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Sleep Disorders

Trazodone advancing delayed sleep cycle

03/13/2007

Question:

Hello! I have a question that I hope you can answer, but not sure if you can or even if i`m asking the right specialist. I`ll give you a little background about myself and problem and hopefully make it somewhat short.

I am currently a sleep tech, and have been for about a year and a half. I am on the 3rd shift schedule. Sleep disorders apparently have always been a problem with me. I have had DSPS at least since I was 11, ( I am now 29). This, as you can imagine, has created many problems for me throughout the years. That is why I was absolutely thrilled when I got a 3rd shift job, (I haven`t been late once to work). In addidtion to DSPS, I am also a long sleeper. If given the opportunity, I will sleep 12+ hours. Longest to date was 19 hours. Within the past month, I finally had my own sleep study done. My RDI was 6.2. I slept supine for approx. 80% of the study, (which is not my normal sleeping position, but I wanted to see how severe I could get). It did take me almost two hours to fall asleep, but that was because I was freezing. As soon as I got a space heater, I was out quickly. During the study I only had three epochs (I guess my arousals were not all that large) that were counted as wake. Even if I do sleep 12 hours I don`t have to get up to use the restroom or get up for anything else. I do REM a lot and usually remember 2 to 3 dreams a night( or day). I was slightly worse in REM.. naturally, however out of approx. 300 min. of actual recorded sleep I had a total of 25 hypops. and O2 dropped to 94%. I am trying to get treated for and have been diagnosed with dysthymia and a mood disorder (irritability [not with my patients]).I am also very tired and fatigued. I am not sleepy, just tired. My Eppworth is 2.

My new problem is this, For these two disorders I decided to enlist the help of a psychiatrist to help with the medication aspect. I have been on all SSRI`s (literally), and Wellbutrin, and Effexor as well. Those all caused nasuea, insomnia, and restlessness. I have also tried some anticonvulsants (Lamictal and Topamax). Now we are trying Trazodone. I was very concerned about going to Trazodone and other tricyclics mainly because I am already a long sleeper and it pains me to think that I will probably be sleeping more then 25 years of my life away. I would like to do things with the living.

The Trazodone, I thought was great at first. It did cause me to be very light headed at first and it took a little while for me get the groggy feeling out of me, but wasn`t causing me to wake up every hour and no nausea. That went well for about a week. Then all of a sudden I started getting tired around 10:00 p.m. and I was waking up around 8;00 a.m. I was so tired at night I could hardly keep my eyes open. On the days that I had to work, I was still waking up around 8:00 a.m. and was unable to go back to sleep before my shift started. This was keeping me up over 24 hours and I was extrememly sleepy in the middle of the night. Very miserable. I don`t get tired normally during the night. I let this go on for about a month, but I had to stop. I can`t tell my patients to scoot over cause I`m tired to. I am also on Provigil. I am currently on 400mg. It has not provided wakefullness before I was on Trazodone and certainly not while on Trazodone. The doctor told me to give it a little more time. I`m sure he is frustrated trying to find the right medication, but not nearly as much as I am. All these medications are seriously messing with me. I have only heard of one other person where Trazodone has advanced their delayed sleep cycle. Have you heard of this happening before? I really want to get the mood disorder and dysthymia under control so I can start enjoying activities again, but I don`t know if there is anything out there that is either not going to make me sleep more or won`t cause me to get up numerous times. I think my Psychiatrist is really going to think I am crazy. I don`t have any other problems with any other types of medications. Just wondering if you have had any experience or luck dealing with very frustrating antidepressent/ sleep disorder cases? I really don`t want to have to resort to the idea that I will either be tired for the rest of my life or miserable. By the way, the lab I work for is accredited and I am very confident and impressed by our scoring technicians knowledge and ability to comply with the national guidelines.

This question turned out a lot longer then I anticipated, which I apologize for. I want to thank you and all the "Experts" on this site. It can be very difficult to research exactly what your looking for on the internet and it is wonderful and very much appreciated that you volunteer your time to help us as much as you can. Thank you!

Answer:

It certainly sounds like you have a complicated situation on your hands! I’m not sure I can give you a complete answer, based on the information provided, however, I will try to address some of the issues that you raise. It sounds like you have several ongoing problems – mild sleep apnea, a mood disorder, a history of a delayed sleep phase and a circadian rhythm disorder related to shift work. How much each of these conditions may be interacting or contributing to each other is hard to know for sure but this possibility should be kept in mind.

As far as the sleep apnea goes, it sounds as though your sleep study revealed some very mild obstructive sleep apnea. Whether to aggressively pursue treatment of this problem depends on certain factors related to your case – primarily how symptomatic you are and whether or not you have any co-morbid conditions that would be of concern (i.e. hypertension, cardiac disease, and diabetes). It is not clear if some of your symptoms of tiredness, unrefreshing sleep and long sleep could be related to the sleep apnea, though a trial of treatment may help to sort this out.

It is a good idea that you are seeing a Psychiatrist to help with the mood problems. Medical therapy can often be very beneficial and sometimes trials of different medications are the only way to determine what will work best. However, you should also consider that it is possible that some of the mood disturbances you are experiencing could be related to other sleep issue, namely your circadian rhythm sleep disturbances. It’s not clear where the history of a delayed sleep phase might fit in – based on the information provided that you sleep from 2200 to 0800 on days off work suggests that it may not be an issue at present. However, there is some concern about your sleep-wake schedule as it relates to your work. It’s not to hard to explain why you might have trouble staying awake at work and why you might feel very tired and fatigued when you are varying your sleep schedule as you describe (working 3rd shift some nights then on nights off work sleeping from 2200 to 0800). This type of schedule wreaks havoc with the body’s internal clock and is really a set-up to cause problems. You are not alone as shift work is quite common in modern society due to the 24/7 nature of world. As a result, about 20% of the population is involved in some form of shift work and about 15% of these individuals will have problems with sleep.

The body’s circadian rhythms usually cycle over a 24 to 25 hour time period. These rhythms are reset daily to match a 24 hour day by factors such as exposure to daylight and social cues, for example when we eat our meals. The internal clock can be advanced (moved forward so you are sleepy earlier in the evening) or delayed (moved backwards so you are more awake late into the night) by changing the timing of light exposure and other social cues (such as when we eat our meals). However, the internal clock can only be adjusted by 1-2 hours in either direction per day with these maneuvers. When individuals try to alter their rhythms by more than this, they tend to feel poorly with fatigue, sleepiness and nausea (as seen with Jet Lag, for example). Furthermore, it often takes several days to fully adjust our circadian rhythms to a new schedule and thus going back and forth between schedules over the course of a few days can be difficult and almost guarantees problems.

It is likely that your shifting sleep schedule is a significant contributor to how you feel and thus trying to make changes in this schedule may be of some help. If you feel you have to stay on a 3rd shift schedule, then you should really try to keep your sleep times on days off of work closer to that of days that you work. This is often difficult to do for many individuals due to family pressures, social pressures or lack of motivation. Short of changing your schedule, there are some things that you can try that may help. The following is a list of recommendations for shift workers:

1) Try to keep your sleep schedule close in time on days you work and days off. Some individuals also find it easier to work shifts on consecutive days as opposed to having intermittent days off.

2) Scheduled napping when at work may help (this may be hard for you to do with your line of work). This should occur during "low points" in the circadian cycle, namely between 0300-0500 and mid afternoon. Naps should be short (< 30 minutes) to avoid grogginess that comes from getting into deep sleep.

3) Timing of light exposure is important. When working at night, the environment should be as brightly lit as possible, especially early in the shift (again, this may be difficult for you to do in your line of work). Avoid bright light in the several hours before bedtime, including on the drive home (wear sunglasses!).

4) Careful use of caffeine may be helpful. Caffeine containing beverages are best when used early in night shift and avoided in the 6 hours before bedtime.

5) For chronic night shift workers, melatonin supplements may be helpful to take before bedtime. Consultation with a physician is advised before pursuing this.

Regarding Trazodone, this drug probably has most of its effects through the serotonin system and is not really considered a tricyclic antidepressant (TCA). There is little data to suggest that it has circadian rhythm shifting properties. However, one of it’s side effects is to cause drowsiness and thus, in a situation such as yours, would best be taken before bedtime.

Given the complex nature of your problems, I strongly recommend you see one of your Sleep Physicians. Working together with your Psychiatrist, the Sleep Physician should be able to help to improve your sleep and how you feel.

If you would like further information about shift work, circadian rhythms, sleep disorders or sleep itself, I recommend the American Academy of Sleep Medicine website. In addition to information about sleep medicine, the website also contains a list of accredited Sleep Centers and may help you to locate one nearest you. The website Sleep Education.com also has plenty of consumer friendly information about sleep. Good Luck!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University