pharmacist if you have any other questions about taking sleeping pills.

You also should ask your doctor about cognitive behavioral therapy for insomnia. It is a safe and effective treatment option.

Get help for insomnia at an AASM-accredited sleep center near you.

Understanding Unusual Ambien Side Effects

A new study may help explain why some people have unusual side effects when taking the sleep aid zolpidem – also known as Ambien.

Reuters reports that the drug can shut down brain circuits that normally inhibit some activity. This may release the brakes on other brain circuits while you sleep.

“In a way, Ambien is awakening other circuits because the brakes are not in place," study co-author Molly Huntsman told Reuters. “It's a population of neurons that is normally in place to stop activity. We find what Ambien does is inhibit their function to inhibit.”

Ambien is a sedative-hypnotic that is FDA-approved for the short-term treatment of insomnia in adults. The most common side effects include drowsiness and dizziness.

But other unusual side effects can occur. In 2007 the FDA requested changes to the product labeling of all sedative-hypnotics.

One of the proposed changes was to include a warning about the risk of “complex sleep-related behaviors.” Examples include sleepwalking and sleep eating. Rare cases of sleep driving also have been reported.

The FDA-approved Medication Guide for Ambien now states that, “You may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night.”

But why do these unusual side effects only occur in some people? Huntsman suggests that something may have happened to their brain circuitry.

It is possible that a previous experience changed their brain receptors. This could affect how they respond to a drug like Ambien.

“A lot of things can change your brain chemistry - stress, alcohol use," Huntsman told Reuters.

The AASM offers these Guidelines for Taking Sleep Medications. Contact your doctor or pharmacist if you have any other questions about taking sleeping pills.

You also should ask your doctor about cognitive behavioral therapy for insomnia. It is a safe and effective treatment option.

Get help for insomnia at an AASM-accredited sleep center near you.

Combining Cognitive Behavioral Therapy with a Medication to Treat Insomnia

For people with insomnia, taking a medication can help break the cycle of sleepless nights. And cognitive behavioral therapy can lead to long-lasting improvements with little risk of side effects. But what happens when you combine these two treatments?

A new study helps to answer this question. The results were published today in The Journal of the American Medical Association.

The study involved 160 adults with chronic insomnia. For six weeks they were treated with either CBT or CBT combined with 10 mg of zolpidem at bedtime. Zolpidem is the generic name for Ambien.

Then the study continued for six months. Some of the people treated with only CBT attended monthly treatment sessions; others had no further treatment. Some participants in the combined treatment group continued with CBT and zolpidem; others continued only with CBT.

Results show that for the first six weeks, both CBT and CBT combined with zolpidem reduced insomnia symptoms. About 60 percent of participants in each treatment group slept better. Treatment eliminated insomnia symptoms in 39 percent of the CBT group and 44 percent of the CBT with zolpidem group. The combined treatment also produced a larger increase in total sleep time.

What was the best long-term treatment? CBT with zolpidem for the first six weeks, followed by ongoing CBT without medication. This method eliminated insomnia symptoms in 68 percent of participants.

The study suggests that a combined approach may maximize the strengths of both common insomnia treatments.

You should never take a sleeping pill without first getting approval from your doctor. A sleep specialist at an AASM-accredited sleep center can develop a treatment plan for insomnia that is best for you.

Are “Smart Drugs” a Smart Choice for a Brain Boost?

Early results from a new study in JAMA show that it may not be smart to take modafinil as a “brain booster.” The drug may have a greater risk of addiction than it was first thought to have.

The small pilot study involved 10 healthy men. Taking modafinil increased the dopamine in their brains. Dopamine is a neurotransmitter that plays a major role in addiction.

The brand name for modafinil is Provigil. It was approved by the FDA in 1998. It is a safe and effective treatment for three sleep disorders. It improves alertness in people who have excessive daytime sleepiness from narcolepsy or shift work disorder.

Modafinil also is approved for people with sleep apnea. Some people remain sleepy during the day even while treating their sleep apnea with CPAP therapy. These people may benefit from taking modafinil along with using CPAP.

But USA Today reports that there is concern that many other healthy people are taking modafinil as a “smart drug.” Students hope it will improve their performance on an exam. Professionals may take it hoping to stay sharp on a long business trip.

Doctors can prescribe the drug for “off-label” use. Or people may buy it over the Internet.

An article in The Times of London shows that this trend is not isolated to the U.S. The New York Times also has reported on the debate in academic circles over the ethics of taking smart drugs.

In 2008 a scientific review analyzed all of the modafinil research. It reports that modafinil can improve mood, fatigue, sleepiness and cognition in sleep-deprived people. The benefit is similar to that of caffeine. But the effect may last longer.

One of the most recent studies was published in the February issue of the journal Sleep. After 44 hours awake each participant was given modafinil, caffeine or dextroamphetamine.

Each stimulant provided a cognitive boost. But the advantages differed according to the type of task being tested.

But does modafinil give healthy people who are not sleep deprived a cognitive edge? The 2008 review states that this evidence is “controversial.”

In November another journal article indicated that there is little evidence to support the use of drugs to improve learning and memory. It reports that, “So far, all clinical trials of neuroenhancing drugs have either failed or demonstrated only very limited efficacy.”

Dr. Nora Volkow agrees. She is the director of the National Institute on Drug Abuse and the lead author of the JAMA study.

"It would be wonderful if one could take a drug and be smarter, faster or have more energy," Volkow told the AP. "But that is like fairy tales. We currently have nothing that has those benefits without side effects."

Possible side effects of modafinil include headache, nausea, anxiety and sleep problems. It also can cause a skin rash or other allergic reaction.

Of course one of the best ways to give your brain a boost is to get more sleep. You don’t need to take a pill, and the only cost is your time. It may be the smartest choice of all.

An Economic Upturn for Makers of Sleeping Pills

Another sign that the economy is affecting our sleep: We’re taking more sleeping pills.

Advertising Age reports that sleeping-pill prescriptions increased seven percent last year. Sales rose even though ad spending dropped by hundreds of millions of dollars.

Sepracor had revenues of $161.9 million for the fourth quarter of 2008 from sales of Lunesta. This was up from $149.8 million for the same quarter in 2007. Full-year revenues were a little more than $600 million in both 2007 and 2008.

But sales aren’t up across the board.

Fourth-quarter net sales of Ambien CR (controlled release) in the U.S. were $170 million for sanofi-aventis. This was down from $190 million in the same quarter of 2007. Full-year sales dropped from $751 million in 2007 to $681 million in 2008.

Full-year net sales for Ambien IR (immediate release) fell to $125 million in 2008. The sanofi-aventis patent for this drug expired in April 2007. Many other companies then received FDA approval to sell less expensive, generic versions of Ambien.

The Boston Globe points out two other reasons why prescriptions may be up.

One reason has to do with safety. Older types of sleeping pills were limited to short-term use for one or two weeks. There was a risk that long-term use could cause addiction. There also was a risk that your body would develop a tolerance to the drug.

But sleeping pills introduced in the last two decades are considered to be safer. Ambien CR, Lunesta and Rozerem all have been approved for long-term use.

A study in the journal Sleep in 2008 found that regular use of Ambien CR for six months is safe and effective. The study was funded by sanofi-aventis.

In 2007 a study in the journal Sleep confirmed the long-term effectiveness of Lunesta. A nightly dose of 3 mg remained effective after six months. The study was funded by Sepracor.

A study in the Journal of Clinical Sleep Medicine in 2007 showed that nightly use of Rozerem was safe and effective over five weeks. The study was funded by Takeda.

The Globe also reports that more doctors are taking insomnia seriously. They recognize that treatment can promote both physical and mental health.

In 2008 a study in the journal Sleep affirmed that primary insomnia is a legitimate disorder. It linked primary insomnia to low levels of the brain chemical GABA. Many of the most effective sleeping pills increase brain activity at the GABA neurons. The study was funded in part by Sepracor.

Read the Guidelines for Taking Sleep Medications from the AASM.

Take Sleep Medications Carefully

Sleep medications are a safe and effective treatment option for insomnia. They can help break the cycle of sleepless nights.

But like any other drug, sleeping pills can cause side effects. These include nausea, headaches and dizziness. A recent incident involving a school-bus driver in Winston-Salem, N.C., is a reminder that daytime sleepiness is another possible side effect.

Some people also may sleepwalk, sleep eat or have other complex sleep behaviors as a side effect. In 2006 the FDA told drug makers to add these risks to their product labeling for sleeping pills.

So how can you reduce your risk of these and other side effects?

First, carefully follow your doctor’s prescribing instructions. Never take more than the dosage that your doctor prescribes. Always talk to your doctor before taking another medication along with a sleeping pill.

Also, allow time for a full night of sleep after taking a sleeping pill to reduce morning or daytime drowsiness. It is also important to avoid drinking any alcohol before or after taking a sleep medication.

Tell your doctor right away if you have any side effects from taking a sleeping pill. Your doctor may adjust your dose. Or you may be able to try a different medication.

There are a variety of effective sleeping pills available. So your doctor should be able to find one that is right for you.

If you prefer a drug-free alternative, ask you doctor about CBT for insomnia. It’s an effective treatment option that can have long-lasting effects.

Get more Tips for Taking Sleep Medications. Get advice from a sleep specialist in this Expert Q&A that focuses on insomnia.

The Curious Case of the Sleep E-mailer

Add e-mailing to the long list of behaviors that can occur during an episode of sleepwalking.

The journal Sleep Medicine has an article “in press” that will appear in an upcoming issue. It describes the case of a woman who sent some strange e-mails while she was asleep.

Sleepwalking can involve routine or unusual behaviors. Examples include making phone calls, walking outside or eating. But this is the first reported case of sleep e-mailing.

The New York Times reports that the woman was taking Ambien for her insomnia. The sleep e-mailing occurred after she decided on her own to increase her dose.

Like any other drug, sleep medications may cause some side effects. These side effects can include sleepwalking, sleep eating and other complex sleep behaviors. Some people also may experience memory problems.

The AASM Tips for Taking Sleep Medications note that you should follow your doctor’s instructions when taking a sleeping pill. Never increase the dose on your own. You also should only take the sleeping pill for as many days or weeks as your doctor tells you.

The Times article also reports that a new feature from Google could help protect sleepwalkers from sending embarrassing e-mails. It’s called Mail Goggles.

When enabled, it stops you from sending late-night e-mails on weekends. Before a message is sent, you have to solve a few math problems. The intent is to force you to stop and consider if you really want to send the message.

The math problems are fairly simple. But for a sleepwalker, it might be enough to prevent you from sending a strange e-mail to a co-worker or friend.

Update 03/02/09: The article appears in the February 2009 issue (volume 10, issue 2) of Sleep Medicine.

More Young Adults Using Sleeping Pills

The New York Times reports that the use of sleeping pills by young adults has risen dramatically. The biggest increase from 1998 to 2006 came among adults between the ages of 18 and 24.

The report is based on an analysis by Thomson Reuters. It examined drug claims by adults under the age of 45. Overall sleeping pill use was highest among adults between the ages of 35 and 44.

The most popular sleeping pills were Ambien CR and Lunesta. The drugs were prescribed for an average of 93 days.

AASM president Dr. Mary Susan Esther told the Times that chronic insomnia often is linked to other problems. These include depression and anxiety. In these cases a sleeping pill won’t address the related problem.

Insomnia also can be caused by disruptions to the sleeping environment. This is called environmental sleep disorder. Dr. Esther pointed out that a noisy dorm is a common sleep disrupter for college students.

The report did not examine the use of other treatments for insomnia. One of the most effective treatments is cognitive behavioral therapy. Following the tips of good sleep hygiene also helps some people with insomnia.

Like any other drug, sleeping pills may cause some side effects. These side effects can include sleepwalking, sleep eating and other complex sleep behaviors. Some people also may experience memory problems.

The AASM offers these Guidelines for Taking Sleep Medications. Contact your doctor or pharmacist if you have any other questions about taking sleeping pills.