How Safe Are Sleeping Pills for the Brain?
More than half of adults surveyed by the National Sleep Foundation report spending several nights each week struggling with at least one symptom of insomnia—difficulty falling asleep or staying asleep, waking too early in the morning, or a lack of restorative sleep that causes distress or dysfunction. Sleeping pills are a widely used response to these sleep difficulties, but are they the right response?
While medications may be prescribed for the estimated 10 to 15 percent of people with chronic insomnia—those whose sleep problems occur at least three times a week for three months or more—the preferred treatment recommended by the American Academy of Sleep Medicine is a type of psychological counseling called cognitive behavioral therapy (CBT). For the 85 to 90 percent of people who experience short-term insomnia, alternatives to sleep meds, with their side effects, may be a better solution, an MGH expert says.
“Although sleeping pills can provide benefits for short-term insomnia, many come with risks for side effects such as cognitive impairment, confusion, and problems with memory,” cautions John Weyl Winkelman, MD, PhD, Chief of the Sleep Disorders Clinical Research Program in MGH’s Department of Psychiatry. “A much more effective approach is to identify and focus on remedying the underlying problems that may be causing the insomnia.”
WHAT YOU CAN DO
If you do decide to use sleeping pills, take steps to avoid potential problems, Dr. Winkelman advises. His suggestions:
- Minimize the use of sleeping pills. Frequent use may increase the risk of dependence and other unwanted side effects.
- Check with your doctor to make sure your sleep med will not interact negatively with other medications you are taking, such as supplements, antidepressants, and even antibiotics.
- Take the minimum dosage and resist the urge to take another pill if you wake up in the night.
- Stay in bed for seven to eight hours after taking a sleep med. No matter how long you sleep, don’t drive until you no longer feel drowsy.
- Never mix sleep meds with alcohol, recreational drugs, other medications, or supplements intended to induce sleep, or with OTC drugs that contain the sedative diphenhydramine.
Address Sleep Interrupters
If you have sleep disturbances that endure for longer than two weeks, resist the urge to address your problems only with sleeping pills. Instead, seek a medical assessment, Dr. Winkelman suggests. Review the possible underlying causes of your sleep disturbance with your medical care advisor, and agree on strategies for addressing them. These causes may include:
▶ Medical problems, such as significant arthritis, menopause, Alzheimer’s disease, heartburn, pain, frequent urination, congestive heart failure, sleep apnea, restless legs syndrome, hyperthyroidism, and alcoholism.
▶ Psychiatric conditions, such as depression and anxiety, as well as panic disorder or stressful life events, such as the death of a loved one.
▶ Side effects of medications, including stimulants, which make it difficult to get to sleep, and others, such as diuretics, which can lead to frequent awakenings. Caffeine is a common ingredient in over-the-counter preparations, including allergy and cold medications. Certain antidepressants can also cause insomnia.
▶ Environmental and lifestyle problems, which include behaviors such as exercising or eating large meals close to bedtime, consuming excessive amounts of caffeine or alcohol, and watching TV or using the computer in the hour before bedtime. Environmental factors, such as an uncomfortable bed, too much noise, or excessive light, heat, or cold, also can disturb sleep.
Pills and Risks
As people grow older, the portion of time in bed spent actually sleeping declines, and the number of awakenings increases. Seniors lose the deeper, slow-wave stages of sleep and they wake up more easily. Some research suggests that, if not resolved, chronic sleep problems can have serious physical and mental consequences, including greater risk for heart disease, high blood pressure, diabetes, obesity, depression, and problems with memory, concentration and decision-making.
Yet sleep meds may be especially problematic for older adults, who are slower to process medications in the liver and to excrete them in the urine, and for whom factors such as age-related brain changes, a weaker blood-brain barrier, the use of multiple medications, and cognitive problems may make these drugs more risky.
A selection of medications commonly used to induce sleep, along with their effects on the brain, are listed here:
- Over-The-Counter (OTC) Meds:
“Alternative” medications: Herbal sleep formulations based on valerian, kava, and chamomile are generally safe with few side effects, but they are considered largely ineffective for insomnia. Studies on the effects of melatonin, which binds to melatonin receptors in the brain, suggest that the supplement may produce mild benefits that help users fall asleep and stay asleep. It has been associated with few side effects beyond occasional nightmares and daytime sleepiness.
Diphenhydramine hydrochloride: An antihistamine used in allergy medications, this drug addresses mild sleeplessness. Examples include Benadryl, Nytol, and Sominex. Side effects might include dizziness, daytime drowsiness, confusion, increased dementia risk and psychological dependence, as well as constipation and dry mouth.
Doxylamine succinate: This is another antihistamine for mild sleeplessiness. Examples include Unisom Sleep Tabs and Equate Sleep Aid. Side effects may include mild dizziness, drowsiness, and blurred vision.
- Prescription Medications:
Benzodiazepine-receptor agonists: These drugs affect the receptors for gamma-aminobutyric acid (GABA), a neurotransmitter that helps control levels of alertness and relaxation. This large group of medications differ from one another mainly in how long they are active in the body. Medications with generally longer action include Valium, Xanax, Klonopin, and Ativan. Those that remain in the system for a shorter time include Ambien, Lunesta, Halcion, and Sonata. These types of medications are linked to greater risk for cognitive impairment, memory disturbances, growing physiological and psychological dependence and complex sleep-related behaviors, such as sleepwalking. Withdrawal symptoms may occur in people who quit these drugs after consuming high doses over a long period of time.
Sedating Antidepressants: These medications block serotonin and other neurotransmitters to produce sedation. The most commonly prescribed drugs in this category are trazodone, mirtazapine, and doxepin. Side effects of trazodone may include morning sedation and a temporary lowering of blood pressure, and mirtazapine may cause weight gain. Doxepin has few side effects at dosage levels prescribed for insomnia.
Ramelteon: This drug binds with melatonin receptors in the brain to promote sleepiness. Side effects are limited to rare daytime drowsiness.
Because some of these sleep meds may be associated with serious side effects in certain people, they are best used as a short-term remedy, rather than a solution to your overall sleep problems, Dr. Winkelman says. MMM
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