Treating insomnia with sleeping pills and sedatives

Elderly woman holding pills and a glass of water
PantherMedia / tetxu

Some sleeping pills and sedatives are available without a prescription, and others have to be prescribed by a doctor. Benzodiazepines (benzos) and "Z-drugs" are prescription drugs that can improve the quality of sleep. But it's easy to become dependent on them, and they have many side effects. There is very little research on the effects of using other medications for sleep problems.

If someone has a real sleep disorder, simple measures like changing their sleeping habits are often not enough. Some people then hope that sleeping pills and sedatives will help improve their sleep and get them through the day. But medications can only be a temporary solution, to help people get their energy levels back up. They don't make the root cause of the disorder disappear.

Strong sleeping pills and sedatives, like and Z-drugs (benzodiazepine receptor agonists or BzRAs), have to be prescribed by a doctor. They are usually only prescribed if a person is suffering very badly and no other treatment (including cognitive behavioral therapy) has helped enough. Experts usually recommend cognitive behavioral therapy for severe insomnia.

What medications can be used?

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)

Do herbal remedies help in sleep disorders?

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.

Are antihistamines suitable?

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.

Who is melatonin suitable for?

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.

When are antidepressants used?

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 .

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 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.

Using antidepressants to treat insomnia

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.

Antidepressants and off-label use

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 "." 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 .

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 . The side effects of using trazodone for insomnia were not investigated enough. There is also a lack of research on its long-term use.

Could antipsychotics help?

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.

What are the pros and cons of benzodiazepines?

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 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 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.

How do Z-drugs compare to benzodiazepines?

Z-drugs work in a similar way to but they belong to a different group of substances. You can become dependent on them after a few weeks. But the body breaks them down quicker than so they don't have such a big impact on the person's wellbeing and productivity the next day. Like , the effects of Z-drugs can still be felt after waking up the next day, too. 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 , 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.

What do you need to consider when using benzodiazepines and Z-drugs?

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 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.

So, before using any of them, it's important to be aware that and Z-drugs can only help in the short term. They shouldn't be taken for longer than four weeks and you might have withdrawal symptoms when you stop taking them.

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 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.

Auld F, Maschauer EL, Morrison I et al. Evidence for the efficacy of melatonin in the treatment of primary adult sleep disorders. Sleep Med Rev 2017; 34: 10-22.

Canham SL, Rubinstein RL. Experiences of sleep and benzodiazepine use among older women. J Women Aging 2015; 27(2): 123-139.

Cheung JM, Bartlett DJ, Armour CL et al. People with insomnia: experiences with sedative hypnotics and risk perception. Health Expect 2016; 19(4): 935-947.

Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). Insomnie bei Erwachsenen. DEGAM-Anwenderversion zur S3-Leitlinie „Nicht erholsamer Schlaf/Schlafstörungen“. AWMF-Register-Nr. 063-003. 2017.

Deutsche Hauptstelle für Suchtfragen (DHS). Die Sucht und ihre Stoffe. Eine Informationsreihe über die gebräuchlichsten Drogen und Suchtsubstanzen. Benzodiazepine und Z-Drugs (Beruhigungs- und Schlafmittel). 2021.

Everitt H, Baldwin DS, Stuart B et al. Antidepressants for insomnia in adults. Cochrane Database Syst Rev 2018; (5): CD010753.

Liu Y, Xu X, Dong M et al. Treatment of insomnia with tricyclic antidepressants: a meta-analysis of polysomnographic randomized controlled trials. Sleep Med 2017; 34: 126-133.

Riemann D, Baum A, Cohrs S et al. S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen. Kapitel „Insomnie bei Erwachsenen“ (AWMF-Registernummer 063-003), Update 2016. Somnologie 2017; 21(2): 2-44.

Rios P, Cardoso R, Morra D et al. Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews. Syst Rev 2019; 8(1): 281.

Schwabe U, Ludwig WD. Arzneiverordnungs-Report 2020. Berlin: Springer; 2020.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

Comment on this page

What would you like to share with us?

We welcome any feedback and ideas. We will review, but not publish, your ratings and comments. Your information will of course be treated confidentially. Fields marked with an asterisk (*) are required fields.

Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and information centers?

Created on March 3, 2022
Next planned update: 2025

Publisher:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

How we keep you informed

Follow us on Twitter or subscribe to our newsletter or newsfeed. You can find all of our films online on YouTube.