Sleep Difficulties and Sleep Medications

"Help! I can’t sleep!"

Nearly everyone will have difficulties sleeping at some point during their lives, and there are as many causes as there are people not sleeping. In most cases, the problem is short-lived and resolves by itself but some people struggle with longer term sleep issues.

What is normal sleep?

How much sleep people need is very variable but is usually between 7 and 9 hours, with an additional period of up to 30 minutes needed to drop off. If you wake feeling refreshed and can get through your normal daily activities without feeling exhausted, without needing a nap or like you have to reach for the coffee, then you are probably getting the right amount of good quality sleep that you need. Children need more sleep and older adults, often a bit less. This link is useful for working out how much sleep you or your child needs: Recommended Hours of Sleep by Age Chart and there is more information here at Sleep Foundation on sleep cycles and stages and why they are important.

There is a sleep self-assessment quiz on this page

Common causes of difficulties sleeping

If you have difficulty getting to sleep, maintaining sleep, waking early or waking unrefreshed which lead you to feeling tired, low in mood or irritable or have difficulties thinking or functioning, you may have insomnia.

Physical and mental illnesses can interfere with sleep, and so having the optimal treatments for these can help improve both sleep duration and quality. Mental illness has a particularly circular effect on sleep – poor mood and rumination can cause insomnia, whilst poor sleep then has a knock-on impact on mood.

Having a good sleep environment is obviously very important. Similarly, making sure your body and mind are primed for sleep through good routines is key – expecting to drop off to sleep after heavy exercise or after a pint of coffee is asking for trouble. There are other, less well-known inhibitors to good quality sleep such as screens, alcohol and eating late. There is information in the next section on how to optimise all these factors: known as ‘sleep hygiene’.

Common sleep disorders such as snoring and sleepwalking can impair quality of sleep. Rarer problems exist such as restless legs syndrome, night terrors and sleep apnoea may need investigating or treating.

Ways to improve your sleep

1. 'Sleep hygiene'

2. Sleep-retraining apps 

3. Meditation, relaxation and mindfulness

4. CBT-i

5. Alternative therapies

  • Over-the-counter medications such as anti-histamines and herbal tablets are available; please consult a pharmacist

6. Shift workers:

Medications

Very rarely, medications are needed to help with short-term sleep problems, for example during a period of acute stress or bereavement. There are several different medications, and they all have different effects and risks. Treating long-term sleep problems with medication not advised, and so these medications will not be prescribed by Rolle Medical Practice as regular (repeat) medications except in very specific circumstances.

Melatonin

Melatonin is a formulation of a natural hormone that regulates our biological clocks. Although melatonin is thought to be relatively safe, its use over the long-term has not been studied and so it only remains licensed for shorter periods.

Who can and can’t take this medication?
  • It is often prescribed in children with sleep disorders (this will be assessed and reviewed regularly by a specialist), and
  • it can be used by older adults for a maximum of 3 months.
  • It is also sometimes used for jetlag
  • It can’t be taken by people who are pregnant, have liver problems or autoimmune disease.
What are the risks and side-effects?

The biggest known risk is of falls and fractures. Common side-effects are headache, nightmares, dizziness, nausea and feeling sleepy during the day. Increased night-time bedwetting is noted in children.

More information

Have a look at the NHS website and there is more detailed information at this New Zealand website: Melatonin: is it worth losing any sleep over?

Benzodiazepines

Benzodiazepines (e.g. Diazepam, Nitrazepam, Tempazepam) are a kind of sedative medication.

Who can and can’t take this medication?
  • They are sometimes prescribed for people with anxiety and panic disorders
  • They used to be used as sleeping tablets but are now rarely used except or very short-term use due to the risks and side-effects
  • They should not be used in children and are not suitable for some people with chronic diseases such as lung, kidney and liver diseases.
  • Drinking alcohol when also taking benzodiazepines can dangerously increase the sedative effect, so they should not be used by people using alcohol or drugs regularly.
What are the risks and side-effects?
  • They stop working so well if used regularly (known as tolerance)
  • Some people find themselves struggling to cope without (known as dependence or addiction), 
  • They can have unpleasant withdrawal effects if use has been long-term. 
  • Benzodiazepines can have many different side-effects, which are listed and described here: Side effects of benzodiazepines - Mind.
  • One of the most concerning effects of longer-term use of benzodiazepine drugs are difficulties concentrating or with memory.
More information

Further information on benzodiazepines and Z-drugs can be found here

Z-drugs

Z-drugs (e.g. Zopiclone, Zolpidem) are non-benzodiazepine sedatives. They act in a similar way to benzodiazepines and have similar issues with dependence and withdrawal.

Who can and can’t take this medication?
  • NICE advises using these drugs for a maximum of two weeks where non-pharmaceutical measures such as those described above have not been helpful and the insomnia is severe, disabling or causing extreme distress. 
  • There are quite a number of people who should not take Z-drugs due to existing medical conditions (such as lung, liver or kidney disease) or interacting medications, so this needs to be evaluated carefully with your doctor.
  • They should not be taken with alcohol or other drugs that depress the central nervous system such as benzodiazepines.
What are the risks and side-effects?
  • Important risks associated with these medications are falls, cognitive impairment (dementia) and problems of dependence (addiction) and withdrawal.
  • Side-effects include gastro-intestinal problems and neurological and psychiatric issues including headaches, balance issues, depression, anxiety, agitation, irritability and hallucinations.
More information

Further information on benzodiazepines and Z-drugs can be found here

Other medications

Sedating anti-histamines such as diphenhydramine or promethazine are sold over the counter in a variety of sleep aids medications. They are slow to act and are long-lasting which makes them prone to causing a ‘hangover’ effect the next day. They are not advised by NICE (for use as sedation) due to concerns over their short and long-term effects on the central nervous system and should be avoided especially if you suffer from an enlarged prostate gland, problems urinating (urinary retention), glaucoma (raised pressure in the eye), liver disease or epilepsy.

However, there are medications which are sold over the counter at pharmacies that contain natural ingredients such as valerian or lavender which can be helpful. Again, they are not recommended long-term.

If insomnia remains persistent and is not helped by all the non-pharmaceutical methods mentioned above, referral to a sleep clinic or neurologist may be appropriate in some special circumstances.

Further information can be found at Mind and at Patient Info.

Find the Sleeping Problems self-help guide on the NHS Devon Partnership website.

 

Young Children

We appreciate that sleeping difficulties in young children can cause significant distress, as well as upheaval, to the child and other family. The best approach in achieving a good long term outcome for managing sleeping difficulties is use of various behavioural strategies – although we acknowledge some of these may have been tried already. Nonetheless, many of these strategies and techniques require perseverance and significant investment of time for them to be successful.

Useful websites

The Public Health Nurses/School nurses/Health Visitors in Devon can offer advice and support if problems are persisting, including a sleep clinic. This is accessed by self-referral only via their website

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