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Amitriptyline for Sleep problems Is a Bad Idea

Getting a good night's sleep can be a challenge, but relying on the antidepressant amitriptyline for sleep problems has its own hazards! Is Brain fog one?
Surprised senior woman trying to close her alarm clock

Amitriptyline (Elavil) is a very old antidepressant. It was first marketed in the U.S. in 1961. Amitriptyline has one FDA-approved indication: “For the relief of symptoms of depression.” For reasons that mystify us, many health professionals prescribe amitriptyline for sleep problems. This is what is referred to as “off-label” prescribing. Doctors can, of course, prescribe any drug for any purpose they choose, even if the FDA has not given the use its blessing In the case of amitriptyline, though, we think this is not a good idea.

Reader Wants an Alternative to Amitriptyline for Sleep Problems:

Q. Is there an alternative to amitriptyline as a sleeping pill? I worry about it because I have read on your website that it is an anticholinergic drug that could affect memory.

I can’t get to sleep. When I do, I keep waking up. Some nights I only get two to three hours of sleep.

A. Amitriptyline is a sedating antidepressant. That means your doctor is employing a side effect of this medication to treat a different problem. Amitriptyline does have powerful anticholinergic activity and could affect cognitive function. Here is why we think doctors should be very cautious about prescribing amitriptyline for sleep problems:

Commonly Prescribed Anticholinergic Drugs Linked to Dementia

Anticholinergic “Burden” and Brain Function:

A brand new study published in JAMA Internal Medicine (June 24, 2019) is titled:

“Anticholinergic Drug Exposure and the Risk of Dementia”

The authors describe the importance of their study:

“Anticholinergic medicines have short-term cognitive adverse effects, but it is uncertain whether long-term use of these drugs is associated with an increased risk of dementia.”

In this study they compared over 55,000 people with dementia to more than 225,000 controls. Here is what they found:

“Among specific types of anticholinergic drugs there were significant increases in risk associated with use of antidepressants, antiparkinson drugs, antipsychotics, bladder antimuscarinics [for overactive bladder and incontinence], and antiepileptic drugs.”

Conclusions and Relevance:

“Exposure to several types of strong anticholinergic drugs is associated with an increased risk of dementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people.”

This Is Not the First Time Such a Conclusion Was Reached:

A German study tracked nearly 800,000 prescriptions given to about 90,000 older patients in geriatric units (PLOS One, Feb. 10, 2017). The investigators noted that:

“Anticholinergic drugs are commonly used for the treatment of various diseases. Drugs with therapeutic anticholinergic effects comprise e.g. antiemetics (nausea drugs), anti-vertigo drugs, drugs for Parkinson’s disease and antispasmodics. In addition, many commonly used drugs have anticholinergic side effects, e.g. antiarrhythmics, antihistamines, antidepressants and antipsychotics. Known anticholinergic adverse effects last from dry mouth, constipation and visual impairment to confusion, delirium and cognitive decline.”

The authors concluded:

“Using a cross-sectional study design, a significant positive association between anticholinergic drug load and cognitive impairment in European patients treated in specialised geriatric units was found. The most frequently used definitve anticholinergic drugs were quetiapine, amitriptyline and carbamazepine.”

To find out more about anticholinergic drugs, here is a list we have compiled:

Where Can I Find A List of Anticholinergic Drugs?

Seeking Other Approaches to Insomnia:

A nondrug option is cognitive behavioral therapy (CBT). It is considered an effective approach for chronic insomnia (Annals of Internal Medicine, Aug. 4, 2015). 

Other ways to get to sleep include acupressure, melatonin and herbs such as chamomile, valerian, ashwagandha and passionflower. To learn more about these and other strategies, you may wish to consult our online eGuide to Getting a Good Night’s Sleep. It is available in our health guide section at www.PeoplesPharmacy.com.

Share your own experience with anticholinergic drugs like amitriptyline or diphenhydramine in the comment section.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Getting a Good Night’s Sleep
  • Pfistermeister, B., et al. "Anticholinergic burden and cognitive function in a large German cohort of hospitalized geriatric patients," PLoS One, Feb. 10, 2017, doi: 10.1371/journal.pone.0171353
  • Coupland, C.A.C, et al, "Anticholinergic Drug Exposure and the Risk of Dementia A Nested Case-Control Study," JAMA Internal Medicine, June 2r4, 2019, doi:10.1001/jamainternmed.2019.0677
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I took amitriptyline for years, not for depression but for its drying effect, since I had chronic diarrhea. Yes, could I sleep! But I was often tired much of the next day until I took my evening dosage. I will say that though it took time, it gradually slowed down the diarrhea.
I have read of instances where people develop nasty bouts of diarrhea from taking melatonin. No, that’s not what happened to me. Mine was more of a functioning problem, but just thought I’d mention that. I don’t know how common it is, but it may be good to do a search on it, if you’re considering taking melatonin.

I am 76 and rarely have a problem falling asleep. Should I awake during the night, sleep resumes within a few minutes. Primarily, I rely on physical labor during the day followed by setting sleep timer on radio to boring talk station. If I add a glass of red wine at dinner to this regimen, I’m in bed by 8:30 and asleep within minutes. Sleep is 8-10 hours depending on what I did during the day. I’ve determined that some daily physical activity is key to sleeping well,clear cognitive function and low blood pressure. Physical activity cannot be over emphasized. It gets the blood flowing which allows organs to eliminate toxins.

I took Elavil for years and it did help my sleep problems and depression but i was so constipated all the time that i had to always rely on laxatives all the time and i gained a ton of weight! I don’t think it was very healthy to live like that

As a psychiatrist with over 40 years of practice, I feel the need to clarify this misleading information. I have to say that few, if any, psychiatrists have used Amitriptyline (one of several tricyclic antidepressants TCAs) as an antidepressant after 1991 when the SSRI (Fluoxetine) was first introduced. Prior to the SSRIs introduction, we knew little about the hormonal deficiencies that were causing depression, and depression was treated by what was called a “chemical straightjacket” approach, thus the sedating nature of the TCA (therapeutic doses of 150 mg to 500 mg nightly) was helpful. But as an antidepressant, it was marginally effective at best.

Back then, patients were placed in state mental institutions for treatment so sedation in that environment was necessary and helpful. The SSRIs revolutionized the treatment of depression and anxiety disorders. The more that the SSRIs were used, the fewer TCAs were used. However, by the early 2000s as the use of TCAs was minimized because of their poor antidepressant efficacy, many patients who had been using therapeutic doses of Amitriptyline complained about unrelenting back pain that was resulting in sleep disturbances. Psychiatrists, along with pain management clinicians, soon were using much lower doses of TCAs for low back pain management and sleep induction.

At doses of 25 to 50 mg, the anticholinergic effects are negligible for many patients yet very helpful for sleep induction and back pain. Every patient is an individual with their own metabolic individuality that makes a specific medication at a specific dose a potential benefit or risk. Discuss with your personal clinician rather than accept generalizations as printed above. Dr. G.

I had delirium when I took it. It was disturbing. I use CBD now to help me stay asleep. It relaxes my whole body, and no high.

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