Episode 49

Sleep. One of the essential building blocks of our lives. It seems so simple to get and it’s really one of the harder things to do at times. Chronic sleep deprivation and insomnia can wreak havoc on a person’s health and mental health. Treatments can vary from sleep medications to CBT to hypnosis. There seems to be no limit to what people will try in order to get some rest. Not that I blame them. I know how desperate I feel when I’m sleep deprived. Sleep medications can be like a miracle. Many people use them without incident. There are some issues though and we’ll be looking at those in this episode and the next. This week we’ll be focusing on what constitutes a sleep disorder, what treatments are suggested in the treatment of insomnia and the general overview of sleep medications. 

Helpful Links

Prescription sleeping pills: What’s right for you? – Mayo Clinic

Chronic and Short-Term Insomnia Treatments and Medications

Flurazepam Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD

Treatment Options for Insomnia – American Family Physician

Pharmacological Treatment of Insomnia



Sleeping Pills: Types, Side Effects & Treatment

Insomnia Medication: Sedative-Hypnotics, Antidepressants, TCAs, Antidepressants, Other

Sleep Aids: How to Use Them to Treat Insomnia | Sleep Foundation

Treatments for Insomnia | Sleep Foundation

Are Sleeping Pills Safe? Here’s What Research Says | Time

Learn the risks of sleep aids – Harvard Health

Focus: Addiction: Prescription Sedative Misuse and Abuse

Antihistamines for Sleep: Is It Safe?

Treating Insomnia: Which Sleeping Pill Is Right for You? – GoodRx

Taking Z-drugs for Insomnia? Know the Risks | FDA

Here’s Why You Shouldn’t Take a Sleeping Pill Every Night | Time

Sleeping Pill Brands and Types: The Pros and Cons

Free Treatment Tool https://betsybyler.com/treatment-tool/


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 49. You’ll hear that I have a little bit of a summer cold. So forgive me if I sound especially scratchy.

Today, we’re going to talk about sleep medications.  The importance of sleep is something that’s been researched extensively. All the time there are articles coming out about the importance of sleep on different functions in the body from brain function, to weight loss, to mood regulation. Sleep affects all of those things.

It’s also one of the first things that gets disrupted when someone is experiencing high stress, a traumatic event, or even a medical issue. Each day in homes all over the world, families ask each other how did you sleep? Because sleep is the foundation of our day. If we wake up feeling great, we start with a little bounce in our step. If we woke up after a rough night of sleep, it’s hard to pull ourselves out of it.

In therapy it’s something that we ask about a lot. In fact, when I’m talking about symptoms, it’s one of the first things I ask about. Most people aren’t very guarded about their sleep habits. They’re willing to share with me whether they sleep well or not. 

So as we talk about sleep medications today, we’re going to talk about the definition of sleep disorders according to the American Association of Sleep Medicine. We’ll talk about the treatments available, the types of medications and how they differ. This is going to be a two-part topic because it is pretty extensive. There are a lot of sleep medications and medications that are used off label for sleep. From the prescription medications, all the way to the over-the-counter medications.

And of course, we are talking about substance abuse on this podcast and so we will talk about abuse of sleep medications, their addictive potential and the difficulties associated with getting off of sleep medications. Addressing someone’s  substance use and they mentioned that they’re taking pills this is where you want to be able to know about some of these sleep medications and how they affect people. 

If you haven’t already head over to betsybyler.com/treatment tool to download the treatment planning tool that I created to help assess your client’s substance use. It’s free you just put your email in and it’ll send you the download link. 

We’re familiar with a lot of different sleep disorders, like sleep apnea or sleep walking. Today, though, we’re going to be focused on one type particularly, which is the most common. We don’t really use the word insomnia very much, but it is what the sleep medicine people use the most. 

Classification of Insomnia

The American Association for Sleep Medicine defines insomnia  as the subjective perception, so the person’s perception of their sleep rather than something that’s been quantified. So their perception of difficulty with sleep initiation, duration, consolidation, or quality. Insomnia according to their definition has to have occurred when there is adequate opportunity for sleep and it has to result in some form of daytime impairment. 


Just like our definitions and diagnoses there are a number of types of insomnia. So when they pull open their manual about sleep disorders, there are a number of them listed. It starts with Adjustment or Acute Insomnia, which is just like our Adjustment Disorder. It has to have a specific cause that we can name and it’s expected that once the stressor is lifted, that the insomnia itself will resolve.

Then there’s what they call Psychophysiological Insomnia which they define as having heightened arousal that could be physiological, cognitive or emotional, and usually is accompanied by muscle tension, racing thoughts or heightened awareness of their environment. And then the learned sleep preventing associations are where the individual has increased concern and worry about the sleep difficulties and the consequences of sleep difficulty is leading to what they call a vicious cycle of arousal, poor sleep and frustration. 

So basically the psychophysiological is two parts. One is that there’s psychological, cognitive physiological arousal that’s happening in the body. And then the person’s thought process about the inability to sleep such as “oh my gosh, now I’m here and I can’t sleep and I have to get up in four hours. And if I go to sleep, now I’m going to get three hours and 45 minutes of sleep” and other thoughts like that.

We’ve seen this time and again in our clients where their body is somewhat having some insomnia symptoms, but their mind is also part of the problem that’s decreasing their ability to fall asleep.

They have a category called Paradoxical Insomnia, which basically is that the person is saying that they can’t sleep and that their sleep is terrible, but that they don’t have the daytime consequences of lack of sleep that would be expected. They call this the misperception of the severity of sleep disturbance.

The guidelines had this sentence, which I found interesting, it said, and I quote “to some extent, misperception of the severity of sleep disturbance may characterize all insomnia disorders”. I take that to mean  that they think that people have a misperception of the amount of sleep they’re getting in general. I found that interesting. If that’s true,  then I can see the importance of a detailed sleep log.

Next is Idiopathic Insomnia, which is the complaint of insomnia with insidious onset during infancy or early childhood along with no or few extended periods of remission. The rest of the categories of insomnia are very similar to ours and don’t really bear listing like insomnia due to a general medical condition or substance use, et cetera. 

Prevalence of Insomnia

It’s estimated that insomnia  affects between 30 and 50% of the adult population. Insomnia symptoms with distress or impairment they estimate accounts for 10 to 15%  of those experiencing insomnia. That would be a general insomnia disorder and that specific insomnia disorders are more like five to 10% of those who have insomnia.

The guidelines noted that risk factors go up in certain conditions, such as increasing age, females, people who have comorbid medical psychiatric substance use and other sleep disorders and those who are doing shift work. The highest rate they state  are those who have comorbid psychiatric disorders and specifically those who have chronic pain.  The research says that the risk between insomnia and psychiatric disorders is bi-directional. It seems that both affect the other, exacerbating them.

Diagnosing Insomnia

They diagnose insomnia primarily through a clinical interview. In this interview, they’re taking a sleep history and a detailed evaluation of their medical history, substance use history and psychiatric history.

The sleep history itself what they’re looking for are specific insomnia complaints, pre-sleep conditions, sleep-wake patterns. Other sleep related symptoms, such as night sweats, night terrors, that kind of thing. And they’re looking at daytime consequences. Insomnia isn’t something that’s going to get diagnosed unless there’s some kind of impairment during the day.

They’ll use different instruments. Typically self administered questionnaires, at home sleep logs, symptom checklists, psychological screening tests, and bed partner interviews. One of the big ones they use is the Epworth Sleepiness Scale, abbreviated ESS. ESS is sort of like our PHQ-9. It has eight questions ranking from zero to three points on each question. They’re looking at your chance of dozing or falling asleep for a little while during different daytime activities like sitting and reading, watching TV all the way to being the person driving a car and sitting in traffic for a minute or two. Other measures are used as well, but that one’s the most commonly used.

Usually for a sleep log they want it to be about two weeks because they want to see how someone is sleeping over time. They want to know about the sleep-wake cycle. So even though the person may have had six hours of sleep, they want to know  whether or not that was consecutive hours, or if there was a break.

What I found interesting is that sleep tests called polysomnography are not typically warranted or recommended for the treatment of insomnia. Typically they don’t recommend having a sleep test unless there is a reason to believe that there’s sleep apnea. Lately in the area where I live, they’ve been doing sleep tests as an at-home activity. Which is really interesting to me because the original sleep test, the polysomnography that they’re talking about in sleep medicine is way more than just what their breathing and respiration is.

They’re measuring a ton of different stuff, including when you go into REM sleep, restless legs, different muscle twitches, and it gives them a host of information. It’s interesting to me now that we’ve gone to this model of sending people home. While it does make sleep apnea, testing more accessible, because you don’t have to wait for an available night. I do think it mostly has to do with money.

Sleep Medication Treatment for Insomnia

When it comes to the treatment of insomnia the general consensus is that cognitive behavioral therapy should be tried first. It seems like pharmacological interventions are generally  what ends up happening. So people are getting medication, but generally the sleep med doctors are wanting people to do therapy at the very least in conjunction with the sleep medication. 

There are some insomnia therapy modalities that exist that have really good efficacy.  I know that our local VA that’s Veterans Administration uses a form of cognitive behavioral therapy specifically for insomnia that apparently works really well. The name is Cognitive Behavioral Therapy for Insomnia or CBT-I

Providers will sometimes use an actigraph. That’s a wrist mounted device that measures the circadian rhythm. A lot of people’s watches, apple watches and whatnot are supposed to measure this as well, but the actual device is more specialized.

The Association of Sleep Medicine doctors did come out with guidelines that they update regularly on how medications should be prescribed. When choosing a med, the guidelines say  that they should choose the medication with the following characteristics in mind: the symptom pattern of sleep issues, treatment goals,  past treatment responses, patient preference, cost, availability of other treatments, comorbid conditions, contraindications, concurrent medication interactions, and side effects.

The guidelines also suggest that medications are prescribed with a particular class first and then moving on into other classes. The first class that they suggest using are short to intermediate acting benzodiazepines and/or benzodiazepine receptor agonists.  So benzodiazepines, which they abbreviate BZ D and then benzodiazepine receptor agonists, which they abbreviate BZDra’s  are the main treatments for insomnia on a short term basis. They do not suggest using these in the long term. We can imagine why. Benzodiazepines definitely can be habit forming, have tolerance and withdrawal.

Some examples of these medications are Estazolam, which is Prosom,  temazepam, which is Resotril. If you listen to last week’s episode on roofie is we talked about temazepam, as it sometimes is used as a date rape drug. Other medications in that class are triazolam or Halcion, Ativan or lorazepam and quezapam or Doral.

The non sedative benzodiazepines are also at the top of the list. An example of those are Lunesta, Sonata and the most popular Ambien.

In all of the discussions about sleep I ran across one medication that gets singled out and I found that really interesting. It’s called Rozerem. I’ve had a number of clients on Rozerem over the years, but typically not until they’ve had a number of other trials of something else. Based on the literature I’m kind of wondering about that because it’s listed in the same breath as talking about using the benzodiazepines or the benzodiazepine receptor agonists. It specifically mentions Rozerem. Rozerem isn’t a benzodiazepine and acts really differently. Roseanne is a different class called melatonin receptor agonists.  It works similarly to melatonin in the brain, which is needed for sleep onset.

That’s a lot of choices for a first-line medication treatment. It makes sense to me now why they put in order to how you’re thinking about which medication to give.

They then suggest that you can alternate short or intermediate acting benzodiazepine receptor agonists or Rozerem again, if the initial agent wasn’t successful in treating the insomnia. After that, then they suggest using sedating antidepressants especially when treating comorbid depression, or anxiety disorders.  Some examples of those medications are amitriptyline, doxepin, mirtazapine and the one we’re probably most familiar with is trazodone.

If all of that hasn’t worked, then they suggest putting together the receptor agonist type of benzodiazepine with the sedating antidepressant. So potentially someone could be on Ambien and trazodone.

The next line of defense in terms of medication  are other sedating agents such as gabapentin, technically an anticonvulsant and nerve pain medication. And also Gabitril, which is another anticonvulsant. Part of the other sedating agents are antipsychotics specifically quetiapine which we know as Seroquel or olanzapine which is Zyprexa.

You’ll notice that on this list, that over the counter medications aren’t listed. They’re typically not recommended by sleep medication doctors, because there isn’t a lot of data on the efficacy of these treatments or on whether or not they’re safe in the short and long-term.

The key thing to note here is not that they never use them, but that they’re not used to treat chronic insomnia. Chronic insomnia is as its name describes more than just once in a while. They expect insomnia to last for more than a month in order to be called chronic.

Insomnia used to really be treated with a lot of barbiturates and barbiturate-type drugs  but those aren’t really recommended for use anymore in treating chronic insomnia.

So let’s break this down a little bit. So there’s these benzodiazepines. I’m probably going to murder some of these names and I’ll give you the brand name of it, just so it’s a little more recognizable. So in our benzodiazepine category, the ones that they’re choosing for that are Prosom, which is temazepam, which is Restoril. triazolam, which is Halcion, quazepam which is Doral and lorazepam which is Ativan. 

Then there’s that other class that we talked about, the benzodiazepine receptor agonists. A better way to talk about that is called Z drug.  Because the generic or chemical name of those medications start with the letter Z, or contain the letter Z in them. 

In our Z drug category, we have ezopiclone which is Lunesta, zaleplon which is Sonata.  And then the most common by far is zolpidem, which is Ambien. Ambien has a number of different formulations including controlled release, extended release. They even have a spray that has the active ingredient that’s in Ambien and it’s by far one of the single most prescribed sleep medications in the United States.

They start with these medications, the benzodiazepines and the Z drugs, because they do basically the same thing which slows down brain activity.  Anyone who’s ever had a benzodiazepine can probably understand why that would work. You can go from full panic to feeling “normal” in about 15 minutes. A lot of times what my clients say is that they can’t sleep because their brain just won’t shut up and they just need something to calm it down.

Sometimes we’re able to help them use strategies and techniques in order to get their brain to get off that hamster wheel, so to speak. But sometimes the brain activity is just kicked up and it will not. Part of that is just us laying down and not having distractions and so our brain gets a moment to just run in the courses that it wants to. It can get caught in that loop and then sleep is a distant memory.

So after that, of course we had the sedating antidepressants that I think most of us are familiar with. Like mirtazapine and trazodone. And then we have two different types  of prescription medications that act differently. One of them is what’s called an orexin receptor agonist. It is a new class of drugs and it’s the first of its kind. The medication is supposed to promote the natural transition from wakefulness to sleep by blocking or inhibiting the production of the wakefulness neurons, which are orexin neurons. So instead of slowing down brain activity, they’re looking to stop the firing of the neurons that tell our body to wake up. The drug I’m talking about is called Belsomra.

In terms of over the counter sleep medications, we typically find that there are a few different types. So a lot of people will use antihistamines such as diphenhydramine. Diphenhydramine is found in things like Benadryl, Aleve, Tylenol PM, and others. While it can help to induce sleep one of the downsides is daytime sleepiness. I’ve had clients report a lot of daytime sleepiness and waking up feeling kind of almost drunk on things like Tylenol PM less so on things like Benadryl, but that’s all anecdotal evidence and definitely not some kind of recommendation.

Another choice that people use for over the counter medications is called Doxylamine succinate. These are things like Unisom. It’s also a sedating antihistamine and the side effects are similar to diphenhydramine. There is a similar medication that is a histamine blocker that is prescription and that’s called doxepin or Silenor.

The last few choices for over the counter are the ones that I’ve seen mentioned most as having at least some proven efficacy. It seems that melatonin is the one that’s going to get recommended over any other over the counter medication because of its naturally occurring production in the body.

Melatonin is something. I think that we find all the time in our work. I know that I have family members who’ve taken melatonin and that clients often have tried it. I’ve talked with them about it as well, and asked them to consider it with their doctor to see if this would help. Melatonin isn’t something that can necessarily be taken consistently forever. Anecdotally it seems to work less effectively the more often you take it. It seems pretty effective though, for the people I’ve known who take it once in a while.

I have had a few people and indeed myself have had this what I think is a rare side effect. I have tried melatonin in the past when I had some difficulty with sleep and I ended up getting nightmares. I tried it on, I think, four different occasions and each time had nightmares.

I didn’t really think much of it, except that I had a client who came in and was telling me that melatonin gives her nightmares. So over the years I’ve had a couple people say that. It doesn’t seem like it’s super common though. As most people find that melatonin is relatively mild.

The last over the counter medication is called Valerian Root. There are a few studies that say that Valerian Root will have some therapeutic benefit, but that the effect is generally really mild. Valerian Root is a supplement. You buy it over the counter. I will warn you if you try it, it smells terrible. I don’t really know how to describe it.  In fact, I remember my sister taking it and we were on a trip together and we ended up putting it into Ziploc bags while it was already in its sealed container. That was the only way to keep it from smelling up the luggage and the trunk. I know that sounds dramatic, but it’s super true. However, it did seem to help with sleep onset.  Again, the sleep doctors are going to go with research and science as they should. They are saying that melatonin has some research more than valerian root, but that the effects of both of these supplements are typically mild.

The most commonly used sleep aid is alcohol. Alcohol is something that is known to help people sleep. I’m not saying it’s a good idea. I’m saying that it’s used commonly. I think that people find that a few drinks at night helps them sleep better. This has a lot of implications and can get people in a lot of trouble. If you haven’t had a chance to check out the alcohol episode, head over to betsybyler.com/podcast and there’s a full list of episodes you can click on to find the alcohol episode. I’ll also link it in the show notes for this episode, if you’d rather find it there,

Where I live in the United States using alcohol in excess is pretty socially acceptable. I’m not certain why that is, maybe it’s because we have like 10 months of winter and there isn’t much to do. I’m not really sure. Maybe it’s because Wisconsin produces a lot of beer.  I do know that Wisconsin has a very seriously powerful political force called the Tavern League that makes sure that our taxes don’t get raised on alcohol and that there aren’t restrictions placed on alcohol that they seem to believe are unfair.

A lot of clients over the years were either raised in homes or currently live in homes where the adults in the house have drinks every evening. This isn’t seen as necessarily a lot. However, having lived in other places in the United States, I can say that this level of drinking on a daily basis, isn’t as common as the people here would believe.

I have heard a lot over the years from clients saying that they use alcohol to fall asleep and one of the troubles with giving it up  is because they won’t be able to sleep without it and they’re worried about how they can function. The reason why someone is drinking is super important. I talk about this in the treatment planning tool that I created for you. If you haven’t had a chance to download it yet, head over to betsybyler.com/treatment tool, pop your email address in there, and it’ll send it to you. 

We always want to know the reason why someone is using. Partly it helps us understand them, but it also helps us understand what’s going to happen if they stop using and what might cause them to relapse.  We need to know somebody’s fears so that we can help them plan for those inevitable issues that pop up.

Sleep issues are really hard. I know for myself, I need about eight hours of sleep a night. Ideally between eight hours and 15 minutes and eight and a half hours. I know there are some of you out there who are like, “oh, I would love to get that much sleep”. And there are others who are like,” I function well on six”.

It all depends on your body and what it is that you need. For myself. I’ve been this way my whole life. When I was an adolescent and would go on a weekend retreat with church or something like that I would always get sick when I got home, not sick, like nauseous, but sick, like a cold and run down. It happened every time I would go a couple of nights with not enough sleep. I’m wondering if that’s what’s happening today. This week’s been really busy between clients and podcast stuff and just things around the house. I haven’t gotten as much sleep as I should.  I wonder if that’s why I’m feeling a little bit under the weather.

I saw a thing in a magazine years ago. I think it was a Real Simple, which I love. It suggested that in order to find out how much sleep you need, you take three nights and you go to sleep at the same time and you wake up naturally. And on the third morning, from the time you went to bed that night to the next morning is the amount of sleep you need. I’m not sure if that’s scientifically founded. I just saw it and I did try it and it’s about eight hours and 15 minutes.

I know that prioritizing my sleep is a big deal. And I know for our clients, it’s something that we talk about a lot. If they’re not sleeping well, it can make everything seem so much worse. I am a big old baby when I don’t sleep enough. I want to cry and feel like nobody loves me. I mean, not seriously, but I do feel kind of down and I feel like everything’s a little harder and I don’t feel like I have the resilience that I have on a normal day. 

I also love napping. Like sleep is like a hobby to me. I love a good nap on a Saturday. I’ll be “hmmm, I’m done with stuff. I think I want to nap” and I’m not talking “I’m going to lay down for 30 minutes”. Oh no, no, no. I’m going to go upstairs. I’m going to get my pajamas on. I’m going to get my bed ready and I’m going to climb in and I’m going to have a sleep mask  because when the sun is up and my body is like “let’s go” And I’m like, no, no, no. I want to sleep. I will lay down and sleep until I wake up again. That could be two hours. That could be three hours. But getting a nap always helps to reset what’s happening in my mood and in my body if I’m not feeling well.

So I firmly believe in the importance of sleep. I feel for those who aren’t able to sleep. These medications can be a lifesaver. We know that sleep deprivation can increase suicidal ideation. , but there are problems with sleep medications.

One of them is that a lot of them have a high risk for dependency. Meaning that your body will get used to it and that you will need more.  Getting off of them is going to be really challenging. 

Remember when we talked about the different kinds of insomnia, we talked about the psychophysiological type where there’s a physical function, but also that the learned sleep preventing associations gets in the way. There’s a reason I don’t have a clock that’s visible to me in my room and haven’t had, since I was probably 10. I used to always flip my alarm clock face down so that I couldn’t look at the time. Because I remember laying in bed being like, “if I fall asleep, now I’ll get five hours and 45 minutes of sleep” or looking at the clock and being like, “oh, I’ve been trying to sleep for two hours” or whatever the case may be.

So these things get in the way and if somebody is getting off of their sleep medication,  the struggle that they know they’re going to have can increase and cause further insomnia. It is normal to have some rebound insomnia when someone’s coming off of the medication. From what I’ve read, it can and does abate in a lot of cases. But a lot of people aren’t able to get through that because of the fear that they’re going to go back to their previous sleep deprived state.

Another problem with sleep medications is the risk of abuse. At first blush these might seem like the same thing. Dependence though, is about a physiological function that’s happening in your body. Abuse is about  taking more than was intended or taking them for a different reason than they were prescribed. 

This is where the substance abuse work and assessment comes in. People get desperate when they’re in pain and when they can’t sleep. That can lead them to do some things that they wouldn’t normally do. Thankfully, I don’t struggle with insomnia. There have been a few nights in my life that I’ve struggled with it, although it’s nothing compared to what other people struggle with. I remember being so desperate that I was willing to take pretty much anything if I could get some rest.

I remember in graduate school during my first year when I lived with a family friend in this giant house and the family was gone and I was alone. It’s this big old farmhouse with lots of sounds and creaks and wind going through. I was scared out of my mind. I actually pushed a bookcase in front of the door. No joke. All the lights were on in the house and I still could not sleep because I kept being afraid that somebody was going to break in. I remember taking Benadryl and NyQuil and I’m not even sure what else to try to knock myself out. I thought about hitting myself on the head. It was a desperate night and I can’t imagine what people are going through, who have that often. When people are desperate, they will do desperate things. 

These medications are really prone to abuse. We’re talking about benzodiazepines, and then we’re talking about other sedative hypnotic medications that can get you high. So either people are taking them for sleep because they feel like it’s not happening fast enough or it’s not working, or people can take them to get high. You can absolutely buy a number of these medications on the street. There is a high traffic for prescription sedative medications. When houses get robbed, their medications get swiped too, because a lot of them have a lot of street value.

I had a client who was addicted to sleep medication and they would take a lot of different kinds. Took some Ambien. Some Halcion. Some Restoril.  Not the Rozerem though, because Rozerem works on melatonin and isn’t a sedative, but certainly a number of the benzodiazepine and the benzodiazepine receptor agonists. The prospect of getting off of those medications and the withdrawal from it was really hard to convince him that it would be worth it. I honestly couldn’t say if his sleep would return to normal.

I haven’t had a ton of people be prescribed, actually things like Ambien, but statistics put it at one in three adults using some kind of sleep medication on at least a monthly basis. That’s a large percentage. Sometimes those sleep medications over the counter are not, can have some serious side effects. 

So we have these types of medications. We have the benzodiazepines, the non sedative hypnotics, which are the Z class drugs. We have histamine blockers. We have the melatonin receptor agonists and the orexin receptor agonists.

Each of these medications is designed to work slightly differently and it’s hard to know exactly which one’s gonna work best. So asleep. Doctors are  going to prescribe what they feel like will work starting with the lowest dose possible. There are going to be frontline medications, just like for us. Our frontline anti-depressants are Celexa, Zoloft and Prozac. We don’t go to things like Effexor or Paxil unless we’ve gotten through the first-line medications. So a sleep doctor’s going to prescribe those and potentially a combination of those  until they find something that works for insomnia.

One of the things I think that’s challenging as a sleep doctor is that people don’t often tell the whole story when they’re talking about something specific. When they go to their sleep doctor, they may not mention stuff that’s happening in other areas of their life. Like they’re drinking or like the fact that they are staying up late arguing with a partner or the fact that they struggle with anxiety and they have racing thoughts. That’s why the sleep doctor’s going to do some pretty serious investigation on what they need. 

I think we can be helpful to a sleep doctor in this as well for encouraging a sleep log for checking on different behaviors and what might be exacerbating their sleep problems. I’m reminded of my professors, always in my head saying that problems are multifaceted and multi maintained. Meaning that there’s many sides to insomnia and there’s a number of things holding it up, not just one. So I think we can be helpful in doing some investigation with the client ourselves, as we have a little more time than a sleep doctor would with the client.

Just because something is being taken over the counter or as a supplement doesn’t mean that we should discount it. Years ago, I had a client who had schizophrenia and also some heart trouble. He read an article about omega-3 fatty acids and so he started taking a number of different supplements. Including a daily vitamin, a fish oil supplement and another one that I can’t remember right now. He started having some side effects where his hallucinations were actually increasing. That seemed odd and we had no extra stressors, no changes and meds, nothing. And so as I questioned him deep trying to figure out day to day. 

I asked him to repeat it to me again. “All right, Tell me about your morning. You get up and you get your pills. Tell me what’s on the counter. Tell me what’s in your med pack. How many pills are there? What are they?” This is how I found out about all those supplements. So I did a little research later and I asked him, “okay, when did you start taking these supplements? Oh, a couple of weeks ago”. This was literally the only change. Well, he stopped taking all those supplements with the direction of his doctor and that stuff went back to normal.

So these sleep medications even over the counter have different side effects that someone might not relate to what’s happening in their body. All of this, to say that when you are doing an assessment on your client and talking about sleep,  it’d be easy for us to add questions about, do you ever take anything to help you sleep? What is that? How often are you taking that? What’s the after-effect like? Do you feel tired in the morning and that kind of thing? How many nights a month do they feel like they have trouble falling asleep?  Sleep is something I think that we can easily assess with people. That knowing about medications and what they’re using to help themselves sleep could tell us a lot about them.

This was the intro of our sleep medication discussion. We needed to establish what we’re talking about when we talk about sleep problems, what the experts are saying constitutes a sleep problem or a diagnosis and what they do for treatment. Next week we’re going to talk about some specific sleep medications. We’ll talk about the addictive potential,  dependence including tolerance and withdrawal.  As well as short and long-term effects of these medications. I hope you’ll join me for that podcast until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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