Medication and sleep

[Dying_Swan]

Wasn't sure where to put this so putting it in general meds forum.

I'm currently on 400mg quetiapine, 75mg venlafaxine and 7.5mg mirtazapine. At first, mirtazapine was incredible for sleep, and it was upped to 15mg. Then when I started quetiapine I was taken off mirtazapine, but quickly put back on it because the quetiapine didn't make me sleep, and just caused agitation.

Mirtazapine stopped making me sleep so I tried 50mg trazodone instead for about a month, but that didn't work so I went back to 7.5mg mirtazapine. It's not working though. Once I'm asleep, it's fine, but often I'm awake a long time, and then the side effects of quetiapine kick in (horrible restlessness) and it's a vicious circle.

So I figured I might as well stop mirtazapine since it's not working and making me crave sugar, but this idea didn't go down too well with the CPN. I'm not sure why because I'm only on it for sleep.

Does anyone know of any other sleep aids I could try? I'm keen to avoid benzos or zopiclone. Might it be worth trying to split the mirtazapine to 3.75mg?

Thank you :)

[lebonvin]

If yous reduce Quetiapine to 50mg it will help you sleep but dunno if they'll let you do that unless you raise venlafaxine to say 150

[WiseMonkey]

With your Dr knowledge, if might be better to come off all these meds and just try a low dose tricylic like Doxepin or Amitryptiline.

[panic_down_under]

Does anyone know of any other sleep aids I could try? I'm keen to avoid benzos or zopiclone. Might it be worth trying to split the mirtazapine to 3.75mg?

I don't think BZDs, or zopiclone are the answer either as tolerance to their sedation build quickly, often within a week or two. Doxepin might work as it is a little more sedating than mirtazapine, but I suspect that won't last long either.

Imho, the real issue is you're taking 3 meds, none of which seems to be helping much and arguably are probably making things worse and just throwing more and more meds into the mix in the hope of either stumbling onto some miracle combination, or to reduce the side-effects of the others is nutz.

If memory serves, you started on venlafaxine which proved inadequate even at high doses and the mirtazapine was added to counter the SNRI induced insomnia. Then quetiapine was added in the hope it might either boost the venlafaxine, or be the answer on its own. So my first question for the CPN is why you're still on venlafaxine when it is doing bugger all? The second question is why are you still on quetiapine when it seems to be mostly just causing agitation and possibly the insomnia too? And the third question should be why are you still on mirtazapine for insomnia when it isn't helping you sleep?

I really think your med regime needs to be reviewed by a psychiatrist. I don't see the point in taking 3 ineffective meds when another might do the trick on its own if given the chance. Poly-pharmacy is sometimes necessary, but it should be among the last options tried, not the first.

</soapbox>

[Dying_Swan]

Thank you all for your replies. I've not heard of doxepin so maybe that's an option. I've got reviews with both my private psychiatrist and the NHS one coming up, but I don't think they'll let me reduce quetiapine. If anything I reckon they'll increase it. It seemed to work for a couple of weeks but then stopped. I think the private psych is likely to take me off venlafaxine, but I haven't met the NHS one yet so don't know what he will do. I've not taken the mirtazapine for the last two nights and I've slept as well as if I took it. It's just disheartening as it was working so well. Thanks again guys. Some things for me to mull over.

[panic_down_under]

I've not heard of doxepin so maybe that's an option.

Doxepin is a TCA, or at least that is what it says on the box, but whether it has any real antidepressant activity is debatable. Mostly it is just another very potent sedating antihistamine vying with mirtazapine as to which is the more powerful. It might be a little more sedating, but how long this will last is the question. The problem is quetiapine is also a strong antihistamine so is probably adding to tolerance building.

[Quinn1]

I was put on Doxepin a few years back i didn’t like it,it was like Zoloft I had suicidal thoughts whilst on them:mad:

[Dying_Swan]

Thanks PDU and Quinn. I will ask one or both psychiatrists what they think I guess. I get a bit fed up when they start on about sleep hygiene, having had this problem nearly 20 years. Mirtazapine was such a miracle, but quetiapine never got close in terms of sleep. I think it perhaps keeps me asleep though, it's just falling asleep that's the problem. I have read of people taking a really tiny dose of mirtazapine and wondered whether that might work. Sorry to hear you felt so awful on doxepin Quinn. Sounds like it's one to be careful of.

[WiseMonkey]

Doxepin is one of the older tricyclic antidepressants but it works well for sleep at a low dose (10 mgs). It can be used specifically for this. At this dose it doesn't have a antidepressant effect. Doxepin and Amitryptiline both have an antihistamine effect, they are also used for some painful conditions at this low level.

[Dying_Swan]

Thank you WM. I will definitely ask about it. I don't think 7.5mg mirtazapine is enough for an antidepressant effect either so they might be willing to let me try it. It's a relief to at least know there's something else I could try. Thank you :)

[Dying_Swan]

Just to update, they wouldn't prescribe me anything else for sleep. The psych wasn't familiar with doxepin and for whatever reason wouldn't give me amitriptyline. He thinks my sleep will improve when my mood improves, so is increasing my quetiapine. Thank you to everyone who replied. I really appreciate it.

[panic_down_under]

The psych wasn't familiar with doxepin

Sigh. This is the problem with the profession these days. Too many psychiatrists only know about SSRIs, SNRIs, plus a couple of novel meds such as mirtazapine so go direct to antipsychotics when the limited number of ADs in their bag of tricks fail instead of trying the older *ADs which are often more effective than the newer ones. :sad:


* although doxepin probably doesn't qualify as an AD

[Dying_Swan]

Thank you for your reply. I was surprised he wasn't familiar with it, although I think I'm going to have a med review with the NHS psychiatrist so maybe he will have some other ideas.

[WiseMonkey]

Thank you for your reply. I was surprised he wasn't familiar with it, although I think I'm going to have a med review with the NHS psychiatrist so maybe he will have some other ideas.

I completely agree with Panic Down Under, the older tricyclics can work much better plus they're tried and true meaning they've been around since the late 1950's. I'm surprised that your physc hadn't heard of Doxepin (cousin of Ami and chemically similar)! Unfortunately it's not being imported to NZ anymore, so I'm switching to Ami. As stated before they have a significant anti histamine effect, which is why they're so beneficial for those of us who have autoimmune conditions. Ask your own Dr about Doxepin.

ps. they reason I know a lot about tricyclics is because I'm older and they were the most popular AD's used in the 1980's. They suited me whereas the other certainly didn't!

[MyNameIsTerry]

I have a funny feeling this med isn't used in the UK but checking the BNF site shows it's there. And the MHRA have recently passed a new generic form in March 2019. Maybe he knew it as Sinepin? Still no excuse though. It's supposed to be expensive (would have to check this...but maybe he does know about it and doesn't want to have the conversation which happens with some doctors :winks:) but hopefully the generics will bring it down. But if not many use it that might explain why it's expensive, a drug companies way of discouraging you in the same way a builder giving an inflated estimate because he doesn't want the job.

EDIT: I think it might have been Dosulepin that wasn't available in the UK. Only for those already on it otherwise it has to be prescribed by a specialist initially.

[Dying_Swan]

Thanks guys. He basically just said I'd already tried drugs which have an antihistamine effect (mirtazapine and trazodone) so I think he thought if they don't work, others won't either. After a few good nights, last night I increased quetiapine and didn't sleep well at all. I will ask the NHS psych about something else to help, though I have a feeling they're going to switch me from quetiapine to something else :wacko:

[pulisa]

My son is an inpatient and has been switched to risperidone from quetiapine. The psych says that with ven it's a good combination. Mind you he now needs lorazepam and zopiclone to sleep...

[Dying_Swan]

I'm really sorry to hear that Pulisa. It is supposedly a good combo, or so I'm told. Quetiapine is also supposed to be sedative but as you know, that hasn't been my experience. Once I'm asleep it does tend to keep me asleep, but getting to sleep isn't always easy. How long has he been on it, and at what dose?

[pulisa]

He's been on 2mg risperidone for about a week to help with ruminations but I think the plan is to increase. He has ASD so things are quite complex.

[Dying_Swan]

Sorry, I read it wrong and thought he'd started quetiapine. I really hope the risperidone will help him and he'll soon be better able to sleep. It makes such a difference.

[pulisa]

No he's been on quetiapine but the docs on the ward prefer risperidone. It's all personal preference...or trial and error!:D (i know it's not funny really but MH is so difficult to treat effectively and consistently)