Thirty million Americans have insomnia, trouble falling or staying asleep. Chronic insomnia predisposes people to depression, missed work, drug and alcohol use, accidents, and frequent medical visits in search of relief for the fatigue of sleeplessness. Sleeping fewer than 5 hours a night on a regular basis is demonstrably dangerous. Persons reporting this level of insomnia are at an increased risk of dying over the next decade compared to those who sleep longer. After trying over-the-counter remedies, many seek treatment for chronic insomnia by asking for prescription sleeping pills. Is there evidence that these pills work? And what are the risks?

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Total hours asleep during the night is the number that has potential adverse health implications, even though this total only imperfectly captures whether one’s sleep is deep and restful, or interrupted. Most people accurately report the number of hours they sleep (when compared to a objective data from instruments that measure the brain waves and lack of motion during sleeping), but are not very accurate when judging how long it took to fall asleep.

Sleeping pills can effect the time to fall asleep, the length of sleep, and the perceived quality of sleep. Every sleeping pill approved by the FDA, however, is sanctioned for only short-term usage, no more than a few weeks. Sleeping pills clearly help those who have transient insomnia related to stress or travel or grief. But for people who have chronic sleep disturbance, only one medication has been tested and approved for treatment longer than a month; most medications doctors prescribe for insomnia have never been studied in persons with unremitting sleep problems.

In the nearly 100 randomized, placebo-controlled, short-term (less than 4 weeks, some lasting only a few nights) studies involving adults with chronic insomnia, sleep medication reduced the time spent falling asleep on average 7-13 minutes, and increased total sleep 11-33 minutes. There were only minor differences between individual medications, although head-to-head trials were rare. In any case, these improvements in sleep represent a best-case scenario. Because nearly all sleep medication studies have been funded by pharmaceutical companies, one has to assume that trials with weaker results are less likely to be published. In addition, the elderly, and people with medical or psychiatric conditions were excluded from most published trials, and results might be different for these groups who commonly have insomnia. A considerable proportion of individuals with insomnia use pills on a nightly basis for prolonged periods,either because of persistent sleep disturbances, or in an attempt to prevent insomnia. Whether continuing treatment has any benefit beyond the few weeks tracked during these studies remains unknown.

In exchange for these few minutes of added sleep (although when you are an insomniac, minutes may feel like hours), there are risks. The most commonly reported side effects are impaired alertness in the morning, headache, dizziness, and nausea. There are no reports of more serious effects such as falls, injuries, or death in healthy adults, although sleep-walking is certainly disturbing. Studies in the elderly however, reveal that sleep medications can increase the risk of injury and decrease attention, concentration, and memory.  What about when you stop using them?

With nightly use of sleep medications, tolerance is likely to develop. To overcome the lack of effect, patients increase dosages often beyond the maximum safe level. Attempts at discontinuing can produce withdrawal symptoms, including worsened insomnia for several nights. This experience heightens the patient's anticipatory anxiety and reinforces the belief that he or she cannot sleep without medication. To prevent sleeplessness, the patient then resumes medication use, caught in a vicious cycle. Indeed, insomniacs commonly overestimate sleep time and underestimate wake time while on medication and, upon withdrawal, become acutely aware of their sleep disturbance.

Increasing sleep from less than 5 hours to 7 hours on a regular basis has been associated with decreased risk of mortality. But this increase in sleep is unlikely to come through taking sleep medications. Many people use sleep aids for years, and continue reporting significant sleep problems in spite of nightly use of medications. Reducing alcohol and caffeine, quitting smoking, reducing pain or urinary symptoms that keep one awake, changing home or work environments will be more useful than taking pills. There are also non-pharmacological treatments for insomnia that should be sought because while sleep problems may not disappear quickly, sleep medication use should always be time-limited. When used intermittently, medications will have better effect than if used nightly. 

MD Stein