Your Doctor Is In, But Is She Awake?

Untitled5Last week, to my delight, a returning patient whom I have followed since 2011, began our session with a smile, “I am still cured.” This Ob-Gyn physician, had come to me with a simple request, “I want to get off Ambien and get back to a normal ability to put myself to sleep.” She had been a good sleeper as a child and through college. In medical school, she would manage occasional bad nights of sleep with relaxation breathing and white noise machines. During her residency in Ob-Gyn, she was up 24 hours, at least once a week.

During other stretches of her residency, she would work 6 weeks of 12-hour night shifts (which of course stretched out to 14 hours). But life was simple while in training, work long hours, eat, and sleep from exhaustion. If she had an occasional bad night of sleep, a simple OTC (over-the-counter) sleeping medication, typically containing some form of Benadryl-like medication, would do the trick.

But then “life happened,” as she finished training and her Boards, she married, moved across country, had two children, and entered a busy private practice clinic, which requires she work 5–9 nights/month. While she may work the day in the clinic, before her “on call” night, she typically has the day off after a night on call. She had started to take Ambien (zolpidem) on her night’s when not “on-call.” But her long list of Ambien “misadventures” concerned her and had her husband fed up. She would take her Ambien after putting the children to sleep. But as she wound down doing email, she became aware over time, of more and more problems such as ordering useless items on line, and posts to Facebook she did not recall in the AM. She would repeatedly fall asleep in the bathtub, only to awake when her face hit the water, which was cold by then. She knew she needed to be off Ambien, but wanted guidance.

To begin with, she had been referred by a local sleep specialist, who had done a sleep study (polysomnogram) that showed no sleep apnea or restless leg syndrome. These are two primary sleep disorders that can often contribute to complaints of insomnia. She was also known to be in good health, with normal thyroid studies, and no depression, other common problems seen with insomnia complaints.

She was offered 4 to 8 sessions of Cognitive Behavioral Therapy for Insomnia (CBT-I), which in my clinic we nickname “Sleep School.” She began keeping sleep logs, no longer watched the clock after lights out, and engaged in “dusk therapy” by taking melatonin 3 mg, 90 minutes before lights out, and she avoided bright light and computer/device screens. Interestingly, without much else to do, she started going to bed earlier than she had as an adult, retiring around 10:30 PM and arising a 6:00 AM.

Her attitude toward her sleep “on call” in the hospital changed from worrying that she would not get enough sleep, to allowing herself to get the rest (not necessarily sleep) she needed. She began using a white noise app on her phone, or listening to a Guided Imagery of a beach scene, which we had recorded onto her phone, in one of our sessions. Knowing that she had Nuvigil (see below) available the next day, took away the panic of not sleeping “on call.” Paradoxically this improved her ability to “catnap,” in the hospital’s “on call” sleep room.

Targeted use of prescription medications and OTC medications are used in this integrated approach to Insomnia treatment. She began taking melatonin 3 mg, 90 minutes before her intended bedtime, to signal her circadian clock that sleep time was approaching. She also had the option of taking Nuvigil (armodafinil) on post-“on call” mornings. Nuvigil is an alertness promoting medications that is FDA approved for Shift Work Sleep Disorder. For her, this works best if she can nap for two hours after arriving home from the hospital in the morning, from 9 -11 AM, after the children had gone to school. With low dose Nuvigil, she felt alert the remainder of the day. She no longer had to take naps in the car when she was carpooling her children to activities. Ambien (zolpidem) was discontinued, and replaced short term by a similar sedative hypnotic Lunesta (eszopiclone) at a lower equivalent dose, taken when already in bed for the night “off call.” She was off all prescription sedative hypnotic medications for sleep for three weeks before CBT-I session V, and we have begun periodic 3–6 month follow up visits since that time.

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