A behavioral sleep specialist offers guidance on how and why to take sleep medications.
I spend much of my clinical time helping people learn how to sleep without medication and retrain their sleep process. The role of sleep medication is complicated: It can provide support in a process that we do not consciously control and can be a pathway to relieving pressure on sleep, but medications also can turn into a source of dependence and chronic use. Sleep medication is more effective in the short term, but behavioral interventions are more effective in the long term when medication is eliminated.1
Every person with insomnia has a challenging common experience: You can value sleep, pursue sleep, protect sleep, but there is absolutely nothing that will force your brain to turn off and make you go to sleep. The lack of conscious control over sleep can be overwhelming. This is where medication can be a support.
Here are 6 essential behaviors that will help make medication more effective and limit tendency toward dependency.
1. Intentional. Many people struggle with their desire to take medication. They have received a prescription for sleep medication and still feel uncertain whether they want to take it. This distress can translate into an increase in worry about sleep, which will actually make medication less effective. Your brain looks for a sense of safety to allow for the total unconsciousness that is associated with sleep. Fear of medication will take away that sense of safety.
Discuss from the beginning how long you and your doctor plan for you to take the medication and with what frequency it should be taken.
2. Consistent. It is not uncommon for people to feel they should only take medication when they know that they need it. So they may wait until they have been awake for a long period of time before taking it. When I worked in a sleep lab, we would have patients try to sleep without their medication first, and then they could take their medication if they had waited longer than an hour and were still awake. What would often happen then is patients would fall asleep really quickly after taking their medication, even though we knew that scientifically there was no way the medication had even been digested at that point (much less taken effect). This rapid response was related to the sense of safety associated with medication, allowing for sleep onset. The more you try to push for needing medication, the more that you will find that you need medication, so it is much better to take it as prescribed when prescribed.
If medication is only prescribed on an as-needed basis, it is better to decide which nights you are most vulnerable to needing medication (for example, the night before a big trip or Sunday night before a big work week) and take the medication on the designated nights. This pattern accomplishes two important goals. It keeps the idea of having some nights off medication so you can be challenged to rely on your brain on some nights, and it takes away from surveillance of sleep/wakefulness from the nights in which you would be most vulnerable.
3. Timely. Most sleep medications have a relatively short period in which they are active in the brain and body. That’s because they are intended to be fully metabolized by the morning. It is best to take them within the timing instructed (commonly 15 minutes prior to desired sleep onset) and avoid taking medication too early.
A study by Roth et al found that up to 20% of people with insomnia were taking their medications in the middle of the night, despite being told to take them in the beginning of the night.2 This pattern is problematic for two reasons. First, the medicine does not have time to fully metabolize. Second, this usually involves time checking behavior that exacerbates insomnia.
If a medication has been prescribed this way (and there are a couple on the market), it is better to have a cue of whether it is an appropriate time rather than looking at a clock. My workaround is to have a very dim night-light that is plugged into an outlet timer. If the night-light is on, medication is OK. If the night-light is off, then no medication.
4. Temporary. Overwhelmingly, the literature supports that medication can be a good short-term intervention for insomnia but should not be viewed as a cure for insomnia. Although there is a shortage of clinicians trained to deliver cognitive behavioral therapy for insomnia (CBT-I), there are many online and book resources that can be helpful.
If you have been taking medication consistently for more than 6 months, it is time to reevaluate your intervention strategy. Insomnia is an episodic condition, normally related to stress, and aggravated by behaviors intended to help us cope with sleep loss. Recognizing and addressing the behaviors that aggravate insomnia is a key component to resolving this condition.
I tell my clients that medication is a crutch, meant to help in the short term. But you are not intended to walk with crutches for the rest of your life.
5. Sober. The biggest risk with many of the hypnotic medications is they can be very sedating (this is how they are intended to work!). If you layer alcohol (which is also sedating) with these medications, there is a much higher risk of respiratory problems, poor decision-making, and accidents.3 This is important to recognize because many people have used alcohol as their first method to try to get sleepy (which, for the record, is not recommended), so they may not realize it would have an added effect when combined with medication.
6. Supported. Insomnia has a tendency to be more prevalent in people who also are struggling with psychological disorders such as anxiety and depression. The relationship between insomnia and depression is noteworthy because there is a higher risk of suicide in people who are struggling with both, and medications intended to treat insomnia can sometimes worsen depression and vice versa.4
Although the experience of insomnia may create a desire to be less active (particularly in the evenings), it is important to recognize that social withdrawal can be a sign of depression. Try to keep up with your social ties, and make sure the people in your close circle know to let you know if it seems that you are disappearing from activities.
Like all medical interventions, there is a place for medications in the treatment of insomnia, and this intervention can provide definite relief when there is an experience of acute insomnia. Hopefully, these guidelines provide some insight into the healthiest way to use them short term to manage insomnia.
Kristin L. Daley, PhD, CBSM, is a behavioral sleep medicine specialist at Southeast Psych in Charlotte, NC.
1. Morin CM, Vallieres A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: acute and maintenance therapeutic effects. JAMA. 2009;301(19):2005–15.
2. Roth T, Berglund P, Shahly V, et al. Middle-of-the-night hypnotic use in a large national health plan. J Clin Sleep Med. 2013;9(7):661-8.
3. Ilomäki J, Paljärvi T, Korhonen MJ, et al. Prevalence of concomitant use of alcohol and sedative-hypnotic drugs in middle and older aged persons: a systematic review. Ann Pharmacother. 2013;47(2):257-68.
4. Ashworth DK, Sietten TL, Junge M, et al. A randomized controlled trial of cognitive behavioral therapy for insomnia: an effective treatment for comorbid insomnia and depression. J Couns Psychol. 2015;62(2):115-23.