The year 2009 has been as historic as it has been tumultuous. It began with the United States inaugurating its first African-American president. The country quickly expanded the war into Afghanistan. And now we are facing the worst financial crisis since the Great Depression. Widespread housing foreclosures, bank failures, job losses and rising consumer prices are affecting the emotional stability of many Americans. It's also causing us to lose sleep.
In a recent survey, 80% of people contacted by the American Psychological Association said the economy is a significant source of stress, one that is taking a toll on their health. Nearly one in five reported suffering insomnia. "I don't sleep more than four hours a night," said one respondent. "I get headaches. I worry that my kids can't go to college. And my doctor now has me on anti-anxiety medication."
So among the many types of medications offered for treating insomnia, which are effective? Which are safe? Let's take a look.
Examples of benzodiazepines include Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam) and Halcion (triazolam). Because these medications are all essentially the same, a prescriber's decision as to which benzodiazepine to use is typically based on the anxiety disorder being treated, as well as the drug's onset of action and rate of elimination from the body. For the most part, these medications are quite safe unless mixed with alcohol or other sedatives. But they can cause euphoria, leading to habituation in susceptible individuals. Also, prolonged use has an adverse effect on sleep architecture, particularly rapid eye movement (REM) sleep. Benzodiazepines can also cause "foggy thinking syndrome," in that they are linked to cognitive dysfunction. The best use of these drugs is intermittent and short-term.
These medications probably represent an improvement over the benzodiazepines, but there are other reasons to be wary. We've all seen the direct-to-consumer advertisements for Ambien CR ( zolpidem CR) and Lunesta (eszopiclone). Some studies indicate that these agents are associated with less dependence and cognitive impairment than the benzodiazepines. Also there are less adverse effects on overall sleep architecture. But these drugs (Ambien in particular) are linked to the troubling side effects: sleepwalking, sleep-eating, even sleep-driving in vulnerable people. If you experience any of these effects, stop taking these medications immediately and notify your prescriber.
A Kicked-Up Melatonin Subtype
Rozerem (ramelteon) is a relatively new prescription sleep aid. It is a non-controlled substance, unlike the benzodiazepines and non-benzodiazepines. As such, this medication is not linked to abuse or habituation. Melatonin is believed to be involved in the maintenance of the circadian rhythm associated with the sleep-wake cycle. There are two downsides: This drug is quite costly -- $150 or more for a 30-day supply -- and it typically helps people get to sleep, but not stay asleep.
Good, Old-Fashioned Antihistamines
How long has Benadryl been around? Although not FDA-approved for insomnia, antihistamines typically produce drowsiness through their sedative effects. Like Rozerem, antihistamines can help with getting to sleep, but that's about the extent of their effectiveness. Also, antihistamine use may produce a hangover effect or residual grogginess.
While antidepressants are sometimes prescribed for insomnia, many actually disrupt sleep. That's particularly true for first-line agents, such as the SSRIs (Prozac, Zoloft, Paxil, Celexa, Luvox, Lexapro) and SNRIs (Effexor, Cymbalta and Pristiq). Both SSRIs and SNRIs can suppress REM sleep, particularly if withdrawn abruptly. If you're experiencing depression accompanied by insomnia, discuss this issue with your prescriber. This will help them identify the most appropriate options for managing your sleep difficulties.
The Bottom Line
There has been a veritable explosion in the use of non-benzodiazepine medications for managing insomnia over the last few years. These agents do represent an improvement when compared to the rest of the bunch. But the most effective treatment of chronic sleep problems involves an investigation of lifestyle changes. These may incorporate alternative remedies, such as improving the diet, adding exercise and establishing a regular sleep schedule - changes we are too often unwilling to make.
A Dose of Realism
Do you believe your financial woes mark the end of the world for you? Then it's worth remembering that the actual "end of the world" is an event that will truly happen only once.