The benefits of most sleeping pills are usually evident within a few days, and if there isn’t an improvement after 7-10 days, it can feel discouraging. Insomnia causes a lot of discomfort and there’s a natural tendency to discard the medicine and try new ones, in what can seem like an endless search for the perfect pill. We’ll talk later about considerations in changing medicines, but first, let’s look at a different approach: going back to the beginning, re-thinking about the sleep disturbance and looking for other possible contributors.
Reviewing the Situation
Consider whether a medical illness is contributing to poor sleep:
A number of illnesses or changes in life can disturb sleep, among them:
- Gastric reflux
- Irritable bowel syndrome
- Asthma or chronic pulmonary disease
- Congestive heart failure
- Parkinson’s disease
- Benign prostatic hypertrophy
- Chronic pain conditions
- Changes in life including menopause
If a medical condition is contributing to poor sleep, both the illness and the sleep disturbance should be addressed.
Consider the effect of other medicines on sleep:
A variety of drugs for various medical or psychiatric illnesses can disturb sleep, among them:
- Stimulants, for instance, given for ADHD
- Thyroid hormone
- Some antidepressants
- Beta-blockers for high blood pressure or heart rhythms
- Alpha blockers for high blood pressure or enlarged prostate
- ACE inhibitors for high blood pressure
- Cholinesterase inhibitor drugs used for memory loss
- Some statin medicines for high cholesterol
- Nicotine replacement patches or inhalers
- Caffeine-containing over-the-counter medicines for a headache or alertness
If a medicine may be contributing to poor sleep, it’s important not to stop it abruptly, but rather to discuss with the doctor about possible changes in dose or alternative treatments.
Consider other sleep and body rhythm disorders, including:
Sleep apnea: The obstructive form of sleep apnea results from the periodic collapse of the upper airway during sleep, blocking airflow to the lungs. During these episodes, blood oxygen levels decline and carbon dioxide rises; ultimately a protective mechanism causes a person to have an arousal, and then return to sleep. These arousals are so brief that they are not usually remembered as a true awakening the next day, but the cumulative effect of having many of these is a sense of having slept poorly and awakening unrefreshed. It is often associated with snoring, though many people snore but do not have sleep apnea.
Restless legs syndrome (RLS) and periodic leg movement (PLM) disorder: RLS is characterized by an uncomfortable tingling or ‘creepy-crawly’ feeling in the legs, which tends to occur at night and when one is resting. It is usually temporarily relieved by getting up and walking about, but the uncomfortable sensation when in bed can cause significant sleep disturbance. A related condition is periodic leg movement disorder, which occurs in most persons with RLS as well as many people without it. In PLM disorder, very characteristic movements of the leg and ankle, lasting up to 10 seconds, occur and often are associated with arousals.
Disturbances of body rhythms: The body has elaborate clock-like mechanisms for regulating the timing of sleep and waking relative to the night and day. Sometimes the mechanisms malfunction, resulting in problems sleeping. There are a variety of disorders of body rhythms, including sleep difficulties associated with jet lag, shift work, or keeping very irregular hours of sleep due to lifestyle.
In summary, there are many sleep disorders which should be considered in evaluating what at first appearance seems to be insomnia which is unresponsive to medicine. If a person suspects that one of these is possible, it would be appropriate to seek consultation at a sleep disorder center.
Consider what else is going on in life:
Waking and sleep are connected. Just as disturbances of sleep can affect a person’s daytime life, upsetting events or ongoing conflicts during the day will make sleep more difficult. Even though a person knows this logically, when sleep is disturbed there’s often a tendency to consider it in isolation and to seek help for the sleep as if it were a world apart from everything else. Of course, this isn’t so. Medicines can help to some degree, but it’s not realistic to expect ongoing good quality sleep, with or without a pill, if there are major ongoing conflicts during the day (or night—for instance, when sharing a bed with a person at the center of the conflict). These kinds of situations need to be addressed, and one good way to do this is in psychotherapy.
Changing Doses or Medicines
If a person is troubled by a side effect that doesn’t go away, for instance, an unpleasant taste, or persistent sleepiness in the morning, opting for a different medicine is an appropriate choice. If the issue is that a medicine doesn’t seem to be helping sleep, it’s natural to think about taking a higher dose, but it is rarely successful. Most currently available sleeping pills have a very narrow dose range.
Sometimes increasing the dose inside the recommended range is helpful, but often it increases the risk of side effects with limited incremental benefits for sleep.
If sleep is not getting better, and other causes of poor sleep have been considered and ruled out, this is the point to review the qualities of the medicine and determine if they are a good match for an individual’s sleep difficulty. If a person has trouble both going to sleep and staying asleep, for instance, then the use of short-acting sleeping pills might be reconsidered in favor of a longer-acting medicine. If the kinetics of the medicine and the indications for which it has been shown to help do not match a particular person’s symptoms, it’s reasonable to try other medicines. This should be done judiciously, however, and with realistic goals. Some people, in a natural desire for relief from the discomfort of insomnia, get caught up in a continual series of switches between medicines, in the hope that the next one will change everything. It’s rare that this will happen, and more likely that any new benefits will be incremental.
Instead of reflexively searching for more and more medicines, the fact that sleep isn’t getting better should be a signal to sit back and reconsider the beginnings, as we have outlined in this chapter. It’s the right moment to review whether other disorders or medicines or upsetting events are contributing to insomnia and if so, to treat them. It’s a time to consider that although a person’s focus is on the poor sleep, it might be in the context of unrecognized depression, which also needs treatment. And finally, it is time to consider whether non-medicine talking treatments might be in order.
Non-medicine talking therapy is an important alternative—and complementary– approach to insomnia. Although many forms of psychotherapy have been used over the years, the one with the most well-recognized evidence of efficacy is known as cognitive behavior therapy for insomnia (CBT-I). The general notion is that although there can be many initial triggers for poor sleep, for instance, an upsetting event or illness in a susceptible individual, there are other factors that can make it worse or perpetuate it, and these factors can be addressed. Some of these may be behavioral (such as keeping irregular sleep hours), while others can be psychological (anxiety about sleep) and cognitive (inaccurate beliefs about sleep). CBT-I has multiple components, reflecting the many factors that can contribute to insomnia. It typically involves 4-6 one hour sessions with a therapist over the course of 6-8 weeks. During this time several different approaches are used:
Sleep Hygiene: A series of guidelines for sleeping better, for instance avoiding excessive caffeine, and not using cell phones or tablets in bed.
Sleep Restriction: A technique for making sleep more efficient.
Cognitive Therapy: An examination of ideas about sleep that may be contributing to the difficulty.
Stimulus Control: Emphasizes removing arousing behaviors that have become associated with the act of going to sleep.
Relaxation Therapy: Reducing muscle tension as a way of helping the mind relax.
Mindfulness: Living in the present moment, without worrying about the past or future.
CBT-I has been compared to taking traditional sleeping pills, with findings that both improve sleep in the short term. In general, the benefits of CBT-I are slower to appear but last longer after treatment is discontinued. The two forms of treatment can be combined as well.
In summary, if it seems like the sleeping pill isn’t working, it’s a good opportunity to sit back and reconsider the situation. Sometimes looking at the possible contribution of other illnesses or medications to poor sleep can be helpful. It’s important to match the particular type of sleep disturbance with the qualities of the medicine. It’s also appropriate to consider non-medication alternatives, and in particular cognitive behavioral therapy for insomnia.
Editor’s note: You can learn more about sleep and sleeping pills in Dr. Mendelson’s new book, Understanding Sleeping Pills.