Medication and Sleep

Insomnia is one of the most common reasons people consult their health care providers. Most everyone struggles with an occasional sleepless night. And approximately one-third of us struggle with more prolonged and life-affecting sleep disturbances at some point.

Whether you consult a primary care physician, psychiatrist, or other prescribing health care provider, medication generally will be the first-line treatment approach. Several behavioral therapies are available that have been shown to be more effective than pills. However, these treatments generally are provided by psychologists, professional counselors, and social workers. Since most people seek help for insomnia from their primary care provider, the pill generally rules the day.

There are many different types of sleep medications. Unless you are familiar with the medication, or understand why it has been prescribed, it can lead to confusion or hesitation or even prevent you from taking it.

For example, antipsychotic medications commonly are used to treat insomnia. One in particular is quetiapine, also known as Seroquel. Quetiapine is classified as an atypical antipsychotic medication and is generally used with people suffering from severe psychiatric illnesses such as schizophrenia and bipolar disorder. However, due to its pharmacological properties, particularly its influence on the histaminic receptors in the brain, the medication is used in low doses to help induce sleep. Granted, quetiapine may improve sleep in some people, but it comes with risks. Quetiapine and similar medications increase risk for high cholesterol, diabetes, and possibly cardiovascular disease.

Another commonly prescribed sleeping pill is zolpidem, also referred to as Ambien. Zolpidem belongs to a class of medications referred to as non-benzodiazepine hypnotics. It works by altering receptors in the brain that control arousal and relaxation. In fact, zolpidem affects the same receptors in the brain as alcohol, which in turn, is responsible for the sedative effects one feels after having a few alcoholic drinks. Similar medications include eszopiclone (Lunesta) and zaleplon (Sonata).

Zolpidem and its cousins are very effective for sleep. However, as with all medications, there are risks. Some people report memory loss after taking zolpidem. There are many documented cases in which a person engaged in typical daily activities (eating, driving, going outside, having sex) with little memory of the events. This is both scary and dangerous. In addition, people can develop a psychological or physical dependence to the medication if taken for long periods of time. Initially, medications like zolpidem were created for short-term management of insomnia; this has given way to nightly use over periods of months or years.

Similar to zolpidem are the medications referred to as benzodiazepines. Temazepam (Restoril) belongs to this class and is approved for the short-term treatment of insomnia. Others include alprazolam (Xanax), diazepam (Valium) and clonazepam (Klonopin). Although effective in the short-term, these medications tend to lose their effectiveness over time. Also, similar to zolpidem, some people develop physical and psychological dependence.

Physical dependence is a serious issue with this class of medications, much more so than the non-benzodiazepine hypnotics. Over time, people can find it very difficult to stop taking the medication. They may experience serious complications if they try to quit “cold turkey.” Therefore, if you use one of these medications for sleep, talk to your health care provider before quitting.

Antidepressants also are commonly used for insomnia. Desyrel (Trazodone) is commonly prescribed for insomnia, but almost never prescribed for depression. Likewise, doxepin (Silenor) has recently been approved for insomnia, but has been around for decades as an antidepressant. Other commonly used antidepressant medications include mirtazapine (Remeron) and amitriptyline (Elavil). Each antidepressant has different risks and side effects. Make sure you read the informational package insert included with your prescription prior to taking the medication.

It may seem strange that an allergy medication would be prescribed to help you sleep, but if you’ve ever taken the antihistamine Benadryl, you know why. Drowsiness is a side effect of antihistamines. Similar to quetiapine and some antidepressants, alteration of the histaminic receptors in the brain via these medications promotes sleep. The most notable example is hydroxyzine (Atarax and Vistaril). There are also a number of over-the-counter medications that have antihistaminic properties, such as Unisom and Nytol. Other nondesirable side effects include dry mouth, blurred vision, weight gain, and confusion.

There are a number of safe and effective medications available on the market. However, there are also safe and effective behavioral therapies to help with insomnia. The approach you choose should be made in conjunction with your health care provider.

This article was adapted from a previous article written by Dr. Moore for his column “Kevlar for the Mind.”