Insomnia is common, and becomes more so with age. Sleepless nights can come with a host of problems and much distress: grogginess and poor daytime functioning, anxiety, irritability, depressed mood, increased chance of accidents and injury, weight gain, multiple chronic health problems, and even elevated risk of death. So, it’s perfectly understandable that many people turn to medications to get to sleep, and that many physicians (including myself) are quick to prescribe them.
Medications for insomnia include sedative-hypnotic medications that are approved by the Food and Drug Administration (FDA) for treatment of insomnia (e.g., zolpidem, eszopiclone, temazepam, lorazepam, suvorexant), sedative-hypnotic agents that are not officially FDA-approved for insomnia (e.g., clonazepam, alprazolam, diazepam), other classes of medications that have an FDA indication for insomnia (e.g., ramelteon, doxepin), and other classes that are used off-label for sleep (e.g., trazodone, amitriptyline, hydroxyzine, quetiapine). Many people find medications for insomnia helpful, but the science doesn’t necessarily reflect this anecdotal experience.
First, when rigorously compared to placebo, medications for insomnia seem to only marginally improve the amount of time that it takes people to fall asleep and the total duration of sleep they get per night. In addition, insomnia medications are associated with many side effects and poor outcomes. Most reduce sleep quality by suppressing important phases of the sleep cycle, such as deep sleep and rapid eye movement sleep (REMS). So, even if you’re technically sedated, you might not be getting restful, restorative sleep.
Studies of sedative-hypnotic medications have found that they may increase the risk of dementia and death. Many of these drugs are also potentially addictive and can interact with other medications (e.g., opioids) to increase the risk of accidental overdose. Even if you don’t get addicted per se, they tend to cause a physiological dependence, such that if you try to stop them, you will experience “rebound” insomnia and anxiety.
Non-sedative-hypnotic sleep medications may not share these concerning side effects, but have other drawbacks. Drugs that have anticholinergic properties can cause constipation and dry mouth, may make people mentally foggy throughout the day, and could increase the risk of cognitive problems. Medications with antihistamine effects can also cause daytime grogginess and may cause weight gain.
The risks of insomnia medications may be particularly concerning in older adults, in whom they have been associated with multiple problems including cognitive decline and increased fall/fracture risk. But all of these dangers have not deterred prescribing, and in fact rates of insomnia medication use have been steadily increasing, especially in older adults.
So, what should you do if you’re struggling to get a good night’s sleep but don’t want the risks and problems associated with insomnia medications? First, you should speak with your healthcare provider to make sure you don’t have an underlying, treatable cause of insomnia, such as anxiety, depression, an endocrine problem, or sleep apnea. Consider requesting an official sleep study. Second, if you are already on sleep drugs, discuss with your provider how to slowly and safely taper off them. It isn’t a race, and you don’t want serious withdrawal! Third, be sure to learn about and practice good sleep hygiene.
Avoid bright lights (especially screens!) within a few hours of bedtime; by mimicking sunlight, they send a strong “awake” signal to your brain. Instead, do something relaxing, like listening to music, meditating, or reading from a (physical) book or magazine under a relatively dim, warm light. Make sure your bedroom is as dark, quiet, and cool as possible. Try to maintain a consistent sleep routine by avoiding naps and going to bed and waking up at the same time each day. Don’t consume caffeine after lunchtime. Steer clear of alcohol or other drugs like marijuana before bed, as they will suppress restful sleep even if they sedate you. Restrict bedroom activities to sleep and sex; don’t work, eat, or socialize in bed. Set an alarm and then turn the time display away from you; repeatedly checking the clock all night does nothing other than cause anxiety, which contributes to insomnia.
Finally, consider asking for a referral to cognitive behavioral therapy for insomnia (CBTi). CBTi is an evidence-based psychotherapy that has been shown to be at least as effective as insomnia medications, without any of the side effects. It involves correcting false beliefs that cause anxiety around insomnia and disrupt sleep (i.e., “cognitive”), and changing behaviors that harm the natural sleep cycle (i.e., “behavioral”). During CBTi, your therapist will help you over time to reduce self-perpetuating worries about sleep, and to slowly adjust your sleep schedule until it is natural and healthy.
Insomnia is very common and highly distressing, so reaching for the pill bottle is an understandable reaction. But there are proven ways to improve sleep without drugs. Trust that with a little effort, you can get the natural good night’s sleep that you need to be healthy and function at your best.
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