antipsychotics vs benzos for sleep

Factual Questions
1

This isn’t a thread about medical advice but asking of the different side effects. I’ve been prescribed by a psychiatrists both for sleep. The antipsychotics were (aripriprazole - Abilify, risperidal - Risperidone) and the benzos were (alprazolam - Xanax and diazepam - Valium).

I can safely say that the benzos were by far superior for sleep. The antipsychotics are less effective but that aside, my sleep was not uninterrupted like with benzos. It wasn’t a peaceful sleep at all, I felt a druggy-like sleep (I know they’re all drugs) and still very tired and lethargic from antipsychotics. Even the most potent one, quetiapine - Seroquel is effective for being uninterrupted but still leaves you very groggy.

Benzos enable me to sleep like a baby without feeling tired during the day and unsurprisingly, are very very calming. Of course my doctor doesn’t prescribe thedue to the addiction risk and withdrawal symptoms. I’m also actually suffering insomnia from past benzos abuse and I know they’re not meant to be used at a high dose long term.

So back to my question, is there anything in the pharmacology that explains why benzos offer a much more pleasant sensation of sleep?

2

I’m surprised you were prescribed Abilify for sleep. My psychiatrist told me that it’s well known for causing agitation rather than relaxation. If someone needs to be calmed down from agitation rather than lifted up out of depression he normally uses Seroquel.

I’ve slept on both Seroquel and Klonopin for other reasons and while both greatly enhanced my sleep and cured my insomnia I didn’t notice any difference in sleep quality and did not have any grogginess as the result of them.

3

I used Seroquel for sleep several different times. I developed a tolerance for it and as the dosage went up the anti-psychotic aspect of the drug began to dull my mind so I would stop. And I was taking very small does, 50mg and less, it was very effective at getting me to sleep. I can’t imagine what the people on hundreds of mg a day feel like. The last time I used it after not sleeping almost altogether I began to develop Tardive Dyskinesia so stopped immediately. Luckily the shakes went away in just 24 hours.

My advice is use Seroquel to sleep cautiously and minimally.

4

Psychiatrist here. I’m always surprised when I hear of Seroquel being prescribed for insomnia. The drug has a substantial side effect profile and IMO the risks aren’t worth the benefits for someone whose sole or main complaint is insomnia. I do tell patients who are having trouble sleeping that the side effect of sedation may be beneficial in their case, but I don’t prescribe it solely for that purpose. And as someone else mentioned, Abilify is one of the least sedating antipsychotics, and if anything many people find it activating, so I’m not sure why someone would prescribe that for sleep.

In terms of why their effects feel different, sedating antipsychotics have an antihistaminic effect, just like Benadryl, while benzodizaepines act on GABA receptors.

5

I’m posting to warn you and everyone of the dangers of benzos, but I see you’ve already learned that the hard way. I’ll write this post anyway, for emphasis.

Benzos are drugs from Hell. As with opioids, your nervous system will acclimate itself to them, with the result that the effects become less, and you need ever-larger doses to get the same effect. And you become dependent on them, so it becomes difficult to quit. Benzos are outrightly addictive and dependency-forming, and quitting can produce hellatious withdrawal problems (including intense insomnia), which may even last for months or years.

Guess how I know all that.

If your problem is specifically insomnia, discuss the “Z” drugs with your doctor – these are, e.g., Ambien and Lunesta, I think. These behave much like benzos, but are said to be less addictive and easier to quit when you want to quit.

6

Seroquel exhibits remarkably potent antihistamine (H1) antagonism. The system is slow, so once off Seroquel, it’ll take months to return to normal histamine responses.

7

I take a drug cocktail for really bad insomnia, which I have had since my 20s. I have been through everything.

Right now, I take Topamax (topiramate), and I take it around 5pm. So by the time I am ready to go to bed, it has kicked in.

I also take a tiny dose of aripiprozole, 5mg (I break the 20s, or I wouldn’t be able to afford it). I take it at the same time I take the topiramate. It helps, I don’t know why, except that I have had sleep studies, and apparently almost every time I go into REM sleep, I startle, and most of the time, it wakes me up. The topiramate mostly makes this go away. But once i was maxxed out on this, my doctor decided to try something that enhances topiramate when it is used as an antidepressant. He told me to take them at the same time at first, and if it seemed to make things worse, then to take the aripiprozole in the morning. It helped, so I never did take it in the morning.

I take 10mg melatonin about 1/2 hr before bed.

A have Ambien and clonazepam as PRNs. I get 10 Ambien a month, and 15 clonazepam. I use the clonazepam when I have something going on in my life that is particularly stressing me out and making it extra hard to sleep, and I use the Ambien when something throw my schedule off, and I need to get back on it, or if, for some reason, I need to go to bed very early for an early morning (like when I work at the polls). I actually usually end up breaking the Ambien in half, because I don’t need the full strength. I don’t think I’ve ever had something going on that required me to take clonazepam for more than about 5 days in a row (except when my mother was in hospice 2 & 1/2 years ago). Also, because I am an insomniac, if something wakes me up in the middle of the night, I sometimes have a great deal of trouble getting back to sleep. so then, I take half a clonazepam, and sometimes another 5mg of melatonin, depending on what time it is. I get right back to sleep.

So, that’s what works for me.

Been sleeping pretty well for several years.

8

I have no observations to make on the anti-psychotics except to also express surprise that they would be used for insomnia.

As long as we’re relating personal experiences – IANAD and this is nothing but a personal anecdote – here’s mine. Due to a recent stressful situation my doctor was going to prescribe clonazepam, but foremost in my mind was my recollection of the beneficial effects (for me personally) of diazepam (Valium) back in my younger days. Doctors these days are reluctant to prescribe it because of its strong potential addictive effects, as noted upthread, though I never experienced any myself. Anyway, I did my best sales job and convinced her to provide quite a generous supply of Valium. I also got one of the Z-drugs for sleep, though I don’t normally have insomnia. Specifically it was zopiclone, which is in a slightly different subgroup but in the same Z-drug category as zolpidem (Ambien). Lunesta, incidentally, is something called an (S)-enantiomer of zopiclone, meaning basically that it’s a mirror image of the identical molecular structure.

Wikipedia claims that “Z-drugs are a group of nonbenzodiazepine drugs with effects similar to benzodiazepines”, to which I say: absolute bullshit, even if it’s medically true that both affect the GABA[sub]A[/sub] receptors in similar ways.

At least for me, Valium has distinct psychotropic effects: it’s soothing, relaxing, and a very pleasant way to get to sleep if you take it at night. It does not, however, make for a solid good night’s sleep because my usual habit of waking up in the middle of the night persists, something I’ve heard is associated with getting older. It isn’t for that purpose anyway. Whereas zopiclone is a hypnotic. It has no discernible (to me) psychotropic effects. You can take it and decide not to go to sleep and go about your business (just don’t drive!). Whereas if you lie down and close your eyes, you will. I’ve sometimes taken zopiclone and laid in bed thinking “this stuff isn’t doing anything” and my next thought was, “hey, it’s morning!”. And there is very little or or no aftereffect. I’ve had the same experience with Ambien. I love hypnotics for insomnia on the rare occasion that I need them.

9

To put it very simply, benzos more directly target parts of the brain that have to do with the sleep cycle. Antipsychotic are more indirect. However, both have lots if other effects that can get in the way and possibilities of the brain adapting in bad ways to mitigate their effects. However, antipsychotics can be effective for sleep at doses with less of hese problems.

My personal experience was that Seroquel worked without tolerance ever building, but benzos were a mess. However, after benzos, I can’t go on even low dose Seroquel without feeling like I need to claw my way out of my skin. Granted, that was during withdrawal, but it was bad enough I’ll never try it again.

I’ve had better luck with sleep hygiene (look it up) and low dose (0.3-0.6 mg) of melatonin, along with somebmagnesiumbfor muscle tension. Any higher dose of melaronin is too much, and a common mistake. Take it 1 hour before bed and start your bedtime routine (ala sleep hygiene) to cindition your brain that it is bed time.

10

The various benzos have different addictive potentials, and it depends largely on their half-life: The longer the half-life of a benzo, the less addictive. The shorter the half-life, the more addictive.

Valium has a long half-life and is not as strongly addictive as some others. I was a long term user for several years and never had any problem quitting, but I had to quit because of other adverse reactions. Clonazepam (Klonopin) is more addictive. I used that for a while and when it quit working for me, I had a horrendous ordeal kicking the shit. Xanax is reputed to be even worse.

11

Professor C. Heather Ashton (Ret.), professor of neuroscience at Newcastle University, ran a benzo withdrawal clinic for twelve years, and wrote a paper on the subject addressed for a lay audience:

Benzodiazepines: How They Work And How To Withdraw (aka The Ashton Manual)

This is a gold mine of reputable information and should be REQUIRED reading for anyone who has any issues or questions about benzos.