DEAR DR. ROACH: I am a 77-year-old woman. I have had problems with insomnia for at least 50 years, but it is much worse now. Some nights I don't sleep, and some nights I get maybe three or four hours. My primary doctor will prescribe only certain meds and will not prescribe meds I took in the past, like Dalmane or others. All he will prescribe is Lunesta or Ambien, and lorazepam when needed. I do take melatonin 5 mg. I am at my wits' end. I have OCD about insomnia -- I worry what will happen to me with all of this sleep loss. My doctor says I am relatively healthy, with normal blood pressure and recent blood tests. Should I see a psychiatrist? Maybe they can find some med that would work. -- Anon.
ANSWER: Insomnia is a common problem, and while medication treatment can be useful, medications should not be the first line of treatment. Most people with insomnia do well with behavioral changes. Hopefully, you have made some of these changes over 50 years of having insomnia.
When people don't have success with sleep hygiene, then sometimes medications are used. I am a bit concerned about the three different classes of sleep aids you are taking. Eszopiclone (Lunesta) and zolpidem (Ambien) work on a receptor in the brain called the GABA receptor, which is the same receptor that the benzodiazepines lorazepam (Ativan) and flurazepam (Dalmane) affect. Dalmane is seldom used anymore for sleep, because it is converted by the liver a metabolite, which can last for days. Long-term use of benzodiazepines has the potential for development of withdrawal symptoms even while taking the same dose. I avoid prescribing them long term. They also increase the risk of falls, and of driving accidents for people who drive. Melatonin works on its own, separate receptor, and is much safer.
Many people have anxiety about sleeping. I think you are using the term "OCD" here as it is commonly used in everyday speech, meaning you have anxiety about it. This should not be confused with the actual diagnosis of obsessive-compulsive disorder, which is very different and has its own specific behaviors that dictate diagnosis. Anxiety about insomnia can lead to worsening of insomnia, and treatment of the anxiety -- with counseling or with medications, not the kind used for sleep -- may help the sleep issue.
Referral to a sleep specialist could help you; however, in your case, a psychiatrist may be of benefit given your level of anxiety about the sleep disturbance. On the other hand, a sleep specialist probably has more experience in dealing with sleep issues, and may find a successful regimen that will prevent you from being anxious about sleep.