Many clients with co-occurring disorders experience sleep problems but have difficulties with sleep medications. Physicians and experts at Dartmouth offer their insights on safe and effective treatments.
Most patients with untreated and symptomatic co-occurring disorders have disturbed sleep. These patients deserve a careful evaluation of the sleep problem and proper diagnosis prior to initiating treatment. Many patients with substance use disorders experience sleep disturbances as a symptom of intoxication (for example, from stimulants, including caffeine) or withdrawal (for example, from sedatives, including alcohol) or as a common symptom of co-occurring mood, anxiety, or psychotic disorder. In these patients, the primary mental health disorder must be treated with psychosocial and pharmacologic interventions. The addition of a hypnotic medication for a few days to a few months while the acute symptoms improve may be helpful. Furthermore, hypnotics may be beneficial in the context of hospitalization or detoxification.
While all of the benzodiazepines can be abused and have street resale value, which limits their use in patients with co-occurring disorders, the other medications used for sleep problems do not appear to have the same negative characteristics. Trazodone, the antihistamines, melatonin, and ramelteon are probably the safest for use as hypnotics in this population. Zolpidem, zalpelon, and eszopiclone are nonbenzodiazepine 1 receptor agonists that do not appear to be frequently abused, but since cases of abuse or dependence have been reported, these medications are not ideal choices for use in patients with co-occurring disorders. Experts do not recommend the use of benzodiazepines as hypnotics in this population.
The prescriber must clarify the cause of the sleep disturbance before prescribing a medication. First, the prescriber must determine whether the sleep disturbance seems to be caused by or exacerbated by substance intoxication or withdrawal, remembering that caffeine and nicotine are stimulants that frequently contribute to insomnia. Second, the patient must be evaluated for the presence of a possible co-occurring psychiatric disorder. Difficulty falling asleep is a common problem with stimulant abuse, and it is also typical in anxiety disorders. Mid-cycle awakening is common in patients with depression. Patients with mania have a dramatically reduced need for sleep overall. Finally, the prescriber needs to assess for the presence of common sleep disorders, such as sleep apnea or restless leg syndrome, that may contribute to insomnia.
Patients with sleep problems as part of a mental health disorder may benefit from a medication that both has sedating properties and treats the mental health disorder. For example, paroxetine at bedtime may be given as the sole pharmacologic treatment to help patients with insomnia due to major depression or an anxiety disorder. Another strategy is to prescribe a hypnotic in addition to a medication for the mental health disorder. The hypnotic may be used for three to four weeks while the psychotropic takes effect, then tapered off and discontinued. A common strategy would be to combine the use of fluoxetine (an SSRI) and clonazepam (a benzodiazepine) or trazodone (a 5-HT2 receptor antagonist) for the treatment of a patient with panic disorde.
Behavioral Approaches to Sleep Disorders
Ideally, behavioral approaches should be utilized for all patients with sleep disorders. All patients with sleep problems should be given education and coaching on the use of appropriate sleep hygiene. (See the tips on health sleep practices.) Research suggests that providing education on healthy sleep practices is a necessary but insufficient intervention for patients with sleep problems. Other cognitive and behavioral strategies are useful as well.
Healthy Sleep Practices
- Maintain a regular bedtime and wake-up time, even on weekends.
- Avoid taking naps. If you do, nap in the early afternoon and keep it to less than one hour.
- Get exercise every day, but not within three hours before bedtime.
- Don't work late into the evening. Allow a few hours to wind down.
- Avoid nicotine in the four hours before bedtime; avoid caffeine in the eight hours preceding bedtime.
- Avoid heavy meals later than three hours before bedtime.
- Don't use alcohol to fall asleep.
- Make sure the bedroom is quiet, dark, and at a comfortable temperature.
- Reserve the bedroom for sleep and sex only. Don't work, eat, read, or watch TV in bed.
- Avoid watching the clock. Turn it so you can't see it, and then don't think about what time it might be or how much sleep you may be getting.
- Decrease the amount of time spent awake in bed. If you can't sleep, leave the bed until you feel sleepy again.
- Don't try too hard to fall asleep.
Formal behavioral interventions involve stimulus control (reserving bed for sleep and sex only) to avoid linking the bed with frustration and sleeplessness, as well as an intervention known as sleep restriction. In sleep restriction, the patient begins a sleep schedule that reduces allowable sleep time until the patient sleeps 90 percent of the time in bed. With this procedure, the patient reduces time in bed to the amount of time the patient typically sleeps. Once the patient sleeps for 90 percent of the time in bed for at least two days, the amount of time allowed for sleep is then increased by fifteen minutes. Using this process, the amount of time in bed is gradually increased over weeks and months.
Education should be combined with ongoing coaching for behavior change or with pharmacological interventions or with both approaches. Sleep interventions then need to be integrated with treatments for the substance use disorder and mental health disorder.
Excerpted and adapted from Medication Management, Hazelden Co-occurring Disorders Program, Dartmouth Medical School, published by Hazelden, 2008.