Managing Sleep Issues: Transitioning from Anxiolytics to Mood Stabilizers

Q: Managing Sleep Issues: Transitioning from Anxiolytics to Mood Stabilizers

Hello： It seems that you are troubled by difficulties sleeping and various situations arising from medication use; I empathize with you! First of all, insomnia is usually just a symptom, and when it occurs, we need to understand why it happens. <br>Factors such as stress, changes

Metoprolol and Anaprilin?

Hello, doctor.
This summer, I experienced difficulty falling asleep and visited a nearby family medicine clinic, where the physician prescribed me 0.5 mg of Alprazolam.
Initially, I only took it occasionally when I had trouble sleeping, but it later evolved into a daily routine of taking it before bed.
Upon my request, the doctor increased the prescription from a week's supply to a month's supply (28 tablets).
However, I noticed that it didn't always help me fall asleep, so I wanted to gradually reduce the dosage.
I decreased my intake from one tablet to half a tablet, then to a quarter of a tablet, but I hesitated to stop completely because I once tried to quit and found myself unable to sleep in the middle of the night, overthinking and wondering if it was related to withdrawal.
This anxiety seemed to affect my ability to fall asleep.
Following the clinic doctor's advice, I consulted a psychiatrist at a larger hospital.
The psychiatrist prescribed me Mirtazapine, stating that it could be used as a transition to discontinue Alprazolam, and that Mirtazapine has a lower risk of dependence.
I was advised to take it three to four hours before bedtime for better effect, with a dosage of either half a tablet or a quarter of a tablet.
I initially took half a tablet, then reduced it to a quarter, which I have been taking since.
Since the doctor indicated that Mirtazapine and Alprazolam could be taken together, I maintained a regimen of taking a quarter of each for a period, spaced two to three hours apart, but I am unsure if this is appropriate since it was not specifically directed by the doctor.
However, my sleep issues have generally improved.
Once I fall asleep, I can sleep for over eight hours, sometimes even longer, which makes me wonder if it is due to the sedative effects of the medication.
I have never needed much sleep, often feeling refreshed after just five or six hours, and rarely sleeping for such extended periods.
Additionally, the side effects of the medication have been bothersome, particularly the dizziness that I experience almost every day, from day to night.
While it is not severe enough to interfere with my daily activities, it is still uncomfortable.
I also experience palpitations and chest tightness.
Recently, I underwent an electrocardiogram, echocardiogram, chest X-ray, and blood tests, all of which returned normal results, and I do not have high blood pressure.
I have had similar tests done five or six times over the years.
Therefore, I wonder if this is related to autonomic nervous system issues.
I want to discontinue the medication, but I hesitate to do so without a doctor's guidance.
I would like to ask the doctor whether I should discontinue Alprazolam or Mirtazapine.
The psychiatrist mentioned that Mirtazapine can be taken long-term.
Since the outpatient consultation time is limited, I often cannot express everything I want to say, so I hope to seek your advice here.
Thank you.

Ong Picton, 60~69 year old female. Ask Date: 2021/12/22

Dr. Lin Mianzhang reply Psychiatry

Hello: It seems that you are troubled by difficulties sleeping and various situations arising from medication use; I empathize with you! First of all, insomnia is usually just a symptom, and when it occurs, we need to understand why it happens.
Factors such as stress, changes in routine, environmental changes, caffeine, alcohol, or the intake of other substances can all contribute to insomnia.
In addition to these more easily adjustable factors, physiological conditions can also cause insomnia.
Statistically, more than half of individuals with chronic insomnia (lasting over three months) also have mental health disorders, so it is important to assess for conditions such as depression or anxiety.
If a cause can be identified, then treating that cause will more fundamentally improve insomnia.
Of course, there are also individuals whose insomnia has no identifiable cause; in such cases, medication may be necessary.

There are many factors to consider when choosing medication.
If there are symptoms of depression or anxiety, the use of antidepressants is warranted.
Antidepressants are not addictive and do not lead to dependence over time, making them a preferred option.
However, if insomnia is severe, sedatives may sometimes be required, but long-term use of sedatives can lead to addiction and dependence, so they are not recommended for prolonged use.
For instance, if you find it difficult to sleep after stopping Ambien, this indicates withdrawal symptoms due to physical dependence.

As for alternating between Melatonin and Ambien, it is generally acceptable, but it is usually recommended to take Melatonin before bedtime.
I wonder what your reasoning is for alternating; this could be discussed with your physician.
Common side effects of Melatonin include dizziness, and it may also cause orthostatic hypotension, which can lead to palpitations.
If your physical discomfort is troubling you, it is advisable to discuss with your physician whether a medication change is necessary.

The autonomic nervous system regulates many bodily functions, including heart rate, blood pressure, respiration, and gastrointestinal function.
Therefore, any condition affecting these systems can be described as autonomic dysfunction, but it is not a precise medical diagnosis.
If you wish to discontinue medication, it is best to discuss this with your physician first.
The general principle is to consider tapering off medication only after the condition is stable, and this should be done gradually.
Given the side effects of long-term sedative use, it is generally recommended to taper off sedatives (such as Ambien) first.
However, since you cannot tolerate the side effects of Melatonin, if you switch to another antidepressant, you may still need a sedative during the transition to help with sleep.
Therefore, it is advisable to have a detailed discussion with your physician about how to taper off medications appropriately.
Wishing you a speedy recovery!

Reply Date: 2021/12/22

More Info

Managing sleep issues, especially when transitioning from anxiolytics like Alprazolam (安邦錠) to mood stabilizers such as Quetiapine (美妥平), can be a complex process that requires careful consideration and guidance from healthcare professionals. Your experience highlights several important aspects of medication management and sleep hygiene that are crucial for improving sleep quality and overall well-being.

Firstly, it’s essential to understand the role of the medications you are taking. Alprazolam is a benzodiazepine, which is commonly prescribed for anxiety and sleep disorders. While it can be effective in the short term, long-term use can lead to tolerance, dependence, and withdrawal symptoms, which may explain your anxiety and sleep disturbances when attempting to reduce the dosage. On the other hand, Quetiapine is an atypical antipsychotic that is often used off-label for insomnia and mood stabilization. It generally has a lower risk of dependence compared to benzodiazepines, making it a suitable option for those looking to taper off anxiolytics.

Your decision to gradually reduce the dosage of Alprazolam is a prudent approach, as abrupt discontinuation can lead to withdrawal symptoms, including increased anxiety, insomnia, and physical discomfort. It’s important to follow a tapering schedule that is guided by your healthcare provider, as they can help monitor your progress and adjust the plan as necessary. Mixing medications without medical supervision can be risky, as it may lead to unpredictable side effects or interactions. Therefore, it’s advisable to consult your psychiatrist about the appropriateness of taking both medications simultaneously and to clarify the best tapering strategy.

Regarding your sleep issues, it’s encouraging to hear that you are experiencing improvements in your ability to fall asleep and stay asleep for longer periods. However, the side effects you mentioned, such as dizziness, palpitations, and chest tightness, warrant further investigation. While your recent tests have returned normal results, these symptoms can sometimes be related to anxiety or the effects of medication on the autonomic nervous system. It’s crucial to communicate these side effects to your healthcare provider, as they may need to adjust your medication regimen or explore alternative treatments.

In addition to medication management, incorporating good sleep hygiene practices can significantly enhance your sleep quality. Here are some strategies to consider:
1. Establish a Sleep Routine: Go to bed and wake up at the same time every day, even on weekends. This helps regulate your body’s internal clock.

2. Create a Relaxing Bedtime Environment: Ensure your bedroom is conducive to sleep—dark, quiet, and cool. Consider using blackout curtains, earplugs, or a white noise machine if necessary.

3. Limit Stimulants: Avoid caffeine, nicotine, and alcohol, especially in the hours leading up to bedtime, as these can interfere with your ability to fall asleep.

4. Wind Down Before Bed: Engage in calming activities before sleep, such as reading, gentle stretching, or meditation, to signal to your body that it’s time to relax.

5. Limit Screen Time: Reduce exposure to screens (phones, computers, TVs) at least an hour before bed, as the blue light emitted can disrupt melatonin production and hinder sleep onset.

6. Physical Activity: Regular exercise can promote better sleep, but try to avoid vigorous workouts close to bedtime.

7. Mindfulness and Relaxation Techniques: Practices such as deep breathing, progressive muscle relaxation, or guided imagery can help reduce anxiety and prepare your mind for sleep.

8. Seek Professional Support: If sleep disturbances persist, consider cognitive-behavioral therapy for insomnia (CBT-I), which has been shown to be effective in treating chronic sleep issues.

In conclusion, transitioning from anxiolytics to mood stabilizers requires a thoughtful approach that considers both the pharmacological and psychological aspects of sleep management. Open communication with your healthcare provider is key to navigating this process safely and effectively. By combining medication management with healthy sleep practices, you can work towards achieving a more restful and restorative sleep pattern.

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