Marks Psychiatry

I’ve frequently prescribed benzodiazepines (benzos) such as Klonopin and Ativan for patients with anxiety. For some patients who are particularly anxious in the evenings, taking the medication can help relax them to the point of falling asleep easier. I usually tell them it’s not a good long term solution for sleep and the most obvious was the habit forming potential and the need to resolve the sleep issue without the long term use of medications. However, another important reason is that benzos decrease slow wave sleep. As mentioned in a previous post, stages 3 and 4 are slow wave, or deep sleep and necessary for us to wake feeling rested. So a benzo can knock you out for several hours which can make you feel better in the short term, but in the long term you need adequate amounts of the deep sleep that you get in stages 3 and 4 to have healthy and restorative sleep.

So how has the pharmaceutical community addressed this? Medications like Ambien, Sonata, and Lunesta have no effect on stage 3 and 4 sleep. In fact, in studies Sonata was shown to increase stages 3 and 4. Do these medications work? Well, for me anecdotally (meaning this is not a scientific study, but based on my practice experience with a limited population), I’ve had the most success with Ambien. I’ve had several patients complain of a bad aftertaste – a kind of metallic taste when taking Lunesta. Brushing their teeth forever didn’t help. BUT, everyone is different and I always tell people, what works for one person may not work for someone else.

Ambien has it’s own quirky side effect that is fairly rare and that is nighttime eating. For those who it affected, I was told they would wake up in the morning and notice plates in the sink or partially eaten food on plates and would not remember leaving their bed.

Despite this issue with Ambien, it’s probably better than taking a benzo for an extended period of time because it doesn’t affect your sleep architecture. But it is important to discuss this with your doctor as all medications have pros and cons and your doctor should prescribe something meets your needs.

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You may have heard this term used before, it refers to the different stages that make up our sleep. Understanding these stages of sleep help scientists and clinicians target treatments for insomnia.

Sleep is divided into two stages – Non-rapid eye movement (NREM) and Rapid eye movement (REM). NREM is further divided into four stages, numbered 1-4. Stage 1 is the drift off into drowsiness and it usually lasts about 5 -10 minutes. If you were awakened at this time, you’d probably feel like you never fell asleep.

In stage 2, brain waves slow and eye movements stop. You may observe some muscle twitching in someone in this stage of sleep. Stages 3 and 4 are deep sleep and brain activity will show slow delta waves. Stages 3 and 4 are responsible for the restorative effects of sleep and allowing us to wake feeling refreshed.

NREM sleep cycles throughout the night usually lasting 90-110 minutes for each cycle. This means usually 90 minutes after falling asleep, you enter REM sleep, which is when we dream. When we cycle through NREM, it goes Stage 1, 2, 3, 4, 3, 2, REM. Therefore, we enter into a lighter stage of sleep when we are dreaming. Our brain has heightened activity but our muscle groups are paralyzed. This paralysis is temporary and normal during this stage of sleep as it prevents us from acting out our dreams. Some disorders of sleep inhibit the muscle paralysis and the person can sleep walk or act out their dreams while their brain is still sleeping.

There are several REM periods throughout the night, the first one lasting about 10 minutes and each subsequent one getting longer. It is thought that the last REM period lasts about 1 hour. This means you can have several dreams throughout the night, but since the last one is the longest, it is this dreamtime that you are most likely to remember.

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