As of Wednesday, July 10, 2013
DEAR DOCTOR K: I can’t sleep. Behavioral changes haven’t helped. Can you tell me about prescription medications for insomnia?
DEAR READER: I typically prescribe sleep medications only for short-term sleep problems. For example, I might prescribe them for a patient who is traveling across time zones or coping with a death in the family. Even then, I prescribe them at the lowest dose and for the shortest possible time. Behavioral changes — such as going to bed and getting up at the same time each day, not reading or watching TV in bed, etc. — usually work if you keep at them.
Several categories of medications, which I discuss below, are used to treat insomnia. (I’ve put a table listing specific medications in each category on my website, AskDoctorK.com.) After taking any sleeping pill, allow for a full eight hours of sleep.
— Benzodiazepines calm brain activity. They are useful for patients with insomnia that results from anxiety. Different benzodiazepines vary in how quickly they act and how long they remain active in the body. That’s important because people have different types of sleeping problems. Some people have trouble falling asleep: They need a fast-acting medicine. Others fall asleep easily but find themselves waking in the middle of the night: They need a longer-acting medicine.
These drugs can cause next-day drowsiness and sedation. They can also reduce how much deep sleep you get — and you need deep, restorative sleep. So benzodiazepines can help you sleep, but they don’t increase what I think of as the most important kind of sleep. Another problem with benzodiazepines is that they start to lose their effect over time. As a result, many people find they need more and more of the drug to obtain the same effect.
— Nonbenzodiazepines act on sleep receptors in your brain. They help you fall asleep more quickly, but they may not lengthen your total sleep time. These drugs vary in how quickly they act and how long their effects last.
Earlier this year, the FDA warned that people who take zolpidem (Ambien) can wake up the next morning with drug levels high enough to impair their ability to drive and do other activities safely — even if they feel wide awake.
— Antidepressants can reduce the time it takes to fall asleep and decrease nighttime awakenings. The tricyclic antidepressants are particularly good for increasing the time in deep, restorative sleep. And they achieve this effect at very low doses —— well below the doses used to treat depression. Antidepressants are safer for long-term use than benzodiazepines. Their effect on sleep quality varies. The tricyclics should be used with caution in people over age 50, however, as they can contribute to heart rhythm problems.
— Melatonin-receptor agonist. Ramelteon (Rozerem) is the only drug in this category. It mimics the body’s naturally produced melatonin, a hormone that promotes sleep.
Before you try a prescription sleep medication, give behavioral changes another chance. They are often just as effective as medication and may have longer-lasting benefits. This time, work with a sleep specialist trained in behavioral medicine.
Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.