Ask the Expert: Medications for Insomnia

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Q: I haven't been able to get a good night's sleep for months. Is there a medication that can help me?

A: First, if you are having persistent sleep problems, you should talk them over with a health care professional. There may be underlying physical and/or psychological factors at work, such as depression, which need to be addressed by a medical professional.

Some physicians readily prescribe sleeping pills to treat insomnia, while others are completely opposed. In my practice, I do prescribe medications, but usually only after trying other approaches first.

For example, I recommend that my patients with chronic insomnia watch their diets, reduce nicotine and alcohol, set regular wake times and meal times, manage the lighting in their rooms, among other things, to help regulate their sleep schedules. I also try to help them gain insight into lifestyle issues that may be at the root of their insomnia. For instance, if job-related stress is keeping them awake at night, I recommend learning skills and behaviors to reduce the stress. Regular exercise, preferably done at least three hours before bedtime, may help improve sleep, stress and depression.

If I see a menopausal woman who is not sleeping well, I might ask her to consider hormonal replacement therapy (HRT) and other substitutes, if appropriate for her medical history and her lifestyle.

I strongly advise anyone who's considering taking a non-prescription sleep aid or herbal remedy, to talk to a health care professional first. If you take other medications, consume alcohol in the evening, or have any breathing, heart, or anxiety-related conditions, sleeping aids of any kind could make them worse. Unfortunately, along with aging, more medical problems are likely to occur, leading to more risk of insomnia. Older people are also more sensitive to medications and may experience more side effects.

Popular over-the-counter sleeping aids contain antihistamines such as diphenhydramine and doxylamine. These products are not very effective sedatives; they cause daytime hangover and grogginess, as well as other side effects, and there is a potential for drug interactions. These over-the-counter products often are not useful long-term. I do not recommend regular use of over-the-counter remedies as sleep aids without the guidance of a health care professional, particularly if they are combined with other drugs such as acetaminophen.

"Night-time" cold remedies also contain antihistamines such as doxylamine, diphenhydramine and chlorpheniramine to help you sleep better, but they can also contain alcohol, pain relievers, cough suppressants, expectorants and decongestants. These products should not be used to manage insomnia--or other forms of sleeplessness. They can cause breathing difficulties, interact with other medications you may take, and produce heart rhythm problems, nervousness, hangover and grogginess.

Many patients are turning to herbal or alternative products to relieve insomnia. I have concerns about using herbal pro. ducts as sleep aids, as well. Herbal products are not regulated, and frequently they fail to meet the same rigorous production standards required of pharmaceuticals. With a few exceptions, herbals are also not supported by the same degree of research and testing, as are prescription medications. And there is the problem that herbals may not be dosed properly, again because the FDA does not closely regulate them. People may therefore wind up taking quantities far in excess of what is recommended. Some herbals are toxic at high levels and many may interact with other medications.

Synthetic versions of melatonin, a natural human sleep hormone, are another popular sleep aid. Melatonin is a fairly weak sedative, and some people report benefit from it, but it can cause daytime hangover and headaches. Some people with mild insomnia seem to achieve relief with aspirin and other over-the-counter pain relievers, calcium, magnesium, and other mineral supplements and vitamins. Scientific evidence for the effectiveness of these various remedies is weak. However in the case of certain physical disorders, such as pain and restless legs syndrome, some of these may be helpful.

Prescription medications should be the last resort for treating most chronic insomnia, in my opinion. But, that being said, there are effective prescription medications available that may be used safely, if other strategies for managing insomnia have failed. The key to safe and effective treatment with medication is to have your insomnia accurately diagnosed. Second, your treatment plan should be tailored to your specific type of insomnia. For example, one type of medication may be good for trouble falling asleep, while another type of medication would be more effective if the problem is waking up in the middle of the night and then not being able to get back to sleep. It's important to share as many details as possible--through the use of a sleep diary, for example, with your health care professional, to help tailor your treatment plan. If it is necessary to use a prescription sleeping pill regularly, you should keep close follow-up with the prescribing physician and follow directions carefully.

Depression, Anxiety and Insomnia

Insomnia is often a symptom of depression and/or anxiety, and in these cases treating the underlying psychological problem--whether through counseling, stress management, medication or a combination of all--may resolve the sleep problem.

It's important to note that some antidepressants, such as Wellbutrin (buproprion), Zoloft (sertraline) and Prozac (fluoxetine) actually cause insomnia, especially if taken in the evening. The effect may be offset for many patients by taking the pill in the morning instead. However, the beneficial effect of these medications on depression and anxiety often leads to improved sleep when they have been taken long enough to take effect. Sleeping pills can be added when starting the antidepressants to give relief from the initial insomnia.

Discuss your insomnia with your health care professional.

--Virgil Wooten, MD, Medical Director TriHealth Sleep and Alertness Center Good Samaritan and Bethesda Hospitals Cincinnati, Ohio

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By Virginia Wooten

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