One of the hardest things I treat in practice is chronic insomnia. I try to convince people to do behavioral interventions, CBT (using the CBTi app) and mindfulness but I have had very little success with patients buying in to the concepts. I never prescribe Z drugs such as Zolpidem/Ambien but I have inherited many patients who have already been on them for years. These medications were never meant for long term use and from what I can tell, Ambien CR was only approved for 24 weeks at a time. Regardless, patients have been on them for extended durations, sometimes decades, and have now developed both tolerance and dependence. I try my best to wean off at a slow pace (16-30 weeks) but unfortunately many patients are still unsuccessful. For those who qualify, I will try low dose mirtazapine, trazodone, melatonin, TCAs, or SSRIs (if treating underlying mood disorders). Sometimes this approach is helpful but there are some who still have chronic insomnia. I never use benzodiazepines chronically because of the same fears of tolerance and dependence I have with Z drugs. I have also anecdotally heard that these medications cause your sleep cycle to be altered? I’m unsure about the last part.
What approaches to chronic insomnia have you found to be most effective? What approaches to weaning a patient off of Z drugs have you found to be most effective?
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