ATAP: Ambien for depression?

This was sent from an MD to both the DrugNazi and myself. Here is my take on it.

I know you both probably think Ambien is bad medicine….
If you don’t, I do.

Eh, for occasional use its perfectly fine (especially if the patient just had a traumatic event/surgery/etc). Obviously if the patient needs 30 a month in order to sleep there is something deep underlying that needs to be addressed.

Regardless, today a miniskirted, stilletto heeled prostirep came into my office and tried to tell me that some Doc, which she desribed as a “sleep guru”, is now reccomending Ambien for depression.
Yes, depression.
The premise of the argument is that SSRIs can be activating and that ambien CR (which is magical as opposed to regular ambien which is poison) should be used to combat the insomnia “common” to ALL SSRIs.
Ok. Last I checked, and granted its been awhile, but all SSRIs are not created equal. some sedate, some activate, and those of us who prescribe with half a brain will tell the patient to take the activating ones (i.e. paxil) in the morning. and the occasionally sedating (i.e. zoloft) in the evening.

Ambien for depression? Maybe if you are depressed because your brain cannot recharge its neurotransmitters during sleep. Even that is a stretch. I think that people underestimate the power of a good solid 8+ hours of sleep. However one of the clinical side effects of depression is lethargy/sleeping a ton.
Funny how you mention that Ambien vs Ambien CR. I think you’re on the right track here. People are beginning to realize that they can pay 10 bucks cash for 30 generic ambien vs a $50 copay for trade name Ambien CR. Sinofi must be crapping their pants and trying to come up with new indications.
As far as the SSRI’s go, last I checked Prozac was the most activating (which is why it was initially investigated as a weight loss drug, only to be found to improve mood. Henceforth the SSRI craze was born) while Paxil (and its anticholinergic effects) was the most sedating. Its like Artane is way more activating than Cogentin is. Some people have even resorted to abusing Artane just to get that amped up feeling.
If the patient is responding bad to an SSRI, why not just give him/her Remeron and kill two birds with one stone? Knocks him/her out, and has antidepressant effects. Plus its dirt cheap. Trazodone has been used for years for this, and even though one out of a million men will have an eternally hard pecker, its worked wonderful for the last bazillion years.
Treating the side effects of a medication with another medication (AKA PolyPharmacy) just leads down the road to trouble. Next think you know the patient is on 30 different meds, you cannot switch any of them without a cascading failure as they get out of equilibrium, and when they get hospitalized its a real pain in the ass to treat them.

Oh, and the advisability of giving a patient a clearly addicting medicine (I dont care what the prostirep says) especially when they are depressed and at high risk for overdose seems inadvisable at best, and possibly malpractice at worst.

Yeah, I think something is seriously retarded with this drug rep or some key information was not being relayed to you. Giving a clinically depressed person (who doesn’t want to get out of bed, shows no sign of doing things that would normally make him/her happy, etc) a CNS depressant seems like pouring gasoline on the fire.
Overdosage might or might not be an issue here. Clearly the SSRI’s are tons more dangerous in high doses than Ambien (which is very Benzo like). Actually people don’t realize how hard it is to treat an aspirin overdose, and that kills more people than Rx medication does.

Am I off base here? It seems the reps have a new strategy for pushing off label uses. they just pop up with some “study” and pass them out like they are “educating” me. It seems that this is barely legal. (in the bad sense)

No, actually I’m thrilled that you are questioning what the talking heads are blabbing at you. More doc’s need to do this and show the drug companies (and the hot reps they employ) that doctors are not their little pawns in a money-making scheme.

Anyway I thought I would send this to both of you, TAP and Drugmonkey to see if you had a rant to develop.

Mine wasn’t very rant-a-licious. You had a legit question and deserved a professional answer rather than something with a lot of swear words and foul humor. Sorry if I disappointed you. :)

BTW, I am a professor at a family medicine residency, I frequently print out both of your blogs and post for the residents to read. I am pushing for a prostirep free clinc. I am not in charge or it would be.

Ah, we are corrupting the youth of medicine one resident at a time. Excellent.

Also, either of you want to travel to Arkansas and give a cme lecture to a bunch of docs?

I’ll keep your contact info.. :)

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30 Comments

  1. some guy in Arkansas who wishes not to be contacted by the Ambien police says:

    As the sender of the email in question, I just wanted to point out, that she was reccomending starting Ambien CR and an SSRI concurrently. or at least was referring to this “study”
    I wish I had grabbed it from her, but I was in clinic, and did not have the time to really argue with her.
    I love remeron, I think it is good medicine. I use it and even older ones like doxepin all of the time especially for people with anxiety type depressions. (incidentally I have never seen the remeron rep ever, and I know for a fact I write more remeron than ambien)
    I usually use paxil for depression with anxiety features, and they usually do not have psychomotor retardation, so maybe I haven’t picked up on the sedation with paxil.
    My biggest concern was that a rep was in my clinic pushing an off label indication via surrepetous means. very similar to the way the manufacturers of neurontin got in trouble with the FDA. (if i remember my history correctly)
    In my experience, and possibly I am a bit skewed here, there are two types of people. those that take ambien everyday, and those that do not take ambien. I think it is addictive, and is generally way overused, at least that is my experience locally. It seems that every new patient I see lately comes to me on Xanax, Hydrocodone, Soma, and Ambien. It is also seen frequently as a drug of abuse in the high schools here.
    Regardless, when the rep came in touting a new indication, that is in fact not indicated made me pretty irritable.
    thanks for responding to my Email, I appreciate it.

  2. Ok says:

    I’m a new grad pharmacist. I have heard there’s kind of a triangle relationship between pain/depression/insomnia, so IMO it’s not all BS they’re blowing at you. I was pretty depressed as a teenager and was more hypersomnic back then, but my classes and what I’ve read says that insomnia is more common for depressed patients. But really. trazodone or mirtazapine are probably far better choices than Ambien CR. That kind of stuff where you just get a whiff of BS makes you just as sick to your stomach and if it were all lies.

  3. M2Pilot says:

    CR really stands for continued revenue doesn’t it?

  4. Ambien for depression?

    Are you kidding me?

  5. EEJ says:

    Heck, if you think that’s bad, you should see some of the stuff presented at supposed “CME” events.
    TAP, what’s your take on the “new” soma 250?
    I’m assuming it falls in with all of the other CR, XR, etc. versions of meds.
    Apparently, they’re having a hard time getting docs used to pushing 350 to start Rxing the “new” 250 version. IMHO, it’s because the docs who are still pushing 350 never got it right to begin with…..

  6. http://openid.aol.com/MidwestPharmer says:

    On a random note, why does theAngriestPharmacist copy you blog topics immediately after you rant about them? Just wondering…

  7. depressed insomniac says:

    I’ve been prescribed both Remeron and trazadone for depression-related sleep issues. In my case, once I fell asleep at 3, 4, 5 a.m., after several hours of lying awake/flopping around/being depressed, I could stay asleep for a normal 7-8/10-12 hours. And by “could” I mean “three alarm clocks and friends calling me couldn’t wake me up”.
    So the sleep-inducing meds, in conjunction with other SSRIs, were prescribed pretty much because employers with cubicles expect too see their employees before lunchtime. I could take it around 9 or 10 p.m., fall asleep shortly, and wake up fairly well 6-7 a.m.
    (I wonder how many people are taking/abusing sleep medications for the same reason–the 8-5 thing just doesn’t work for some bodies, but they’re forced into it by external forces and it reads as insomnia or depression.)
    Remeron worked OK but made me gain 35lbs; the trazadone worked really well and I didn’t notice any effects. Sometimes I miss it (life improved and I’m no longer being treated).

  8. Gurl says:

    In the pamphlet they give you at the pharmacy it states that ambien can cause euphoria OR dysphoria.
    …just sayin’.

  9. limari says:

    I’ve heard of cases where Ambien can cause “sleep-eating”. You take your nightly dose, and wake up in the morning covered in mustard and Oreos and have no memory of it at all.

  10. Tyler says:

    Sometimes depression can cause people to have a hard time sleeping. I know many times all they want to do is lay around and not do anything, but there are some cases, especially the death of a loved one, where people are unable to sleep.

  11. rph3664 says:

    Have you heard the stories about people in persistent vegetative states taking Ambien AND WAKING UP?!?!?
    They are not normal by any stretch of the imagination, but some of them are functioning at a higher level.
    Speaking of which, has anyone by any chance seen “The Diving Bell and the Butterfly”? I read the book when it came out about 10 years ago, and it was very good. It’s not playing in my area but has already received several Golden Globe nominations.

  12. http://openid.aol.com/mikells43 says:

    next thing ull have is people crashing cars at 1pm in the afternoon cause they took too many ambien for their depression. gosh ambien is very addictive and dangerious.

  13. apgad says:

    Ambien is called Stilnox in Australia, and has been widely reported as causing all sort of bizarre side effects. Here’s some info from our FDA equivalent: http://www.tga.gov.au/alerts/stilnox.htm
    In addition to sleep-eating and sleep-driving, there have even been cases of sleep-sex reported. In one case a woman took a dose and was shocked to wake up the next morning beside her ex. She’d rung him and invited him over, and had no memory of doing so. He said she seemed a little spacy, but didn’t say no…
    Zolpidem has also been used in Europe for some time to temporarily “waken” patients in coma-like states, with varying degrees of success. It’s a very interesting drug…

  14. Rio Iriri says:

    I think the rep-free practice is overall a great idea in some respects, BUT, because you question their input instead of taking it as gospel, I think having them around and educating those around you as to how to deal with them critically might be more beneficial in the end.
    It would keep you up to date on the b.s. that they’re spewing, at the very least, so that you are able to anticipate it when a patient comes from another doctor who hasn’t been as critical of the information, or when a patient asks about the information (because they’re targeted, as well, through advertising and websites). Know thy “enemy” and all that.
    I am also going out on a limb as far as samples are concerned…I am very grateful for my doctor’s sample cabinet, as it’s kept me with a backup of Imitrex that I wouldn’t otherwise be able to afford, and it’s helped me through some lean times with a medication that isn’t generic yet. It also allowed me to try something before purchasing it, since a lot of things just don’t do what they’re supposed to for me.

  15. rph3664 says:

    I’ve been a big R.E.M. fan since their very first record. Google “Peter Buck” and “Ambien” together; this made big news in early 2001 when he took some (allegedly 35mg! Wonder what it really was) and went berserk on a trans-Atlantic flight. The next day, one of the Obnoxious Morning Deejays said simply, “This is not Ozzy.” And this was well before “The Osbournes.”
    Had it happened 6 months later, America’s Best Rock’n’Roll Band (as Rolling Stone dubbed them in 1987) would now be a duo, not a drummerless trio.
    Here’s another doozy Ambien story. One day, I was dinking around online and found a woman’s blog. She had been going through a messy divorce for the previous 2 1/2 years, and one night, she took some Ambien because she was too upset about it to sleep. Her 9-year-old daughter crawled into bed with her around 1 a.m., and a few minutes later, the child vomited all over herself, the bed, her mom, etc.
    So what did Mom do? Mom sniffed it, thought, “This is nasty!”, rolled over, AND LAID IN IT UNTIL MORNING! And she can’t figure out why her divorce proceedings were so terrible (besides the fact that she was posting them on the Internet, along with her full name, address, the names of her kids, etc.)?
    The comments were disabled. Gee, I can’t imagine why.

  16. Jane says:

    Ambien ruined my life! I want it back! Last year my GP prescribed Ambien after I told him I was having a sleeping problem. I was seeing him for servere pain due to a bad gastrointestinal infection. I so wish I had never mentioned my sleeping issue, which would have most likely dissipated once the infection was gone and our noisy eldery cat was dealt with. I also wonder why the GP did not inquire about my sleeping problem, or at least had given me some information about the drug and its possible side effects.
    Believe it or not, I had never heard of Ambien – never saw the TV ads, and had no friends or acquaintances on it. Now all I hear about is Ambien horror stories! I had never taken many medications and just assumed it would work much like an antibiotic. In less than the recommended limit of 10 days, I went from a person who had a situational sleeping problem to a chronic insomniac. Eventually the Ambien only provied 3-4 hrs. of sleep and left me feeling agitated the next day. I made the mistake and called the GP telling him I thought I was experiencing anxiety -another first for me. He prescibed Xanax, another med. I had no knowledge of. I think the “anxiety” feeling was a physiologic response I had to ambien.
    I feel just terrible that I never looked up information about these drugs, but it never dawned on me how dangerous and addictive they could be. The insomnia became so bad I was unable to work or function. A Psychatrist tried other meds. but nothing else worked. I think the Ambien destroyed something in my sleep center – I hope it is not permanent. Depression then set in. As a prior well-adjusted, outgoing person, I was trapped in the home that before was a wonderful place for friends and relatives to gather. I had no history, or familial history, of any sleeping problems, addictions, or mental health issues of any sort.
    There might be another class of people who unwittingly get on these types of meds. and before they know it, their life is destroyed.

  17. janet says:

    I began taking ambien about 6 months ago. Off and on for a month or two – perhaps only a couple of times a week. Then I would take it every night. Admittedly for the buzz and the fear that I wouldn’t be able to sleep. I even restricted my food intake in the evenings so that I could feel the effects.
    About three weeks ago I sunk in to a horrible depression. I have a family history of depression but who doesn’t? I have no reason to be depressed. I wanted nothing more than to sleep my nights and days away, even taking ambien during the day claiming I was “sick”.
    I started journaling and looking through old sent emails to see when/how I got into this funk and I finally attributed it to ambien. I stopped taking it immediately and noticed a difference in two days.
    I was practically home bound. I wouldn’t go to the bank, shop, go out at night. I would suffer through work and get home as quickly as possible in order to avoid the outside world and sleep.
    I have my life back. I still crave ambien but even taking 1/2 will make me meaner than snot the next day. Now I take over the counter meds to sleep if I need it..otherwise nothing.
    I can’t imagine what would have happened had I continued on that road and added a anti depressant. HOT MESS.

  18. My name is Carrie James and i would like to show you my personal experience with Ambien.
    I have taken for 30 days. I am 23 years old. First I took it to help me fall asleep. After a couple of days I noticed that it made me feel really good, so I would take it just to feel the high that it gave me. I would had no memory of what I did the night before. Every night I did really weird things like send out strange emails, take weird pictures, and I fear that I did things that I still don’t know about. I would also hallucinate. I would just spend a lot of time staring at things watching them move, like the wall or notes on sheet music. I was way too distracted to go to bed. It made me tired, but I didn’t want to go to bed. I stopped taking it because I don’t want to get involved with something like that. I think about it all the time and I have cravings for it, but I just don’t think I need anymore problems.
    Side Effects :
    Hallucinations, feeling of being high, and no memory of things I did the night before.
    I hope this information will be useful to others,
    Carrie James

  19. www.whatkillsme.com says:

    I love the comment the doc made about there being 2 types of people – those that take ambien every day, and those that do not take ambien. This is right on. I don’t think I have ever seen somebody use ambien the way it is supposed to be used. But lets face it, thats the way sanofi wants it.

  20. beth says:

    I assume most of you are somewhat educated. Then why is it none of you can spell?
    “psychatrist,” “trazadone,” “surrepetous”
    What’s up with that?

  21. norma says:

    I’ve been taking ambien for 12 years 5mg at 11;00pm and I sleep till 2:30am ,wake up instantly then take the other half pill (5mg) and sleep till 7:am. I’ve tried the whole 10 mg at 11pm, but still have the same sleep pattern. I tried ambien cr and it was terrible, gave me a fearful feeling and bad dreams.
    I have been having bad GI problems, and the doctors say it has nothing to do with the ambien. As soon as I wake up,I feel nauseous and it now lasts the whole day, like having morning sickness .I,m 65 and not pregnant. Is there anyone else having the same type of GI problems? I,ve tried going off ambien , but my sleep is terrible.

  22. Terri Marie says:

    I take about 30 to 40 mg Ambien CR nightly starting at 7:30, I finally fall asleep only to wake up 2 to 3 hrs later and take another and repeat until I have to get up. I have no side effects, don’t drink and sometimes take Ativan .5mg for Anxiety. I have survived Breast Cancer, multiple tumor removal from my lower back and just had a perforated diverticuli in my colon burst, suffered septic shock, an appendectomy and had a large ovarian cyst removed along with 13 inches of my descending colon removed. all this within three years and I never took anything before this happened in 2007. I am 50, very outgoing, busy mother and grandmother and now cannot sleep without Ambien CR. 12.7 mg pills. Zolpidem 10 mg do the same and I take two at a time if I don’t have the CR. Zolpidem is covered on my insurance, Ambien CR costs $150.00 for 30 pills. I have always had insomnia, feel like a Vampire. I feel beat up after these medical issues and need the rest. My Doctor say’s it’s ok after my history as long as I don’t drink or take antidepresants. Any help, and what is really an overdose amount? I know some patients at the Nursing Home I work at take extra ambien when disturbed in the night and have extra Ativan during the day to keep them calm when they get upset. The elderly rely on these drugs and antidepressants also. I appreciate your comments

  23. ambien says:

    I took Ambien for a couple of nights, great drug, really works, slept like a baby deeply. Felt drugged the next day but I’m very sensitive to these feelings. Then I decided to not take it again, and had “rebound insomnia” the first night, that was last night. Today I feel very tired after getting maybe 1 or 2 hours of sleep last night. I’m going to try everything I know to get a good nights sleep tonight. Usually I do not need any sleep aids at all. Only took it recently because my sleep got messed up after a travel and being in a difficult place to sleep.

  24. As the sender of the email in question, I just wanted to point out, that she was reccomending starting Ambien CR and an SSRI concurrently. or at least was referring to this “study”

  25. Joe9090 says:

    Remeron just makes you feel a lot worse. Oh, it will make you sleep, but when you wake up you will feel like you are in a Nazi concentration camp. It is a miserabe drug, and unlike Ambien it does not make you feel good at all. At least Ambien and lunesta give you a somewhat relazed and pleasant sensation.

    Also stay far..far away from Zoloft and Abilify they do just the opposite of what they are suppose to. Actually, abilify does nothing at all and should basically be flushed down the toilet.

  26. Amanda says:

    I take Ambien every night…some nights I sleep and some nights I am up and down all night. I like antipsychotics better for sleep to be honest…going to get back on Saphris when I go back to my psychiatrist and off Ambien :)

  27. Scott says:

    This is actually helpful. I am bipolar II . I am on 30 cymbalta and 300 twice day of lamictal. I have had this 90 day supply of ambien for a year, taking probably 5 – 6. Now, I am no doctor, but after the last five nights, I took an ambien, not before bedtime, but with my night meds 300 lamictal, 40 Lipitor and an ambien. I can appreciate the whole blood build up serum levels. This has made a difference for me for the better. I am bipap user, ambien, no ambien, I sleep good times I do not. The ambien, other than maybe once the last five nights did I feel it assisting in any better sleep. Even the. Real life wicked dreams I would get so vividly a few years ago when first prescribed, are not doing that. So is this a sit by the bed stand half-life scenario where the medication is not what it was fresh? I do not care, if a placebo or other, I am on this horse until it dies of thirst.

    Thank you, I was just searching this put, like I said because I believe that an ambien is doing to my depression is like adding abilify

  28. DeleriumEndless says:

    Dear lord! How incredibly interesting and unsettling all this is. I must say, I don’t understand the comments regarding inability to stop taking Ambien. A little background: A year ago I was advised that Ambien (Zolpidem) might help with my inability to adhere to a “normal” sleep schedule. I don’t sleep well during the “socially acceptable sleep times”; e.g. 9 pm to 6 am. I have never been good at waking up early in the morning, my best sleep times seem to be between 3 am and noon. Naturally this doesn’t work for today’s 9-5 world. I also suffer from a certain amount of depression and anxiety, which contributes to my sleep issue. So, drugs! Why not?
    But I never had any trouble not taking the Zolpidem when I didn’t think I needed it. I just didn’t take any if I felt tired. I would be very interested in finding out what other people were feeling, in what way did it feel like it was necessary to take the Zolpidem? Anxiety about not being able to sleep? Physical symptoms? Perhaps I had a response and didn’t recognize it. I don’t know if I’ll get any responses here, but I’ll keep an eye out.

  29. Amanda says:

    Never had a problem stopping Ambien…it just doesnt work for me anymore. It worked for a few months but now its like taking candy. I even tried stopping for a month and starting back..I habe to take an antipsychotic to sleep now. I hate antipsychotics but what do you do?

  30. Luna says:

    I can say that there is legitimacy to the ambien for depression/anxiety. Much of the time when a person starts to go into a depressed episode, the worst thing for them to do is to sit there and feed it with constant thoughts. That in turn changes into a downward cycle until the person reaches the point where they are in such a dark place that that’s when they’ll want to attempt the suicide.
    If you can get the brain to SHUT UP, in essence, slow it down, other skills to keep oneself from going into an episode can be put into effect like distracting yourself from the negativity, perhaps even sleep the episode off.
    Prescribing it to take as a daily thing isn’t such a good thing, but prescribing it for the patient to take a low dose of it when they recognize they’re heading down into a depression hell, that patient is more likely to be diverted from ever reaching the point they will do damage to themselves or others.
    A lot of depression episodes can go hand into hand with anxiety. The body starts to panic, everything is overwhelming, and the negativity starts up. If the negative thoughts and anxiety feed together and is not stopped then a suicidal episode is likely on the way.
    By calming the person’s brain and body down, it is that much easier to apply distraction skills, etc. to avoid an episode.
    This is why Ambien, in low doses and used by an as-needed, is viable for treating the depression and anxiety.
    Question: how do I know this? Over the past many years I have suffered from the depression and anxiety episodes. While my regular meds keep me just up afloat, they do not help during the times things take a spike for the worse. I’ve learned by being able to recognize when I’m headed into a depression episode that by taking a low does of Ambien I’m able to calm down, distract myself, and keep myself from getting to the point where I want to slit my wrists.

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