When suffering from disturbed sleep, turning to medication to treat sleeplessness may seem like the easiest solution. However, current medical guidelines for the treatment of insomnia recommend caution. There is no ideal sleeping pill.
Psychiatrists advise that patients should first follow proper sleep hygiene rules and consider cognitive behavioral therapy before reaching for pills. Sleep medications could only be considered if these measures do not help.
In general, the treatment of sleeplessness with medications issued on prescription should not last longer than four weeks.
There are a variety of medications used for the treatment of sleeplessness that belong to different groups. Most of them are psychiatric drugs.
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Benzodiazepines and Non-benzodiazepines (Z-Drugs)
Benzodiazepines and non-benzodiazepines, also known as Z-drugs, are among the most commonly prescribed sleeping medications. They enhance the effects of the body’s natural neurotransmitter GABA acting at various areas in the brain, which leads to sleep-inducing, calming, and anxiety-reducing effects.
Benzodiazepines and non-benzodiazepines vary in how long they work, depending on their “half-life,” which refers to how long it takes for half of the drug to be eliminated from the body. The longer the half-life, the longer the sleep-regulating effect lasts. This duration also can vary from person to person.
Benzodiazepines
The unwanted effects of benzodiazepines may include dizziness, drowsiness, concentration problems, and impaired driving ability, which can persist into the next day. These effects are more pronounced in drugs with a longer half-life. In elderly individuals, the combination of drowsiness and muscle relaxation can lead to falls, such as during nighttime visits to the bathroom.
Another concern is the rapid development of tolerance. If benzodiazepines are abruptly discontinued after long-term use, sleep problems can quickly return. This is why guidelines recommend limiting their use for insomnia to no more than four weeks, followed by a gradual reduction in dosage and extended intervals between doses to avoid withdrawal or rebound symptoms.
There are six benzodiazepines used for short-term treatment of insomnia: flunitrazepam, flurazepam, lormetazepam, nitrazepam, temazepam, and triazolam.
Non-Benzodiazepine (Z-Drugs)
Z-drugs, or benzodiazepine receptor agonists (BzRA), usually have shorter half-lives than benzodiazepines, meaning they do not last as long in the body. This reduces the risk of next-day drowsiness.
Z-drugs carry the same risks of tolerance and dependence as benzodiazepines. In many Western countries, two Z-drugs, zolpidem and zopiclone, are approved for the short-term treatment of insomnia.
Antidepressants as Sleep Medication
Antidepressants refer to a group of drugs with varying mechanisms, primarily used to treat depression. They have mood-enhancing and energizing effects, reduce anxiety, and after a few weeks, they regulate sleep.
In Germany, only doxepin is officially approved for treating insomnia without depression. However, a few other antidepressants originally approved for treating sleep disorders alongside depression are frequently prescribed off-label for insomnia alone. These drugs carry a lower risk of tolerance than benzodiazepines. Antidepressants can interact with other medications, which must be carefully considered before starting treatment.
Treating Sleeplessness with Antipsychotics
Antipsychotics are used to treat severe mental health disorders such as psychosis. Some types of antipsychotics slow down mental activity, reduce drive, and cause drowsiness. In Germany, only two antipsychotics—pipamperone and melperone—are approved for the short-term treatment of insomnia. They are mainly prescribed for elderly patients, and the treatment duration should not exceed a few weeks.
Antipsychotics may cause side effects such as dry mouth, sweating, vision problems, trembling, and low blood pressure. Long-term use of high doses may lead to movement disorders affecting the face, hands, or feet, called “dyskinesia.”
Antihistamine Medication for Treatment of Insomnia
Antihistamine medications were originally developed for treating allergies such as hay fever or asthma. They also cause sedation and can be used for insomnia. Some of these older antihistamines, such as diphenhydramine and doxylamine, are available over the counter for short-term treatment of sleeplessness. In allergic reactions, the body releases histamine, a key neurotransmitter found throughout the body and in the brain.
Tolerance also develops with antihistamine medications, meaning they lose effectiveness after longer use. Increasing the dose is not recommended because it raises the risk of side effects. To avoid daytime drowsiness, they should be taken at least eight hours before waking up.
Treatment of Sleeplessness with Melatonin
Melatonin is a hormone that regulates the sleep-wake cycle. Therefore, it can be used for the treatment of sleeplessness. In Germany, melatonin is approved for short-term treatment of insomnia in people over 55.
Potential side effects of melatonin include irritability, nervousness, restlessness, and nightmares. No tolerance or withdrawal effects have been reported so far. In some countries, melatonin supplements are sold over the counter.
Herbal Sleep Aids
Herbal remedies for sleep are widely available in various forms, such as liquids, tablets, capsules, or teas. These traditional medicines rely on historical use rather than scientific proof. Only a few scientific studies have evaluated their effectiveness, but the results are inconsistent.
Common ingredients include valerian root, passionflower, and lemon balm, often used alone or in combination. Because herbal products contain multiple plant compounds, their exact effects and mechanisms are difficult to predict.
Due to the variety of products on the market, it is difficult to determine optimal dosage or duration of action for herbal sleep aids. When used correctly, they tend to have few side effects and are not addictive. Ever since, past reports have raised concerns about contaminants, especially in teas.
Medication for Treatment of Insomnia
When a pronounced sleep disorder is identified, simple measures such as changing sleep habits often reach their limits. Some people then hope that sleeping pills or sedatives will help them sleep better again and get through the next day. However, medications can only provide temporary relief. The sleep medications do not address the underlying causes of the sleep disorder. Experts recommend cognitive behavioral therapy as the primary treatment for sleep disorders.
Strong sleeping and sedative medications, such as benzodiazepines and Z-drugs (benzodiazepine receptor agonists), must be prescribed by a doctor. They are only considered when distress is high and other therapies have failed. An effective sleep medication should restore natural sleep patterns, be well-tolerated by patients, and be compatible with other medications they may be taking.
