Appropriate treatment depends importantly on the exact cause and nature of a patient’s sleep dysfunction. Many psychiatric medications have sedative effects, Dr. Dasgupta cautioned: “The worst thing you want to do with somebody with undiagnosed sleep apnea, is put them on medication that causes more sedation, because that can worsen their sleep apnea.”

Drug-drug interactions are an important consideration when helping a patient with a psychiatric disorder to manage sleep problems, experts agree.

“When you are already on a medication for depression or anxiety, or schizophrenia, and then add on one of these prescription sleep medications, a lot of these medications work on the same receptors,” explained Dr. Dasgupta.

“When we talk about anxiety, we focus a lot on the benzodiazepine receptor, the GABA receptor,” he [BF4] said. “A lot of sleep meds work there. But by having too many drugs work on the same receptor, that’s going to give you a negative effect.”

Similarly, selective serotonin reuptake inhibitors (SSRIs) prescribed to treat clinical depression can contribute to patients’ sleep problems.

“Serotonin is an alerting neurotransmitter,” explained Dr. Dasgupta. “If you are preventing its re-uptake, and you have excess serotonin in your central nervous system, then you can imagine that it’s going to cause insomnia.”

It is not always safe to discontinue a patient’s SSRI pharmacotherapy, however.

That’s why the search for sleep drugs that target different neurotransmitter pathways is so important, Dr. Dasgupta said. Two new categories of insomnia drug help manage sleep problems via receptor systems that are not targets for psychiatric pharmacotherapy, Dr. Dasgupta said: melatonin agonists like ramelteon, and orexin (hypocretin) agonists such as suvorexant.

“Melatonin receptor drugs are good because melatonin does not play a very strong role in psychiatric disorders,” Dr. Dasgupta said. “I’ve been getting referrals for many patients who have psychiatric illness, to be considered for the orexin-agonist category of medication, because orexin agonists are very specific and don’t have that overlap with other receptors that we use in psychiatric illness,” he noted.

Melatonin supplements are widely used by patients with sleep problems but have not been approved by the FDA, Dr. Dasgupta was quick to note. “Like many dietary supplements, the questions is: what dose? At what time? Using what route,” he cautioned. “You don’t want to rely on any medication life-long—whether it’s prescription or nonprescription supplement—and there are going to be some drug-drug interactions.”

Melatonin does not present a particular concern for patients with schizophrenia, Dr. Dasgupta said.

“I think you’ve always got to weigh the alternatives,” Dr. Dasgupta said. “What’s better than melatonin? Well, no drugs is better! I always joke with my patients: if you want to double-dose on cognitive behavioral therapy, feel free! Take as much as you want!”

“It is both fortunate and unfortunate that we rely so much on chemical treatment using medications,” believes Dr. Dasgupta. “One of the foundations of treatment should be cognitive behavioral therapy, both during the day and during the night, addressing the patient’s nighttime issues. Because if you don’t address the nighttime issues, you’ll just make the daytime functioning a lot more difficult–whether you have a psychiatric disorder, or not.”

References:

1. Chan MS, Chung KF, Yung KP, Yeung WF. Sleep in schizophrenia: a systematic review and meta-analysis of polysomnographic findings in case-control studies. Sleep Medicine Reviews. 2016. Published ahead of press. DOI: 10.1016/j.smrv.2016.03.001.

2. Klingaman EA, Palmer-Bacon J, Bennett ME, Rowland LM. Sleep disorders among people with schizophrenia: emerging research. Current Psychiatry Reports. 2015;17:79. DOI:10.1007/s11920-015-0616-7.