![]() ![]() BenzodiazepinesĪ number of controlled trials have established the efficacy of benzodiazapines for the treatment of insomnia. It is not clear to what extent they succeed, and, in fact, there are only two studies that compared a benzodiazepine and nonbenzodiazepine hypnotic (zolpidem and temazepam) and these two agents are quite different in other important ways (temazepam has a much longer half life) which limits our ability to interpret the results. The nonbenzodiazepine agents were more recently introduced and were designed to avoid some of the adverse effects of benzodiazepines. Adverse effects may include sedation, cognitive impairment (anterograde short-term memory loss), motor impairment and the potential for abuse. These additional effects include reducing anxiety, stimulating the reward circuits in the brain (which is linked to abuse potential), anticonvulsant and muscle relaxation effects. Since GABA-A receptors are distributed throughout the brain, these medications have many effects on brain activity. The most widely prescribed medications for insomnia enhance the activity of GABA-A receptors. Benzodiazepine and Nonbenzodiazepine GABA-A Enhancing Medications ![]() Other medications that we will mention have even less data supporting their use. Melatonin does not have consistent data and has been studied at many different doses and formulations. The other treatments that have good evidence for efficacy, include CBTi and low dose doxepin. Not surprisingly, the bulk of the studies have been done on prescription medications and were sponsored by the manufacturer (zolpidem, zaleplon, eszopiclone, ramelteon, suvorexant, temazepam). This chart, from the Wilt, et al, Annals of Internal Medicine review shows how many studies have been done on various treatments of insomnia. For information about the Neuroscience Based Nomenclature, an alternative system that is supported by a number of prestigious organizations click here. This page uses the traditional scheme for classifying psychotropic medications. This may explain why patients feel that benzodiazepines and related medications are much more effective than sleep study data would suggest – patients no longer remember transient awakenings, nor how long it takes to get to sleep. Among other problems with patient self-reported sleep quality is the fact that many of the medications used to treat insomnia also interfere with memory. This type of research is much less costly to perform but much less useful. This seriously limits the list of studies since most research uses patient reports of sleep duration and quality. ![]() In addition, where available, I have tried to identify sleep studies that include sleep studies. If you are interested in a more detailed discussion of the psychopharmacology of sleep and wakefulness (but one which does not focus on strength of the data supporting efficacy) I recommend this summary by Flavio Guzman. There are many, many medications and non-prescribed supplements that are felt to improve sleep quality, but have limited, if any, evidence to support their use. This review attempts to focus on evidence based treatments. People with sleep disorders secondary to another psychiatric condition (major depression, PTSD, generalized anxiety, psychosis, etcetera) need to receive treatment for that condition or they will not get better.Cognitive Behavioral Therapy for Insomnia (CBTi), which we have discussed elsewhere on this website, is generally more effective and certainly safer than medications for the treatment of most types of chronic insomnia.People with insomnia should be evaluated to rule out specific disorders of sleep (such as periodic leg movements during sleep (PLMS), sleep apnea, and narcolepsy) which need other types of treatments and should receive a general health screen to rule out other medical conditions that may cause disrupted sleep.I will complete the article soon…īefore discussing medications, I want to make three important points: It is a work in progress and I should note that the text in italics is from the Minkel and Krystal article. Heart Practices for Challenging Time ClassĪ recent thread on the Women’s Mental Health listserve prompted the creation of this summary of information about medications used to improve sleep. ![]()
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