Insomnia: The pharmaceutical phase

Once my doctor recommended I see a psychiatrist, the first task was to find one. I contacted more local clinics than I ever want to recall. Almost all of them were not accepting new patients, or weren't accepting patients like me, or had a waitlist, or just never picked up the phone! Imagine being someone desperately in need of support and having to go through all that! Trying to find a psychiatrist is enough to make you need a psychiatrist!

Anyway, I eventually succeeded in setting up an appointment for the last week in April. The virtual appointment was just as nerve-wracking as the original search had been—the audio on the video call was so bad that I spent the entire appointment asking the doctor to repeat himself and cringing at the sound of my own words echoing back at me 1 second after I'd said them. Somehow I survived my psych appointment with my sanity intact, and came out the other end with a prescription for mirtazapine.

I was afraid to take it.

I have always been a little leery of prescription medicines. I'm fine with taking a course of antibiotics or whatever is necessary to rid myself of some temporary invader, but the idea of using drugs to alter the way my own body functions kind of gives me the willies, especially if there's a possibility that I'll become dependent on the drug forever. My limited experience with pharmaceuticals also tells me that the side effects are usually just as bad as the condition they purport to treat! I won't digress too far with the tale of when I was prescribed Nexium, but let me just say that a few days on the purple pill made me feel worse than no pill at all, and it took me over a month to get back to feeling normal!

So I approached the use of prescription sleep aids with extreme trepidation and read the entire list of side effects before I began. There were a ton, and they were all very worrisome! I really, really, really, didn't want to become dependent on mirtazapine, but I did have high hopes that it would at least give me a few nights of decent sleep, so that my body could remember what it felt like.

Oddly enough (or unsurprisingly, depending on how you look at it), as soon as I had received the prescription but before even taking it, I started sleeping better (from around 4 hours a night to 6). Just believing that relief was only one pill away helped me relax immensely. But curiosity won out, and I decided after a few days to try the prescription.

I don't really recommend reading the next part, unless you're a glutton for overly procedural accounts of solutions that didn't work and near-infinite variations thereof. If you're not that sort, I'll catch you after the curtain. If you are that sort, settle in for what can only be described as a shitshow—in 4 acts!

ACT 1: Mirtazapine

I took my first mirtazapine dose five days after the appointment. It did not help me fall asleep any faster (I still lay awake for 2 hours), but I slept for 7 hours straight, which was a nice change! Unfortunately, it made me extremely groggy the next day (I didn't stop feeling tired until early evening), and never worked as well again after that. Most nights when I took the mirtazapine, I slept for four miserable hours, and felt like a zombie the day after.

I feel that the medical institution let me down during this phase. I barely got any instructions on how to use the medication (I probably wouldn't have been able to hear them if I had) and no instructions on what to expect or what to do if it didn't work as expected. So I had to figure it out all alone. I was told to take one-half pill an hour before bedtime, and that's what I did. I felt tired within minutes, but I forced myself to stay awake for the full half hour.

This, I have since learned, is a mistake. When you take a sleep aid, you should be prepared to go to bed immediately, and ideally, you should already be in bed when you take it. That way, when the sleepiness hits, you can just lie down and hopefully zonk right out. The longer you spend powering through the drowsiness and trying to stay awake, the less likely you are to sleep (and with some drugs, the more likely you are to engage in strange semi-somnolent behaviors like sleep-driving and extreme eating). But no one told me that, so I missed the optimal timing by trying to do it by the book.

And then I compounded the problem by experimenting. I tried taking the pill even farther in advance of bedtime (hoping that this would reduce the next-day drowsiness), not knowing that this was going to make it less likely to help me sleep. 

 

I also experimented with the dosage. I had found enough information online to learn that mirtazapine is more likely to help you sleep if you take a smaller dose, while higher dosages can actually be stimulating. I tried taking smaller and smaller doses, but that didn't do anything. One night, I took double the recommended dose, and I was up half the night, not only unable to sleep, but also afflicted by weirdly twitching thigh muscles. Never again!

I was supposed to follow up with the doctor after 4 weeks, but I hated the mirtazapine so much that I called the office after 2 weeks and was able to schedule a 15-minute chat with a different doctor. This consultation was over the phone, so I found it much more pleasant (no maddening audio issues this time), and the doctor was helpful and reassuring. I told him that since taking the mirtazapine, my insomnia had actually gotten worse. "Don't worry," he said, "We'll get you to sleep."

ACT 2: Trazodone

This time, I was prescribed trazodone. I researched the mechanism of action of that and mirtazapine and was disappointed to find that both of them do essentially the same thing: act antagonistically on various histamine receptors, to cause a sedating effect. If one histamine blocker had failed to help me sleep, I doubted a different one would do anything, but I dutifully gave it a shot anyway.

The results were even worse than before! This time, the instructions were to take the pill at bedtime, but I had found something on the internet that said you should take it 2 hours before bedtime. I split the difference, took the pill an hour before bed...and proceeded to lie awake for the next four hours! After a few days, I found different advice on the internet saying that best results are obtained when you take your dose as close to bedtime as possible. For a few nights, I took the trazodone just before bedtime and slept, but only for a paltry few hours.

Trazodone is not known for helping its users stay asleep, whereas mirtazapine is, so I decided to have another go with the mirtazapine, this time armed with the knowledge of proper administration timing. For one night, I had an almost perfect 7 hours of sleep! And then the next night, it was back to my old ways—took the pill, went to bed, lay there until, in desperation, I drank some alcohol. You're not supposed to combine alcohol with sedatives, because that's what people do when they want to die, but 1 or 2 shots is probably not going to make the difference between life and death, if the sedative isn't having any effect anyway. That was my rationale in any case—don't construe it as advice! Given that the mirtazapine wasn't effective at anything but making me feel comatose the next day, I gave it up and waited for my next 4-week appointment.

ACT 3: Lunesta

At this appointment, I had gotten a little wiser about the audio problems on the virtual meeting, so I was able to communicate better. I told my doctor that neither of the prescriptions had helped thus far. He asked me if I had ever tried Ambien. At this point, I bashfully (bashful because, like combining alcohol and sedatives, you're really not supposed to share prescription drugs) mentioned that someone had once given me a Lunesta and it had worked pretty well! So I left that appointment with a new prescription for Lunesta.

Oy vey, the Lunesta cost a pretty penny! I coughed up the 92 dollars for a month's supply, and really hoped that it would do the trick.

But — surprise! — it didn't!

By this time, I felt like an expert at taking sleeping pills, and the first night I took Lunesta, I did everything right. I'd been off caffeine for days, I took it right as I crawled into bed, I waited to get sleepy and then lay down my head. Instead of falling asleep, I started to get more antsy! I had a few intense muscle twitches, and after I'd been lying there for 2 hours, I began to feel hot and anxious. I had to get out of bed and walk around to calm myself, but even that didn't work, so I took comfort in my old standby – a shot of vodka – and finally slept for four hours. I woke up too early and didn't sleep again, and my anxiety skyrocketed! My ace in the hole, Lunesta, hadn't helped! I was pretty sure there was something wrong with me that couldn't be fixed.

But "pretty sure" isn't 100% sure, and I didn't have anything else to do but keep trying, so a few days later (after I had steeled myself against undesirable results), I took the Lunesta again—this time the maximum prescribed dosage of 3mg (the previous dose had been 2mg). This time, I fell asleep almost immediately and slept like a baby. That is to say, I kept waking up all night, but at least I slept! I was so pleased with myself, that I had another Lunesta the next night, and...got 2.75 hours of sleep. What had gone wrong!? I didn't know, but I was so disheartened.

I'd never planned to take sleep aids for the long term, but I'd really hoped that if I found the right one, I could take it enough days in a row that my body would catch up on sleep and stop perpetuating the cycle (did you know that sleep deprivation can actually cause physical symptoms that make it harder to fall asleep!?). But it was not to be. I was out of hope. I didn't think I wanted to try any more drugs, and I was just going to have to buckle down and do things the hard way: with cognitive behavioral therapy, However, that will be a topic for another post. In this one, we still have one more prescription to talk about.

ACT 4: Quetiapine

At my second 4-week follow-up with the psychiatrist, I explained my failed experiments with the Lunesta, and he said he was out of ideas. I should probably go get a sleep study. But first, there was one more thing I could try: quetiapine. Quetiapine is a little different from the other drugs I'd been prescribed thus far. Whereas Lunesta was designed specifically for sleep, and mirtazapine and trazodone are actually antidepressants prescribed off-label for insomnia, quetiapine is an anti-psychotic. It sounds powerful, right? It goes by the more common name of Seroquel, and several members of my insomnia support group (which I had joined in the midst of this saga) swear by it.

Although I was pretty weary of the revolving door of prescriptions, I filled this one, too (I'd asked for only a 7-day supply after the fiscal fiasco with Lunesta). My doctor had recommended that I take it jointly with the Lunesta, but I tried it one night by itself because I wanted to see its effects without being combined with other drugs. It took me almost an hour to fall asleep, but by this point, I had acquired some emotional regulation skills, so I refused to panic—I just stayed in bed, eventually drifted off, and clocked a delightful 7.5 hours! Victory! I knew better than to try and tempt fate by taking it another night, but I was pleased to find that drugs still could help me sleep...if I let them.

CURTAIN

You see, over those 2½ months of medical trial and error, I'd learned a lesson. Insomnia (in most cases, and definitely my own), is largely psychological. It comes from a misdirected activation of primitive survival instincts, and no exogenous chemical is going to override your survival mechanisms for very long (unless you take enough to kill you). 

 

Ask almost any long-term insomniac, and they'll happily (or grimly) tell you exactly how many prescriptions they've been on and how long it took before they had to switch to the next one. Every drug eventually stops working, because to truly overcome insomnia, your mind has to be a willing participant!

By early July, I'd learned how to help it do that, but it was with no thanks to conventional medicine. My psychiatrist certainly never had anything to offer but a drug and some crossed fingers. I promise I'll tell you, eventually, what set me on a better path... but first, I must share a little interlude, about a particularly wrong path! Tune in soon for the next terrifying installment of my insomnia chronicles!