Wednesday, September 28, 2011

Antipsychotics Are For Psychosis, Not Insomnia Redux

In my post of February 16 of this year, Antipsychotics Are For Psychosis, Not Insomnia, I reported on the increasing off-label (non FDA-approved) prescription of so-called atypical antipsychotic medication for insomnia and anxiety, despite the risk these drugs pose of causing metabolic syndrome (diabetes, obesity, and increased blood cholesterol and triglycerides [blood fats]) as well as an irreversible neurological problem called tardive dyskinesia. 

Somehow doctors - mostly primary practitioners but many psychiatrists as well - have been brainwashed into thinking that this risk is somehow much less than the risks posed by addiction from sedatives and hypnotics  - the old fashioned tranquilizers and sleeping pills. (Tranquilizers and sleeping pills are actually one and the same thing, by the way.  What's the difference?  Marketing.  Some of these drugs are marketed for sleep and some for anxiety, but they all do both of these things).

Anyway, a class of drugs called benzodiazepines are the most commonly used drugs indicated for insomnia and anxiety.  These include drugs like Valium, Librium, Ativan, Klonopin, Dalmane, Restoril, and Xanax.  They replaced the far more addictive and dangerous barbiturates several decades ago.

A newer (and of course much more expensive) group of drugs (Ambien, Lunesta and Sonata) were marketed as being "different" from the other benzodiazepines, so many doctors are much less afraid of prescribing them than the old drugs. 

In truth, these drugs work almost exactly the same way as the older benzo's.  They also cause sleepwalking. And they are every bit as addictive.  In fact, according to my prime source for all things concerning drug abuse, Rolling Stone magazine, the latest fad in D.C. is staying awake while on Ambien. Apparently, you can get really high if you do that. (Now that you know, please don't go out and do it!)

Of course, mild and moderate anxiety and insomnia can often be treated without any medication at all, but don't even get me started on that.

Actually, benzo's (with the possible exception of Xanax, which is very short acting), are not abused by themselves very much at all by addicts.  When was the last time you read a horror story in the news about valium addiction? It is also almost impossible to die from a benzo overdose if no other drugs are taken with them.

The drugs can create trouble, however, when they are combined with opiates - in which case one can overdose on the combination and die.  Unfortunately, this has been happening with increasing frequency lately.  But I digress.

Not only are benzo's by themselves pretty safe, but they have almost no side effects at all except in the elderly.  Compare their risks with the risks of atypical antipsychotics, and it is absolutely no contest at all.  Personally, if I had to choose, I would much prefer to be addicted to a benzo than be addicted to insulin shots!

Despite this obvious discrepancy in the risks, the problem of the misuse of prescriptions for antipsychotics by physicians to treat insomnia and anxiety continues to worsen.  In the September 2, 2011 issue of Psychiatric News, an American Psychiatric Association newspaper, there were two headlines side by side:  "Antipsychotics Increasingly Prescribed for Anxiety" and "Concern Raised Over Antipsychotic Use for Sleep Problems."

Even well known drug company apologist Charles Nemeroff was quoted as bemoaning the use of antipsychotics for anxiety disorders like panic disorder.

For insomnia, the biggest seller is the drug Seroquel (Quetiapine), which is second only to Zyprexa (Olanzepine) in causing metabolic syndrome.  Indeed, Seroquel is probably the most sedating atypical.  The article in the paper pointed out that a lot of physicians who prescribe this medication do not even bother to monitor the patient for increases in weight, blood sugar, and serum fats. 

The article about insomnia was prompted a large increase in prescriptions for this drug for insomnia in military personel.  According to the Department of Defense, in 2001 20-30 soldiers per ten thousand were treated for insomnia.  By 2009, the figure had soared to 226 per ten thousand. 57% of all prescriptions of Seroquel were for insomnia! 

Soldiers reported gaining an average of 6.3 pounds each on the drug.  Only 61% had a check of their blood sugar within six months of starting the medication.  Fortunately, no actual cases of diabetes were found.  The author of the study that generated these statistics agreed with my theory that these drugs were being used by physicians instead of benzo's because of fear of addiction.

That reasoning is a bit like the reasoning of people who will not fly in a commercial airplane for fear of a crash, but refuse to use seatbelts when they ride in a car.  These doctors apparently are completely clueless when it comes to evaluating relative risks.


  1. I was interested to read your opinion about ambien being addictive. I took it about 11 years ago for a while, don't remember how long. I didn't have any problems with addiction, but I did build up a tolerance to it and the rebound insomnia wasn't fun to deal with. I guess I'm glad I stopped while I was ahead, because sometimes I did stay up purposefully for that high feeling. I liked that it didn't leave a hung over feeling the next day. When I did use it properly it was the best sleep I have ever had.

  2. David, excellent article as usual. We simply can't find this kind of practical reasoning and candor in any of the garbage bag liners in mainstream publications. In addition to your academic work, it's obvious that you see patients as these are common conundrums that occur in the field. Anyway, insomnia must be the most common complaint in clinical practice, regardless of what one practices. I supervise both psychiatry and family practice residents, and they concur with my position. I'm amazed that there is so little education about sleep hygiene in medical school, given the frequency of this syndrome. Before embarking on the seemingly endless road of sequential sedative prescribing, as much as we hear about "best practice guidelines", medical students should be given more guidance in first line patient education prior to the first medication being prescribed for this common malady. By the time I see a patient with a complaint of insomnia, it's often clear after taking a cursory history that the condition is chronic and psychologically conditioned. I have a handout with assigned homework that I give patients up front before I prescribe anything. Most of them don't come back, but those who do are presumably motivated toward lifestyle changes and are willing to keep trying. When I see objective signs of insomnia; ie, when they look like residents who are coming off an all nighter of call, only then will I consider prescribing medication, but I inform them that my intent is to use it only as a short-term facilitator, and not as a long-term fix. I agree that benzos are safe and effective compared to non-controlled alternatives which often have unpleasant side effects. I'm convinced that the most commonly prescribed of these, Vistaril and Trazodone, are arguably 2 of these worst considerations, given the cognitive impairment associated with the former and the frequently observed intolerance of the metabolite (m-cpp) of the latter. I certainly concur that antipsychotics, particularly atypicals such as Seroquel, have no place in the treatment of insomnia without another associated diagnosis, such as Major Depression, Bipolar Disorder, PTSD, or Schizophrenia. In resistant cases after I'm well assured that the patient has at least attempted some reform in their sleep habits, my go to drug is a benzo, and I have a personal preference for Oxazepam because of its clean metabolic profile, slow absorption which reduces addictive potential, reasonably short half-life, and excellent effectiveness in promoting restful and sustained sleep. All of my comments, of course, are based on the treatment of primary insomnia and not sleep disorders that are secondary to a mental illness, which in such instances, should be primarily and appropriately treated prior to focusing management on the insomnia per se.
    Again, I commend you for an outstanding and timely article.

  3. Excellent article. I respectfully disagree about benzos -- their use should be minimized as well. Statistically, the rate of addiction might be fairly low, but if your number comes up, you get addicted, sometimes in a very short amount of time and with low doses.

    It doesn't take an addict to get physically addicted to benzos, hundreds of thousands of trusting but neurologically susceptible people have wandered into this, and withdrawal is h*llish.

    Absolutely do agree the proliferation of antipsychotics for all kinds of conditions is pernicious, and soon to be a major health problem as it adds to astronomical diabetes rates.

  4. this is what it's like to come off a benzo if one is susceptible to the addiction (video included):

    from the post:

    "A quite good documentation of what it’s like for a lot of us. Some of us have it even worse than what is depicted here. The fact is that once one gets drug sick the only way to freedom is often getting much sicker through the process of withdrawal. It’s a true journey into the dark night for many people. There are generally few regrets to have taken the journey on once one is on the other side though. It becomes clear the drugs stole our lives and we fight for them back.

    This is a 15 year old documentary. It’s horrifying to think all this was known about this class of drugs so many years ago and yet doctors still happily prescribe benzodiazepines as “safe” drugs to treat anxiety and insomnia and many other things too.

    This phenomena of severe benzodiazepine withdrawal and post-withdrawal syndrome has been known about for two decades at least!
    The package inserts on benzos still say not to these drugs for more than 2 weeks.

    The woman they are profiling most closely at the beginning takes “weeks” before she can leave the house. I unfortunately know all too many for whom it takes many months and in some cases years, like Jill’s situation closer to the end of the documentary."

  5. Luce,

    Of course benzo withdrawal can be very severe in some people, including having seizures. No one denies that

    However, there is a highly effective protocol for getting even highly addicted people off benzodiazepines (even Xanax) in just a week or two with almost no symptoms of withdrawal using a drug called carbamazepine (Tegretol) over a very short term. Most doctors do not know about it.

    Sometimes, however, patients getting off of benzos's re-experience the panic attacks they were put on the medication for in the first place. That is not withdrawal but a return of symptoms that were being treated effectively.

  6. tegretol by no means works for everyone...every quick fix only works for some people and those prone to severe withdrawal still face severe withdrawal.

    if it's worked for anyone people like to generalize with the quick's too bad we've not found one that actually works in a generalized way.

    I've seen people try no go there...

  7. oh...and finally...I've seen severe withdrawal...that includes terror (the gaba receptors being damaged) in people with ZERO psychiatric history. People who were given benzos for muscle pain or some other purely physical problem.

    Withdrawal terror and fear has no relation to the garden variety anxiety that some folks come to benzos for as well.

    do some people have severe anxiety that predates benzo use, sure, but most people face far far worse...and some face it for the first time when they withdraw.

    benzos can also cause brain damage:

  8. Luce,

    Of course nothing works for everybody. And some people have severe reactions to anything -folks have bled to death after taking an aspirin. Does that mean the rest of us should never take an aspirin?

    Epidemiological studies show a lot of contradictory information about the dangers and positive effects of nearly everything we ingest. Are red wine and coffee bad for you or good for you? Depends which study you read.(I'll be discussing this in a future post about a book called Stats.con).

    I'm sorry, but you are grossly exaggerating the risks of benzo's. They are a hell of a lot less problematic than cutting and burning yourself (when combined with SSRI) or having incapacitating panic attacks so you are stuck in your house.

  9. You might want to spend some time in benzo groups online where there are literally thousands of members who are very very sick. Google the withdrawal groups if you care to see. Most of those folks are told by doctors that it's in their heads and it's not.

    You too run the risk of minimizing it. When someone experiences this ugliness there is no exaggerating it.

    from: "Overcoming Prescription Drug Addiction: A Guide to Coping and Understanding"

    Ronald Gershman MD says:
    "I have treated ten thousand patients for alcohol and drug problems and have detoxed approximately 1,500 patients for benzodiazepines – the detox for the benzodiazepines is one of the hardest detoxes we do. It can take an extremely long time, about half the length of time they have been addicted – the ongoing relentless withdrawals can be so incapacitating it can cause total destruction to one’s life – marriages break up, businesses are lost, bankruptcy, hospitalization, and of course suicide is probably the most single serious side effect."

    yes, lives are DESTROYED, just as he says. No exaggeration.

    when you spend time with these folks it becomes very real. most of them leave treatment with regular shrinks because they are not supported by them.

  10. "They are a hell of a lot less problematic than cutting and burning yourself (when combined with SSRI) or having incapacitating panic attacks so you are stuck in your house."

    hmmm...the problem is they are given to all sorts of people for far less problematic issues...and even such people as you portray above deserve options. Benzos are not curative. There are actually quite a lot of drug free methods that can help with the issues you speak about above.

  11. I agree that benzo's are overused and are not curative. And I do or recommend psychotherapy for anyone on a benzo with a goal of getting them out.

    Thousands? But that is out of MILLIONs and millions of perscriptions. The vast majority of people have no such problems. And a good percentage of people who's lives are "ruined" abuse other substances.

    And even more of them blame the drugs when their relationships, self-destructive behavior and personality problems are the real cause of their misery. A very convenient scapegoat!

    A lot of psychiatrists ignore the other problems and go right for blaming the drugs as well. It's how they make their living.

    If you have had a bad experience with the drugs, then I can understand your anger.

  12. I'm talking about physical devastation caused by iatrogenisis, not other issues.

    And wow, what psychiatrists are your talking about? I've not met too many that understand the damage drugs can cause.

    I've met plenty of people who have none of the additional issues you are talking about above...they do have the physical devastation.

    Anyway, it's clear you don't want to know what these drugs do to a good number of people.

    The 1000s of people in the groups are a drop in the bucket of those harmed. Most people don't know what is wrong with them. They get chronically ill from this stuff but never make the connection. And of note they are not addicts in the traditional sense. They are patients that have been prescribed drugs by their doctors. The vast majority of them are not doing any other drugs. I'm talking about the people who are sharing their methods for getting well on the boards. Drug abuse exists, I of course don't deny that.

    Anyway...thanks for allowing my comments. Maybe someone will see and take heed...

  13. Luce,

    Thanks for writing. I agree with you that there is a lot of iatrogenic damage from all sorts of things, because doctors don't monitor their patients closely and don't ask the right quetions - not because the drugs are inherently bad, however.

    The psychiatrists who I was talking about are those that work in the drug abuse and detox field. You are right absolutely right about many of the others!

    I do have to take issue with "I've met plenty of people who have none of the additional issues you are talking about." And you know this how? You think people just advertise all the things they are ashamed of and brag about family dysfunction?

    I've had therapy patients who did not disclose essential informations until MONTHS into weekly sessions. And I know a lot of time-tested techniques for getting people to open up.

    If you want to get the last word, please feel free to post again. Take care.

  14. I'm a military psychiatrist. Seroquel isn't used for straight up insomnia. Its primary use is for patients with PTSD that are suffering from intrusive psychotic like nightmares. It is also used as a 3rd or 4th line agent for sleep. It is a very effective drug when used appropriately.

  15. I have severe insomnia. I am very strict about my sleep hygiene, I exercise and eat well. I have followed every guideline regarding sleep hygiene my doctor has recommended. I was on Ambien for a bit, but the side effects were too much. After 4 different sleeping pills, my doctor just prescribed seroquel, I am absolutely terrified to take it after reading all the horror stories regarding side effects. I may just be resigned to never sleep well.

  16. Amber,

    Take it from someone who knows personally, you do not want to take Z-drugs (Ambien, Zolpidem, etc.) or benzodiazepines (Lorazepam, Xanax, etc.) for more than a week, let alone any antipsychotic medications. These drugs, when taken long term (for over two weeks) can cause changes to brain chemistry and it can take YEARS for the changes to reverse. Have you had your thyroid checked (hypothyroidism, hyperthyroidism)? If so, did they test your iodine levels? People that have thyroid issues are usually iodine deficient and this can cause the thyroid to become inflamed, which can lead to many health issues, including insomnia. Many doctors do not test for iodine deficiencies and simply prescribe thyroid medication. Good luck to you.