Important questions to ask yourself: What keeps you up at night? What are you thinking about? Are you in pain? What is your sleep schedule like, in reality or ideally? What do you do before sleep?
Drug wise, one might ask why are you asking us, rather than your own physician? Presumably over 13 years you've seen a doctor, more likely two or three or maybe even more and possibly specialists, about this condition. Most of what you mention there are prescription drugs in almost all countries, but no doctor would prescribe all of them at once, so I can only assume you've collected over the years things that didn't work that well, or sourced them from friends, shady overseas "online pharmacies," whatever.
You need to be actively working with a psychiatrist preferably one who has experience or specialty in dealing with this, and any other coexisting issues that you might have (depression, anxiety, bipolarity, psychotic illness, whatever it may be.)
You should also be in therapy, specifically,
cognitive-behavioral therapy, which even in people without depression/anxiety issues can specifically help with sleep issues, but, for the most part, there's overlap. CBT may be better than most of the drugs on your list.
"Sleep hygiene" which you will hear about from your therapist or doctor, or may have already, is important. You should never lie in bed for any reason or than to sleep or have sex. You should avoid watching TV or using the computer or tablet or phone ("screens," for any time I mention any of them, read all of them) for at least 2 hours before going to sleep. Never go to bed with the TV on.
This includes if you are knocking yourself out with sleeping pills. You should have a routine time to wake and to go to sleep. You should not vary your sleep schedule radically on weekends, days off, or vacations.
Some people benefit from a split-sleep schedule. Doing this with medications is very difficult as it is not what they were designed to do. But, according to fairly recent research, humans for historical/evolutionary reasons, for millenia, time would typically fall asleep after a long day's labor in the fields, a bit after sundown, sleep a few hours, wake up, attend to some chores or other needs (this is also, apparently, when most people would have sex), perhaps get up a bit and move around and talk, all this for a few hours, and then go back to sleep for a few hours waking up around daylight. If you can get yourself into this schedule, especially without medication, it can be just as good and sometimes better than the "standard" 16/8 schedule (an unnatural byproduct of the Industrial Age) to be on something like 15/4/2/3 or something roughly like that (these numbers is off the top of my head, there is actual literature on this.) Keeping a log of your sleep schedules and trying to keep them in order is good.
Medication of course is targeted at trying to get you closer to "schedule."
There are at least two major distinctions, people who have trouble falling asleep and people who have trouble maintaining sleep. For obvious reasons they need different medications lasting different lengths of time. This is important to take into account. If you can sleep but frequently get up, try taking an hour or two
out of bed (this is very important) to read (not on a computer and not to watch TV or listen to music), and then going back to sleep, this is OK. If you are constantly getting up and unable to maintain sleep, and this doesn't help, or if you simply cannot fall asleep, then this is a different issue. The vast majority of these cases have underlying psychological/psychiatric issues like anxiety and depression which need treatment, and pretty much everyone can benefit in some way from CBT.
Some people, though, will need meds, for shorter or longer periods of time (as in how long they will be prescribed) and different medications. A lot of this is just subjective "what works for you" and what your physician prefers, although if this doesn't work, it will have to be tinkered with. Longer-acting medications are good if you have sleep interruptions (but remember these sometimes aren't all that bad if you know what to do), but they can leave hangovers/grogginess/cognitive dulling/etc in the morning, sometimes even to the point of putting you at risk for an accident driving to work, or requiring you to drink lots of coffee. This will lead to a crash and wanting more coffee, which will lead to drinking coffee too late (see below.) Shorter-acting medications are better at knocking you out quick and letting your body take it from there. This is better, when possible.
All that said, some thoughts on sleeping pills.
YOUR LIST
Doxylamine: if it doesn't work alone, drop it. it won't compete with the hydroxyzine enough at the histamine receptors to have a worthwhile effect and as you've experienced the might even not play well together. this goes for benadryl, which you haven't mentioned, too; it is probably the first line sleep aid. ifbenadryl doesn't work at 50-100mg, not worth it, so too for doxylamine 25-50mg. rarely will going above these doses benefit you although it may just by sheer force knock you out.
hydroxyzine, which I take for sleep myself, is better than either because it also has a fairly mild antiserotonergic effect which mildly sedates and is helpful for anxiety, this is a property it shares with many of the newer anti-psychotics, including the abilify you mention here
cyclizine, meclizine, etc: drop for similar reasons.
hydroxyzine: a good option. dose similar to benadryl (50-100mg.) I use it myself (see above) the pamoate formulation (Vistaril) is much better than the HCl (Atarax), while the HCl provides more hydroxyzine per milligram, it has favorable metabolic properties. they have similar pricing and availability. both are cheap.
codeine, tramadol: will only get you addicted. the sleepiness will go away, then you'll start becoming euphoric and actually activated by it, and shortly thereafter you'll become familiar with opiate withdrawal. assuming you aren't already. tramadol does have the benefit of having serotonergic activity (not unlike the hydroxyzine, but more like tricyclics, which are worth consider in and of themselves, actually. hydroxyzine in particular but all the sedating antihistamines will potentiate opiates, as everyone in line at the methadone clinic well tell you. this can kill you. unlikely with codeine at any reasonable dose, though.
diazepam: also addictive, but a much better benzo for most than sleep, will also provided some anxiety relief for the next day (as will hydroxyzine, in a milder way), but the real benzos you should be thinking about are flurazepam,
temazepam (
probably the best, but also addictive, sought after by drug-seekers and therefore somewhat stigmatized), and flunitrazepam, but all of these are highly addictive and start to loose their effect.
pregabalin: quite a nice drug but will also lose it's efficacy for sleep rather rapidly and require higher doses. same goes for gabapentin.
aripiprazole: unless prescribed for a specific indication lose it as a sleep option.
HONORABLE MENTION
other neuroleptics:
Seroquel (quetiapine), 50-100mg. quite effective in many people. side effects intolerable in a minority. at this dose severe side effects and metabolic issues are rare. 200mg is the absolute most anyone should be taking for sleep, although considerably larger doses are prescribed for psychitric issues.
Zyprexa (olanzapine) is quite sedating but one to avoid unless you actually need it for schizophrenia or severe bipolarity, can cause metabolic issues (i.e. weight gain and diabetes). much the same for the other 2GAs. t
the only one I'd think worth mentioning is
risperidone, 0.5-1mg or less, but is not a great option either. to be considered as a close-to-last ditch measure.
aripiprazole isn't going to be very helpful as I mentioned before.
sedating antidepressants:
trazodone (Desyrel),
mirtazapine (Remeron), and
doxepin (Sinequan) are the big three in rough descending order of common use these days.
doxepin is the most powerful. they have roughly similar side effect profiles although one may be tolerated better than other by patients. generally safe but can be deadly when combined with certain drugs, MAOIs especially. do NOT take them with tramadol either under any circumstances unless directed otherwise by your physician.
z-drugs: not a whole lot is great here.
Ambien (zolpidem) is probably the best all around.
zaleplon (Sonata), who's generic name sounds like the home-world of a race of little green men, is the fastest and shortest acting but can also (as can they call, but it's more likely to) give bizarre states of consciousness and hallucinations and stuff if you
don't sleep.
zopiclone is somewhere in between.
eszopiclone is basically just the better isomer of zopiclone. all of these tend to produce tolerance and lesser effect after time, are addictive; but on both instances are less so than benzodiazepines. the essential thing with these drugs is
do not take them until you are lying down, in bed, in the dark, ready to sleep. do not take them before you brush your teeth and put on your PJs, have sex, watch TV, whatever. they will not work,or will not work nearly as well, and can produce some really strange (and not really fun) altered states of consciousness.
EXOTIC, "NATURAL," WEIRD, MISCELLANEOUS & QUESTIONABLE
Belsomra (suveroxant) is a very new sleeping pill with totally new type of action. If you can afford/are covered by insurance for it, it may be worth a try. People's experiences vary. Many were underwhelmed but it works for some. There is a thread on it somewhere where I also discuss a lot of other sleeping issues. I will try to find it ...
HERE. My own experiences with Belsomra, which is followed by some more discussion germane to this thread.
melatonin. works for some, not for all. over-the-counter products are not reliably dosed and vary wildly in the amounts both advertised and actually in the pills. if it works for you, it works, if not, not. it is mostly harmless, overdose is not a real concern. it can be added to most of the drugs mentioned here.
I think they stopped making
chloral hydrate some years back although it is still nominally on-formulary although with a special legal status (a story in itself) but was hardly ever used towards the end except probably in a few very old school institutions and docs and in old people who'd been taking it forever. when I was in training all of my psych patients had it as a PRN for sleep. it is effective, but toxic to the body, potentially lethal in combination with other things including alcohol, opiates, benzos and just about everything listed here.
the same goes for barbiturates and other really old sleeping pills like meprobate and glutethimide. you almost never seen any of these anymore anyway.
see below for a mention of
novel marijuana related products
valerian,
kava kava &c. are mild herbal sedatives. they probably won't help if serious sleeping pills don't, and shouldn't be taken together. kava kava is dangerous to the liver especially in combination with alcohol or other hepatotoxic substances
unmodified
GABA is useless.
chamomile tea never hurt anyone and is nice; some people find warm milk soothing
various
breathing exercise can help but are beyond my expertise
DISHONORABLE MENTION
alcohol: will amplify the effects of just about everything we've covered. you will likely black out and quite possibly continue to drink, leading to a hangover at best, absence at work or serious other consequences including death from overdose, car crash, who knows.
and despite this, alcohol does not lead to quality REM sleep and therefore drunk sleep will not leave you feel well rested. if you constantly drink to sleep you will constantly feel tired and shitty and slow in the brain even if you felt like you slept for a decent time the night before.
you also run the risk of becoming an alcoholic.
marijuana: some people find this helpful. it is almost always a bad idea. it also disrupts normal sleep patterns and can lead to cognitive issues and exacerbation of pre-existing psychiatric problems. it is particularly bad in people who tend to become anxious and ruminate over and over about things in their mind. but again the sleep it provides you is not quality sleep, even if you think it is; similar to the alcoholic, you will feel burn out and not know why. marijuana might relieve this, and you may become an addict. don't believe the stoner clichés about marijuana not being addictive. it is, just not in the same sense as booze, cigarettes and heroin. marijuana may be fun for some people and it definitely in most people increases their enjoyment of music and other entertainment and stuff like that, but it is not good for sleep. in fact it is not good to be stoned for several hours before sleep. if you already smoke marijuana feel that you need to be stoned to sleep or say, within 4-6 hours of going to sleep, then more than likely you have an issue with marijuana that needs addressing. nobody likes a 24/7 pothead.
footnote- derived products. since the advent of legitimized commercial medical and pseudo-medical marijuana in "legal states," various products have been created that have a very high ratio of CBD to THC. these would be preferable for sleep, by far. if they are available to you they might be worth a try still with significant reservation as to the quality of sleep (which goes for most medications though)
typical marijuana is a no-go though. and typical commercial marijuana is often bread for high THC content, which is all the aspects of marijuana you
don't want in terms of sleep (or anxiety)
general
do not smoke marijuana or consume alcohol and expect to get quality sleep until at the very least 2 hours after the acute effects wear off, and then still it will not be as good as sober sleep.
coffee and cigarettes
do not drink coffee or take caffeinated beverages including soda for at least 8 hours before you intend to go to sleep.
smoking cigarettes, especially if you are a chain smoker who smokes indoors, is also not good for trying to sleep, although not as bad as coffee.
none of these medications provide natural sleep.
recreational drugs in general not mentioned above
if you're an opiate addict or pain patient, you have to be careful of this stuff potentiating your drugs and killing you, but you have to keep to your opiate schedule. you may find that hydroxyzine, meclizine, various other things mean you have to take less opiate particularly at night. increasing opiate dose for sleep is not a good idea or sustainable.
stimulants are obviously contraindicated. psychedelics as well. they can keep you up for a day or more after the effect goes away, for both pharmacological and subjective psychological reasons.
none of the other recreational drugs, pretty much, are good for sleep and the effects of any should wear off a good few hours or so before you want to sleep.
good(?) combinations:
that's the title of your thread. there are a lot of reservations to have here.
no combination is good. polypharmacy is discouraged in psychiatry for good reason. but sometimes they help and are needed. some particularly bad combinations are mentioned above.
so with that reservation,
combine
one of { Vistaril, Other Anti-Histaminergic, or Sedating Anti-Depressant }
with
one of { GABAergic, Z-Drug, Tranquilizing Benzodiazepine, Sedating Anti-Psychotic }
especially, Vistaril + GABAergic; Vistaril + Seroquel; Trazodone + Seroquel; Trazadone + Z-Drug
in severe cases, you might consider stacking three, preferably of different classes (e.g. vistaril/temazepam/quetiapine. sometimes combinationsin the same class work, and actually at low doses quetiapine is sedating more on the histamine side than the dopamine side, but in general, you want to keep things simple and not overlapping) this really needs professional attention though. I have taken almost everything mentioned here, and do take several medications for sleep currently, as well as several other medications for other issues. I also am an alcoholic and opiate addict (on Suboxone) contrary to my own advice to you.
In terms of drugs, "LESS IS MORE." Especially in terms of the number of different drugs you are taking. Find the least dose of the least number of drugs you can take, and add that to sleep hygiene/schedule stuff and therapy (CBT) as I discussed above.
None of this is easy. A lot of sleep issues have to do with our bodies and psyches not being prepped for the modern world yet which, after all, has only existed a few hundred years at the most, depending on your definition, as well as the existential crises of the world we live in leading to depression and anxiety which cry out for help in the form of positive, authentic human connection, perhaps more than anything, and treatment or palliation by therapy (CBT and/or other) and palliation (never in the strictest meaning of the word 'treatment,' as there is no medical "cure") by medication as needed.
Good luck.
nothing of the above is medical advice and establishes no professional relationship; I make no claim of any professional credential
