Evie Summers
Sleep is essential for good health, and many people with mental health issues experience insomnia or other sleep problems. Doctors may prescribe sleeping pills to treat sleep problems, and there are many different types available, including benzodiazepines, antidepressants, antipsychotics, and antihistamines. While these medications can be effective in the short term, they should not be used continuously over an extended period due to the risk of dependence and adverse long-term side effects.
| Characteristics | Values |
|---|---|
| Who are sleeping pills for? | Patients with insomnia, restless sleep, or difficulty falling asleep. |
| Types of sleeping pills | Benzodiazepines, Non-benzodiazepine (Non-BZD) or Z-drugs, melatonin agonists, sedating antidepressants, antipsychotics, antihistamines, anti-Parkinsonian drugs, antinarcoleptics, orexin receptor antagonists. |
| Side effects | Dependence, withdrawal, dizziness, fatigue, irritability, depression, constipation, blurred vision, weight gain, decreased sexual drive, dry mouth or throat, hangover effect, next-day sleepiness. |
| Precautions | Sleeping pills are typically prescribed for short-term use and should be combined with good sleep practices and behavioral treatments. They should not be used continuously over an extended period. |
| Risks | Z-drugs may not be suitable for pregnant or breastfeeding individuals. |
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What You'll Learn
Antihistamines: OTC choices for insomnia, e.g. diphenhydramine (Benadryl)
Antihistamines are a type of medication primarily used to treat allergy symptoms such as hay fever. However, some antihistamines also cause drowsiness as a side effect, making them useful for treating short-term insomnia. Diphenhydramine (Benadryl) is the most common antihistamine found in over-the-counter (OTC) sleep preparations (e.g., Tylenol PM and Advil PM). Doxylamine is another antihistamine found in OTC sleep aids.
While OTC antihistamines can be effective in treating insomnia, they may have several drawbacks. Firstly, they can be slow to take effect, and patients may experience next-day hangover effects or develop tolerance over time. Additionally, as these drugs are muscarinic receptor blockers, there is a risk of anticholinergic effects such as blurred vision and constipation, especially in older patients. Therefore, caution should be exercised when recommending these medications, particularly for older individuals.
If a patient responds well to diphenhydramine, it is advisable to recommend the solo preparation to avoid potential side effects associated with combinations containing acetaminophen or ibuprofen. It is also important to note that antihistamines should be used with caution in pregnant or breastfeeding women, and patients should consult their doctor or pharmacist for advice.
While antihistamines can be a helpful OTC option for treating insomnia, they may not be suitable for everyone. Patients should always consult their healthcare provider to determine the most appropriate treatment option for their specific needs and circumstances.
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Melatonin agonist: Ramelteon may be safer for older patients
Sleeping pills are often used to treat insomnia, which is a common comorbidity in patients with mental health issues such as depression and anxiety. Antihistamines, such as diphenhydramine (Benadryl), are popular over-the-counter choices. However, these medications can be slow-acting and may cause next-day hangover effects and tolerance development. Sedating antidepressants and antipsychotics are also used to treat insomnia, but they can have side effects such as weight gain, hyperglycemia, and tardive dyskinesia.
Z drugs, including zolpidem and zopiclone, are non-benzodiazepine sleeping pills used to treat severe insomnia. They are short-acting and less likely to cause hangover effects than other sleep medications. However, they can cause dependence and withdrawal issues, and patients should only take them for a short period, ideally no more than one week.
Now, let's focus on melatonin agonists and ramelteon in particular:
Ramelteon (Rozerem) is a melatonin agonist that does not bind to GABA and thus lacks the side effects associated with GABA-agonist drugs. It may be a safer choice for older patients with sleep phase disorders, insomnia associated with shift work or travel across multiple time zones, or substance abuse issues. Ramelteon is not a scheduled substance like benzodiazepines and non-benzodiazepines. While some patients may find its effect less noticeable than that of a benzodiazepine, it has been well-tolerated in older adults.
Several studies have investigated the use of ramelteon for treating insomnia in older adults, including those with obstructive sleep apnea. These studies generally found that ramelteon improved sleep outcomes, such as total sleep time (TST) and sleep latency (SL), in older patients with chronic insomnia. One study reported an average increase in TST of 21 minutes compared to a placebo. Additionally, ramelteon did not worsen sleep apnea severity in mild-to-moderate cases, making it a potential treatment option for insomnia in patients with sleep apnea.
In summary, ramelteon, a melatonin agonist, may be a safer choice for older patients with insomnia due to its lack of GABA-agonist side effects and its relatively low risk of psychomotor impairments compared to traditional benzodiazepines and non-benzodiazepines. While it may not provide the expected "kick" of a sleeping pill, it has shown effectiveness in improving sleep quality and duration in older adults, including those with sleep apnea.
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Benzodiazepines: Powerful sleeping pills to relieve anxiety
Benzodiazepines are a powerful class of sleeping pills that can help with insomnia, relieve anxiety, and improve learning and memory. They are often prescribed for short-term use, in combination with good sleep practices and behavioural treatments, to avoid dependence and adverse long-term side effects. Doctors will consider the patient's age, severity of symptoms, comorbidities, and any congenital diseases when prescribing sleep medication. Benzodiazepines are typically used for patients who have trouble falling asleep, work late shifts, or have insomnia due to travel across multiple time zones.
Benzodiazepines are a type of hypnotic drug that raises levels of brain GABA neurotransmitters, causing sleepiness and muscle relaxation. They can also be used to treat epilepsy. This class of medication includes alprazolam, clonazepam, diazepam, and lorazepam, which are available in short- and long-acting forms. Non-benzodiazepine or Z-drugs are fast-acting sleeping pills that take effect within 30 minutes and can last up to 8 hours. Z-drugs, such as Zolpidem and Zopiclone, are non-benzodiazepine hypnotics that act similarly to benzodiazepines, including similar problems with dependence and withdrawal.
Other types of medications used to treat sleep disorders include antihistamines, which are popular over-the-counter choices, and sedating antidepressants and antipsychotics. Antidepressants can also be used to treat anxiety and depression, as drowsiness is one of their main side effects. Melatonin agonists, such as ramelteon, are another option that does not have the same GABA-agonist side effects as benzodiazepines and may be safer for older patients.
It is important to note that the best way to treat insomnia is to create good sleep hygiene habits, learn to fall asleep naturally, and gradually taper off sleeping pills with the guidance of a specialist. While sleeping pills can be beneficial for short-term use, they should not be relied upon continuously, as they can cause dependence and adverse health effects in the long run.
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Antidepressants: Treat insomnia, stress, and anxiety
Insomnia is a common comorbidity in people with depression and anxiety. While there is no single antidepressant that is most effective for treating insomnia in patients with depression, antidepressants can have a positive impact on sleep physiology. Sedating antidepressants such as trazodone (Desyrel), mirtazapine (Remeron), doxepin (Silenor), amitriptyline (Elavil), and trimipramine (Surmontil) are often prescribed to help with sleep. These medications are also used to treat anxiety.
Trazodone has a long half-life of seven to eight hours, which helps keep patients asleep all night, but can lead to next-day sleepiness. Mirtazapine is associated with significant weight gain and is therefore not useful for the long term. Doxepin works by blocking histamine receptors in the brain, helping people stay asleep without causing addiction or dependence. However, it may lead to increased sleepiness and confusion in older people, as well as increased suicidal thoughts, worsening depression, and behavioural changes.
The American Academy of Sleep Medicine recommends the addition of a low-dose, sedating antidepressant for patients with comorbid insomnia and depression if not contraindicated. However, it is important to note that there is limited evidence for the comparative effectiveness of antidepressants in treating insomnia in patients with depression.
Other medications used to treat insomnia and anxiety include benzodiazepines such as diazepam (Valium), alprazolam (Xanax), and triazolam (Halcion). These medications can help with early wakefulness and provide anxiety relief throughout the day, but they may cause dependence and rebound symptoms.
Healthcare professionals typically recommend lifestyle changes and behavioural therapies as the first course of action for people experiencing anxiety and insomnia. If these do not help, they may then consider prescribing medications such as sleep aids, antidepressants, or other medications. The type of medication prescribed will depend on the patient's age, health status, personal preferences, and severity of symptoms.
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Z drugs: Zolpidem and zopiclone for severe insomnia
Z-drugs are nonbenzodiazepine sleeping pills used to treat severe insomnia. They are called Z-drugs because their generic names begin with the letter 'Z'. The Z-drugs currently licensed for prescription in the UK are zolpidem and zopiclone. Zaleplon used to be included in this group but is no longer licensed for use in the UK. These drugs are short-acting and are less likely to have a 'hangover' effect than some other types of sleep medication.
Zolpidem is approved in oral tablets, oral spray, and sublingual formulations for initial insomnia. An extended-release (CR) oral formulation is approved for initial and middle insomnia, and a sublingual low-dose formulation (Intermezzo) is available for middle-of-the-night insomnia. Zolpidem was designed to be preferentially effective at the cortical subtype of the benzodiazepine receptor. It has been found to double the risk of developing depression.
Zopiclone is used for the short-term treatment of insomnia, where sleep initiation or maintenance are prominent symptoms. It is not available in the United States. Zopiclone is recommended to be taken at the lowest effective dose, with a duration of 2–3 weeks. Daily or continuous use of the drug is not advised, and caution must be taken when used in conjunction with benzodiazepines, sedatives, or other drugs affecting the central nervous system. Long-term use is not recommended, as tolerance, dependence, and addiction can occur. Zopiclone has been found to increase the risk of vehicle accidents by 50%, causing an increase of 503 excess accidents per 100,000 persons.
Z-drugs are generally only recommended for short-term usage and are only indicated as a backup to nonpharmacological interventions. They are best suited for patients experiencing severe insomnia and only after trying other, non-medication treatments.
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Frequently asked questions
Sleeping pills are prescription medications that contain tranquilizers to treat insomnia, restless sleep, or difficulty falling asleep. They are typically used for a short time, alongside good sleep practices and behavioural treatments.
There are several types of sleeping pills available, including benzodiazepines, non-benzodiazepines or Z-drugs, melatonin agonists, sedating antidepressants, antipsychotics, and antihistamines.
Sleeping pills may not be safe for everyone. They are generally not recommended for long-term use due to the risk of dependence and withdrawal symptoms. They should also be used with caution in older patients and those with liver or kidney disease. Pregnant or breastfeeding individuals should consult with their doctor before taking sleeping pills.
