Medication is a popular choice for many individuals suffering from insomnia because it is fast-acting and widely available in primary care and specialty clinic settings. Those commonly prescribed for sleep include benzodiazepine and non-benzodiazepine hypnotic drugs, sedating antidepressants, antihistamines, and melatonin.
Complementary and Alternative Medicine
Many individuals turn to alternative strategies to aid sleep, such as acupuncture, herbal or dietary medicine, homeopathy, and body work.
Some research suggests that alternative methods are successful stand-alone treatments for insomnia while other research suggests it is more effective when used in combination with other methods. For example, acupuncture plus herbs may be more helpful to promote sleep than acupuncture alone.
Some traditional techniques are recommended as supplements to other forms of Western therapy or medication. For example, acupuncture plus medication appears more beneficial to promote sleep than medication alone.
At this point formal studies are limited, making it difficult to draw firm conclusions in support of many complementary and alternative techniques available. As a benefit over pharmaceutical medication, however, there seem to be few, if any, serious adverse effects associated with many traditional techniques.
A growing body of research supports psychotherapy for treating insomnia. For long-term sleep benefits, therapy may be more beneficial than medication. Effective psychological treatments, such as cognitive behavioral therapy (CBT), are focused on altering an individual’s environment and enhancing awareness of certain patterns that may interfere with sleep.
Research strongly supports the effectiveness of cognitive behavioral therapy (CBT) for the treatment of insomnia. CBT for insomnia (CBT-I), similar to CBT for other mental health conditions, is an active therapy that aims to alter thinking patterns and behaviors that are maladaptive to a patient’s sleep. CBT is available in individual, self-help, and group-based formats.
See pages 2-4 for a more extensive description of these methods.
Bluestein, D., Healey, A. C., & Rutledge, C. M. (2011). Acceptability of behavioral treatments for insomnia. The Journal of the American Board of Family Medicine, 24(3), 272-280.
Cao, H., Pan, X., Li, H., & Liu, J. (2009). Acupuncture for treatment of insomnia: a systematic review of randomized controlled trials. The Journal of Alternative and Complementary Medicine, 15(11), 1171-1186.
Chen, H. Y., Shi, Y., Ng, C. S., Chan, S. M., Yung, K. K. L., & Zhang, Q. L. (2007). Auricular acupuncture treatment for insomnia: a systematic review. The Journal of Alternative and Complementary Medicine, 13(6), 669-676.
Ong, J., & Sholtes, D. (2010). A mindfulness‐based approach to the treatment of insomnia. Journal of clinical psychology, 66(11), 1175-1184.
Taylor, D. J., & Roane, B. M. (2010). Treatment of insomnia in adults and children: a practice‐friendly review of research. Journal of clinical psychology,66(11), 1137-1147.
Wiegand, M. H. (2008). Antidepressants for the Treatment of Insomnia. Drugs,68(17), 2411-2417.
Medications for Insomnia
Pharmaceutical Hypnotics: Benzodiazepines & Z-Drugs
Hypnotic drugs within the benzodiazepine class (also known as depressants) act on GABA receptors in the brain, which modulate activity in major areas associated with the sleep-wake cycle. GABA is an inhibitory neurotransmitter, meaning its role is to suppress brain activity.
Benzodiazepine hypnotics are classified according to their length of action — long, moderate, or short. A shorter half life means the drug will take effect quickly but also leave the system faster. Some examples include Xanax, Ativan, Valium, and Klonopin. Given their sedating effects, these drugs are also used (generally in smaller doses) to treat anxiety.
The Z-drugs, or non-benzodiazepine hypnotics, similarly act on the GABA receptors with some differences as to how, where, and for how long. Some examples include Imovane/Zimovane, Sonata, Lunesta, and Ambien. Individuals with more severe insomnia and greater functional impairment due to sleep problems often prefer these prescription drugs over options that take longer to work (e.g., melatonin, psychotherapy).
There is some concern over prescribing hypnotic sleep medications (both of the benzodiazepine and non-benzodiazepine Z-drug form) given their abuse or addiction potential, as well as their effect on next-day functioning. The day after taking the medication, one might experience a “hangover-like” effect marked by grogginess and/or memory impairments. Suppressed respiration and interactions with other drugs also raise safety concerns. Complex tasks, such as driving, can also be impaired while an individual is under their influence. This is especially a concern in the elderly.
The non-benzodiazepine hypnotics (Z-drugs) have become increasingly prescribed in the past decade, while prescription rates of benzodiazepines have decreased. While Z-drugs have similar but less potent effects, it is unclear where they pose less of a safety risk than benzodiazepines. Patients should have a collaborative discussion to decide which treatment may be best.
A recent study (2012) reviewed FDA data on Z-drugs for reducing sleep latency (time to fall asleep). They found that in 13 studies there were only small effects on sleep latency within persons who were given both Z-drug and placebo. Importantly, their overall conclusions suggested that up to half of the effects of Z-drugs could be attributed to placebo. Because the placebo effect is a psychological phenomenon, the authors of this study suggested looking further toward psychological treatments for insomnia, which may accrue benefits without drug-related side effects.
Melatonin is one of the most commonly-recommended and doctor-prescribed medication agents for treating sleep problems. The effects of melatonin have been evaluated in several research studies among adults and children. The results show that, compared to placebo, melatonin is effective at improving people’s quality of sleep, increasing total sleep time, and reducing the time it takes individuals with insomnia to fall asleep (termed sleep latency). Additionally, melatonin is absent of the adverse side effects and risks associated with hypnotic sleep drugs and, therefore, has become increasingly prescribed in recent years.
Generally, taking melatonin for long durations and in higher potency appears to be more effective at improving total sleep time than taking melatonin for a shorter duration/lower dosage. Dose and duration do not seem as important for aiding sleep quality, as various doses and durations of melatonin use seem to help equally.
Melatonin can be bought over-the-counter or prescribed by a physician, and the health risks appear to be minimal.
Originally considered a “side-effect” of allergy drugs, the sedating effects of antihistamines have now become utilized as a direct sleep-aid. Both their anti-allergy and sedating effects are caused by inhibiting activity of histamine (H1) receptors in the brain.
They are most effective at treating insomnia in those with a brief history of sleep problems who seek short-term relief.
Conveniently, antihistamines can be bought over-the-counter (e.g., Benadryl, doxylamine).
Sedating antidepressants with hypnotic effects have also proven effective as a sleep aid. They are most commonly prescribed among individuals with insomnia related to depression and in individuals with short-term primary insomnia who have a history of depression. Guidelines proposed by the medical community suggest choosing a sedating antidepressant that acts on the serotonin system (serotonin reuptake inhibitors — or SSRIs) and to start at initially small doses (e.g., mirtazapine 15mg, trazodone 50mg, trimipramine 25mg, doxepin 25mg; Wiegand, 2008).
Fortunately, antidepressants are considered safer when taken long term. There is a lesser risk of dependence and tolerance associated with frontline hypnotic sleep drugs. Thus antidepressants may be ideal for treating insomnia in depressed/anxious patients.
In most cases of primary insomnia, off-label use of antidepressants is not considered the most appropriate medication choice given the lack of research supporting their effectiveness in non-depressed insomniacs. Thus, in uncomplicated insomnia, benzodiazepines or Z-drugs are generally recommended over antidepressants due to their fast-acting, reliable effects.
Acupuncture & Complementary Medicine for Insomnia
Acupuncture has been one the most popular Eastern medicine strategies used throughout history. More recently, its effects on various conditions (including insomnia), have been evaluated using Western scientific methods.
A review study in 2007 compiled evidence from various studies that compared auricular (ear) acupuncture (AA) to either placebo, sham acupuncture (i.e., acupuncture methods placed on “non-active” body points), Western medication, or no treatment. Their results found greater rates of recovery and improvement using active auricular acupuncture (ear acupuncture) compared to a benzodiazepine medication, especially for enhancing sleep up to 6 hours. Ear seeds seem to be more-effective than magnetic pearls placed on the ears.
Importantly, acupuncture was the most often preferred and best-tolerated treatment by patients in these studies. A review of needle acupuncture and herbal medicine studies published up to 2008 found similar effects. In short, there were more overall sleep benefits from acupuncture compared no treatment at all, as well as for acupressure over sham acupressure.
Additionally, among those individuals who benefited the most (i.e., those who experienced >3 hrs of sleep improvement), acupuncture proved superior to medications. However, there was no difference between the two when researchers averaged all participants’ sleep time. This suggests that acupuncture may work especially well in some individuals with insomnia, and though the reason is unclear, this might be a better frontline treatment for them than medications given the lack of associated risks.
More research is needed to make firm conclusions on the effectiveness of auricular and other forms of acupuncture for insomnia, as there is room for improvement in the methodological quality of existing studies.
Psychological Therapy Techniques
Various types of psychosocial therapies have been proven to help individuals with insomnia and other sleep disorders associated with delayed circadian rhythms.
Cognitive therapy (CT). CT targets unhelpful thoughts surrounding sleep. When an individual is initially unable to sleep he or she may focus on the dilemma, ruminating on the negative consequences of not getting enough sleep. Ultimately, these repetitive, distressing thoughts about insomnia serve to make the condition even worse. Worrying makes the brain more active instead of relaxed.
An example of an unhelpful, repetitive thought may be, “I can’t fall asleep, I won’t fall asleep, what time is it?” Negative recurring thoughts can also take the form of disturbing content (e.g., death of a loved one) or represent other things that are particularly hard to put out of one’s mind during bedtime (e.g., images of a traumatic event).
As the symptoms of insomnia worsen over time, the person may develop beliefs of its consequences that interfere, not just with sleep, but with day-to-day functioning. A belief surrounding sleep may be, “not getting at least 6 hours is horrible for my health, and there is no way I can function at work tomorrow.” The pattern becomes cyclical over time, further inhibiting sleep. CT aims to intervene in this cyclical pattern through psychoeducation and having clients work with a therapist to “dial down” and alter their negative thoughts.
Stimulus Control & Sleep Hygiene. Stimulus control is a behavioral technique that has received strong research support. It involves teaching patients good sleep hygiene among several other techniques. Sleep hygiene involves treating the bedroom as a place solely for sleep so that the brain can associate going to bed as “time to sleep” and not “time to think.” A patient would be instructed to remove all non-sleep-conducive stimuli from the bedroom (e.g., TV, computer, video games, and reading material). This also includes avoiding substances that can interfere with sleep within 4 to 6 hours of going to bed (e.g., coffee, nicotine) and limit stimulating activities (e.g., watching a movie or something else involving bright lights).
Relaxation. In relaxation-based treatments, patients learn exercises to calm physiological states marked with tension and stress. Some common forms are progressive muscle relaxation, imagery techniques, and meditation. Progressive muscle relaxation involves gradually tensing then releasing each muscle group in the body. In addition to the exercise itself, which forces muscles to a relaxed state by the end, practicing this exercise regularly can enhance patients’ overall sensational awareness, helping them to notice and localize tension states.
The imagery techniques practiced for relaxation involve positive content (e.g., leaves floating along a river). Relaxation training often follows an intensive format, requiring multiple weekly or biweekly sessions. Patients are also urged to practice them at home. The whole range of these various relaxation techniques appear equally effective overall, which allows for a patient to choose their preference.
Paradoxical Intention Therapy. Unlike relaxation-based approaches, this cognitive strategy involves a person imagining their most-feared sleep-related outcome (i.e., staying awake all night). This is based on the premise that performance anxiety contributes to difficulty sleeping. Once one removes pressure on themselves to sleep and faces distressing thoughts through guided imagery with a therapist — during a session and on their own out-of-session (i.e., at bedtime) — the thoughts begin to hold less weight and occur less frequently, making room for sleep.
This approach has shown less adherence by patients than relaxation-based approaches even though it has modest research support. While it may work, patients may be averse to the technique. Therefore, despite the fact that it is indeed safe, its limited attractiveness and feasibility undermines its effectiveness.
Biofeedback. Biofeedback, which has received modest research support, aims to help patients become aware of their body’s stress response as means to learn to relax themselves. One reason biofeedback is helpful is because many individuals tend to be unaware of when their bodies are in an aroused or stressed physiological state. In theory, once a person can recognize when they are experiencing an exaggerated stress response, they can begin to adapt skills for minimizing the physiological reaction. Unsurprisingly, biofeedback is a commonly used adjunct to relaxation training.
Mindfulness-Based Therapy for Insomnia (MBT-I). Because problems with sleep often stem from stress, MBT-I has been adapted in Mindfulness-Based Stress Reduction (MBSR) treatment by Jon Kabat-Zinn. MBT-I is similar to relaxation training in its meditation component; to CBT in the way it targets both thoughts and behaviors about sleep; and to traditional medicine in its Eastern philosophical orientation. See more about mindfulness strategies.