To Sleep, Perchance to Sleep Soundly

Last Editorial Review: 5/12/2005

Is the new generation of sleeping pills the answer for insomnia?

By Gina Shaw
WebMD Feature

Reviewed By Charlotte Grayson

Insomnia has been around as long as sleep has. Some even believe that William Shakespeare was an insomniac, writing as vividly as he did about sleeplessness, tossing and turning, and sleepwalking in plays like Hamlet and Macbeth. Today, old Will has millions of fellow sufferers: in a 2002 survey, the National Sleep Foundation found that 58% of adults have trouble sleeping at least a few nights a week.

One option today's insomniacs have that Shakespeare didn't, of course, is the sleeping pill. These drugs have a checkered past -- those who remember the deaths of Marilyn Monroe and Judy Garland from overdoses of sleeping pills may instantly reject the thought of taking a pill to get to sleep.

But over the past 10 years, a new generation of sleep medications has been developed, offering the promise of a good night's sleep without the perils of next-day hangovers or long-term addiction. They're called non-benzodiazepine hypnotics, but you probably know them as Sonata, Ambien, or Lunesta. Currently, they're considered the first-line medical treatment for insomnia.

A Good Night's Sleep, Without the Hangover

The older classes of sleep medications, particularly the benzodiazepines -- think Valium and Xanax -- do more than just help you sleep. They affect how you sleep, altering your actual "sleep architecture," says Donna Arand, PhD, clinical director of the Kettering Sleep Disorders Center in Kettering, Ohio.

"They tend to decrease the amount of time spent in certain stages of sleep, particularly stages three and four (the deepest, most restful stages of sleep)," says Arand, who serves on the boards of the American Academy of Sleep Medicine and the American Insomnia Association. "People also complained of hangover effects from these medications." That's because they tend to have a longer "half-life," which is the length of time the drug stays in your body.

Non-benzodiazepine hypnotics like Ambien, Sonata, and Lunesta, however, share several advantages over previous generations of sleep drugs:

  • They have a relatively short half-life, so you won't wake up groggy the next day. "There are minimal reports of 'hangover' effects with these new drugs," says Arand.
  • They have little, if any, effect on sleep staging, allowing you the REM sleep you need. "You spend pretty close to the same amount of time in each stage of sleep as you would without the drugs," she says.
  • They are less likely than other sleeping pills to cause addiction, withdrawal symptoms, or a buildup of tolerance (when you require more and more drug to have the same effect).

Why? The newer medications act only on specific receptors in your brain that are focused on sleep, while older groups of drugs have a more generalized effect on multiple brain receptors. "These new drugs are among the safest medications in medicine," says Thomas Roth, MD, Director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit.

But they are not right for everyone. "If you have insomnia due to sleep-related breathing disorders [sleep apnea] or restless legs syndrome, for example, these drugs won't address your underlying problem," says Roth. Pregnant women, of course, shouldn't take these medications. And if you're "on call," frequently getting up in the middle of the night for work or for a child, they might not work for you.

Here, briefly, are the pros and cons of the new sleep medicines, as well as of the older medicines commonly used to treat insomnia:

Sonata: Of all the new sleeping pills, Sonata has shortest half-life, which is the amount of time it takes for the drug to be eliminated from your body. Its half-life is just one hour. That means you can try to fall asleep on your own. Then, if you're still staring at the clock at 2 a.m., you can take it without feeling drowsy in the morning.

Ambien: The most commonly prescribed sleeping pill, Ambien has a medium half-life. It's less than two-and-a-half hours. This means that Ambien is great for helping you get to sleep but, like Sonata, could be less helpful if you tend to wake up a lot in the middle of the night.

Lunesta: Of all the new sleeping pills approved so far, Lunesta has the longest half-life -- about six hours. This means you may feel groggy in the morning if you take it in the middle of the night, or at a time when you can't get a full night's sleep. On the other hand, this pill could help you if you tend to wake up in the middle of the night a lot. Lunesta is the first sleeping pill approved by the FDA for long-term use to treat chronic insomnia. But it won't be alone for long: another sleep aid designed for long-term use, indiplon, is expected to launch later this year.

Benzodiazepines: These older sleeping pills (Valium, Halcion, and others) are useful when you want a drug that stays in your system longer. For instance, they have been effectively used to treat sleep problems such as sleepwalking and night terrors, says Arand. "The biggest problem with these is daytime sleepiness, although you also have to monitor them more closely for dependence as well," she says. (Dependence means that you always need the drug to go to sleep.)

Antidepressants: Insomnia is a common symptom of depression. Thus, some antidepressant drugs, such as Serzone, are particularly effective in treating sleeplessness and anxiety that's caused by depression. "In those cases, the antidepressant helps treat the sleep problem but is really treating the underlying cause," says Arand.

Over-the-Counter Sleep Aids: Most of these sleeping pills, such as Sleep-Eze, are antihistamines. This means they're somewhat sedating and can cause some drowsiness the next day. They're safe enough to be sold without a prescription, but if you're taking other drugs that have similar effects -- like cold or allergy medications -- you could inadvertently take too much.

Combining Medicine With Good Sleep Habits

Roth suggests that it's time to start thinking about insomnia as a chronic disorder -- which he notes that it is in at least 10% of the population -- and treating it that way. "For people who have high cholesterol, you don't just give them a drug to lower their cholesterol and that's the end of it," he says. "You also work with them on other factors in their life that may be elevating their cholesterol."

Similarly, he says, sleep medications for insomnia should not be used in isolation. "You want to use them in conjunction with good sleep practices, good behavioral therapies, and treating accompanying conditions," he says. That means, among other things, practicing "good sleep hygiene:"

  • Use your bed only for sleeping, not for paying bills or working on your laptop.
  • Avoid caffeine, nicotine, and alcohol for four to six hours before going to bed, and don't exercise too late in the evening.
  • Make sure your bedroom is restful and quiet. Get a sleep mask or white noise machine if you can't block out light or noise from outside.
  • Get up and go to bed at the same time every day -- yes, even on weekends!

Studies have also found that cognitive behavioral therapy (CBT) can be a very effective treatment for insomnia, making it easier to fall asleep more quickly and stay asleep longer. "In fact, some research shows that medications aren't as effective in the long term as behavioral treatment of the insomnia problem," says Arand. "Changing behavior can have a greater impact and longer duration of effectiveness. But that doesn't mean you can't use these remedies in combination."

Published February 2005.

SOURCES: Donna Arand, clinical director, Kettering Sleep Disorders Center, Kettering, Ohio. Thomas Roth, MD, director, Sleep Disorders and Research Center, Henry Ford Health System, Detroit. National Sleep Foundation.

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