Treating insomnia with sleeping pills and sedatives

Some medications for sleep problems can be bought "over the counter." In other words, you can buy them without a prescription in supermarkets, drugstores, pharmacies or on the internet. Others have to be prescribed by a doctor – especially if they have strong side effects or can lead to dependence.

All sleeping pills and sedatives can make you feel tired during the day and slow you down. Depending on which medication you use, activities that require concentration and quick reactions – such as driving – can be dangerous. Elderly people who take medication to help them sleep also have a higher risk of falls.

Examples of such medications include:

• Herbal remedies like valerian
• Antihistamines
• Melatonin
• Antidepressants
• Antipsychotics
• Benzodiazepines and Z-drugs (benzodiazepine receptor agonists, also known as BzRAs)
• Dual orexin receptor antagonist (DORA)

Herbal substances that are thought to improve sleep include valerian, hops, passionflower and lemon balm. Herbal sleep remedies contain one or more of these substances. The remedies come in the form of tablets or drops, and you usually don't need a prescription for them.

There is no proof that herbal remedies can reduce insomnia because there hasn't been enough good-quality research in this area.

Over-the-counter herbal remedies aren't very likely to have serious side effects. But they can cause allergic reactions, nausea and abdominal (belly) cramps. Also, some herbal remedies can't be taken in combination with other sedatives. So if you're already taking sedatives, it's best to ask your doctor before you try a herbal remedy.

Antihistamines are mainly used to treat allergies. They stop histamine from being released. Histamine is a local hormone that plays a role in inflammations. Antihistamines are said to help you sleep. But there's a lack of good research on whether they are effective in insomnia.

Antihistamines come in the form of tablets or drops. Some of them, like diphenhydramine and doxylamine, are available over the counter. Others, such as promethazine and hydroxyzine, have to be prescribed by a doctor. It is important to talk to your doctor before deciding whether to use antihistamines.

Although most people tolerate antihistamines well, they do have some side effects. The most common ones are headaches, restlessness, concentration problems, dizziness, a dry mouth and blurred or double vision. It is also important to be careful if you already have certain other medical problems. For example, antihistamines aren't suitable for men with prostate problems because they can make it difficult to pass urine.

Melatonin is a hormone that our bodies make – mainly at night. It regulates our sleep-wake cycle, which is the amount of time we spend awake and asleep within a period of 24 hours. Our natural sleep-wake cycle can be thrown out of sync by things like shift work or traveling across several time zones. This is even likelier in people who are fully blind. They can't use daylight as a guide.

In Germany, melatonin is available in the form of dietary supplements and medications.

The medications have to be prescribed by a doctor. They are only approved for people aged 55 or over who are generally healthy otherwise. An exception is made for children and teenagers with sleep problems caused by autism or a very rare genetic disorder called Smith-Magenis syndrome.

The dietary supplements are available over the counter (without a prescription). Some of them contain small doses of melatonin, and some contain a similar amount to medications.

Early research findings suggest that melatonin can sometimes improve sleep problems. It seems to help you fall asleep, for instance. But a lack of reliable research means it's still not clear how effective melatonin is.

Melatonin can cause side effects such as headaches, restlessness, irritability and stomach problems. It also shouldn't be taken together with certain other medications because they may change each other's effects. So, if you're already taking other medication, it's best to ask your doctor before taking melatonin. So far, melatonin hasn't been shown to cause serious side effects.

Antidepressants are a possible option for people whose insomnia is accompanied or caused by depression. Sometimes a doctor will suggest taking a low-dose antidepressant even though the person doesn't actually have depression.

The nerve cells in our brain need certain substances (chemical messengers) to be able to pass on signals. Antidepressants aim to make more of those substances available. Some antidepressants have a calming effect, and you can't become physically dependent on them (unlike benzodiazepines and Z-drugs). Not much is known about the side effects they have when used to treat sleep problems. There are also a lot of unanswered questions about their long-term effects and how well they are tolerated.

In Germany, the only antidepressant approved as a treatment for insomnia is low-dose doxepin. Research suggests that doxepin can reduce sleep problems for a period of time, at least: After taking it for one to three months, study participants who were given doxepin rated their sleep better than those who took a placebo. The participants who took doxepin also slept a little longer.

Very little is known about the side effects of low-dose doxepin. There is also a lack of research into whether doxepin continues to improve sleep problems over the longer term.

Because doxepin is the only antidepressant approved for the treatment of sleep problems in Germany, if a doctor prescribes a different antidepressant for that purpose, it's referred to as " off-label use." This means the medication has been prescribed for an illness that it hasn't been approved for.

When antidepressants are used for insomnia, the dose is usually lower than for the treatment of depression.

Some of the other antidepressants occasionally used to treat sleep problems include agomelatine, amitriptyline, mirtazapine and selective serotonin reuptake inhibitor (SSRI) antidepressants. There's a lack of good-quality studies on this type of use, too, so not much is known about their positive and negative effects in sleep problems.

Research on the antidepressant trazodone suggests that it slightly improves subjective sleep quality within the space of a few weeks. Study participants who were given trazodone rated their sleep slightly better than those who took a placebo. All of the participants had insomnia, but no depression. The side effects of using trazodone for insomnia were not investigated enough. There is also a lack of research on its long-term use.

Antipsychotics (neuroleptics) are normally used to treat psychosis. They block the activity of specific nerve cells in the brain and can reduce hallucinations and delusions. Some antipsychotics mainly have a calming effect and make you feel very tired.

In Germany, two antipsychotics are approved for treating insomnia (not accompanied by a psychotic disorder) in elderly people who have health problems typical of their age group. They are called melperone and pipamperone. But there is no scientific proof that they improve elderly people's sleep. So it's not clear whether, or how much, they can help. Antipsychotics generally aren't used very often in sleep problems because they sometimes have severe side effects too.

The side effects of antipsychotics like melperone or pipamperone include restlessness, nausea and vomiting, allergic reactions, a dry mouth, irregular heartbeat, changes in blood sugar or blood lipid levels, and involuntary physical reactions such as smacking of the lips, grimacing or frantic head movements. Antipsychotics can't be taken in combination with alcohol or with certain other medications.

Benzodiazepines (or "benzos" for short) are strong sleeping pills and sedatives that have a calming and anticonvulsant effect. They reduce the sensitivity of specific brain nerve cells by stopping signals being passed on. Benzodiazepines have to be prescribed by a doctor. The most commonly used ones in Germany are lormetazepam, temazepam, nitrazepam and flunitrazepam.

Research shows that benzodiazepines can improve sleep problems in the short term. For instance, they can help you fall asleep faster, allow you to sleep longer, and also improve the quality of your sleep. But they don't make the root cause of the sleep disorder disappear, and you can't take them for more than four weeks. So it's a good idea to work out beforehand what you're going to do when it's time to stop taking them.

The effects of benzodiazepines last for many hours or even several days. As a result, people who take them are likely to still feel drowsy the next day. Their ability to concentrate and react may decrease significantly. This means they are less able to drive and unable to operate machinery safely. Benzodiazepines also increase the risk of falls in elderly people because they cause the muscles to relax. They have lots of other side effects too, some of which are severe, and it's easy to become dependent on them.

Z-drugs work in a similar way to benzodiazepines but they belong to a different group of substances. You can become dependent on them after a few weeks. They have an advantage over benzodiazepines because they are broken down more quickly by the body. That means that they have less of an effect on wellbeing and productivity the next day. Like benzodiazepines, the effects of Z-drugs can still be felt after waking up. So it's important to wait several hours before driving a car or operating machinery.

BzRAs are referred to as "Z-drugs" because their names start with the letter z. In Germany, zopiclone and zolpidem are approved as treatments for insomnia. These are the most commonly used sleeping pills. They can provide short-term relief in some people – helping them to fall asleep, for instance. But, like benzodiazepines, they don't make the root cause of the sleep problem disappear and you can't take them for more than four weeks. So, again, it's a good idea to talk to the doctor before taking them, and to have a plan in place about what you will do afterwards.

Z-drugs have many side effects too. These include confusion, hallucinations, nightmares and dependence. People who take Z-drugs might also sleepwalk, which can result in accidents.

Benzodiazepines and Z-drugs are the most commonly prescribed insomnia medications. Because it's easy to become dependent on them, it's important to stop taking them after the prescribed period. Your body can get used to them after as little as two weeks. Then you'll feel the need to keep taking them and to increase the dose because they won't be as effective anymore.

You may have withdrawal symptoms when you stop taking benzodiazepines or Z-drugs. Your body can't always adjust to the change fast enough. This leads to symptoms that are often similar to those that you took the medication for in the first place. For all of these reasons, it can be difficult to stop taking the medication. Whether or not you have withdrawal symptoms – and how severe they are – depends on the length of the treatment, the dose you take, and how slowly you decrease the dose when you come off the medication.

There is also a risk that you might end up taking them for longer. In Germany, roughly 1.2 to 1.5 million people are dependent on benzodiazepines or Z-drugs. So it's important to carefully consider whether or not to use them, and only to take them under the supervision of a doctor.

This group of medications includes the drug daridorexant. It is approved for adults who have serve insomnia that has lasted more than three months and which has a major impact on their everyday life. The substance blocks the effect of the hormone orexin, which is involved in controlling our sleep-wake cycle. That is intended to help us sleep better. It is recommended to take daridorexant only as briefly as possible. You should consider whether it makes sense to continue the treatment together with your doctor within the first three months. It is not clear how effective daridorexant is because there are no good-quality studies available.