Sometimes it’s hard to keep up with all the drugs and medications that affect sleep. For the most part, insomnia is the primary indication for using medications but there isn’t a “miracle pill”. Sometimes medications have major risks, they stop working, or need to be supplemented with therapy or other treatments. Frequent assessments and honest conversations are required and with time, a person can find the best relief. Use this page as a quick reference for prescribing sleep medications.
Several organizations have published guidelines for the management of sleep disorders:
American Academy of Sleep Medicine (AASM) recommends the following pharmacotherapies:
- For sleep maintenance insomnia: suvorexant, eszopiclone, zolpidem, temazepam, doxepin
- For sleep onset insomnia: eszopiclone, zaleplon, zolpidem, triazolam, temazepam, ramelteon
*The AASM recommends against using trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, or valerian for either sleep-onset or sleep-maintenance insomnia.
American College of Physicians (ACP) does not recommend specific pharmacotherapy, but rather that clinicians use a shared decision-making approach when determining whether to add pharmacotherapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBTI) alone was unsuccessful.
Agency for Healthcare Research and Quality (AHRQ) (US Department of Health and Human Services) reported how older adults more often have difficulty maintaining sleep (wake time after sleep onset [WASO]), whereas younger adults report more difficulty falling asleep (sleep onset latency [SOL]):
- Eszopiclone improves global outcomes, SOL, and total sleep time (TST) as well as reduces WASO.
- Zolpidem improves global outcomes, sleep latency, TST, and sleep quality; it may reduce WASO.
- Zaleplon improves sleep quality but likely has no effect on TST.
- Suvorexant improves global outcomes, sleep latency, and TST as well as reduces WASO.
- Ramelteon improves global outcomes and sleep quality but likely has no effect on other sleep outcomes.
*Doxepin may improve some global outcomes. Other antidepressants noted in the AHRQ review (trazodone, amitriptyline, and mirtazapine) are not approved for the treatment of insomnia.
–AJMC
Antidepressants & The FDA
Commonly Used Antidepressants for Insomnia but are NOT FDA Approved
- Trazodone: The most commonly prescribed agent for treating insomnia across all classes of medications.
- Doxepin (Sinequan, Silenor) & Amitriptyline (Elavil): generally avoid use in older adults.
- Mirtazapine: associated with weight gain, increased appetite, daytime sedation, and dizziness. Has an inverse relationship (educate about exceeding the dose, which will make it less likely to help with sleep).
Sleep Medications that have FDA Indications + Warnings
- Sleep onset only: zolpidem (Ambien) and zaleplon (Sonata).
- Sleep onset and sleep maintenance: zolpidem ER and eszopiclone (Lunesta).
- Sleep-onset insomnia: ramelteon (Rozerem) is the only medication FDA approved for insomnia that is not a controlled substance because it does not seem to lead to abuse or withdrawal. High-fat meals can delay absorption, and the potential for drug interactions is moderately high.
- New Treatment: Lemborexant (Dayvigo) treats insomnia characterized by difficulties with sleep onset and/or sleep maintenance in adults.
***The FDA is requiring a new boxed warning – on certain prescription insomnia drugs to better ensure patients and their health care professionals have the information they need when considering the use of these medicines. The boxed warning follows several reports of rare, but serious injuries and deaths resulting from various complex sleep behaviors after taking these medicines. These complex sleep behaviors may include sleepwalking, sleep-driving, and engaging in other activities while not fully awake, such as unsafely using a stove. The new warnings will be required for eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist).
Anti-Psychotics for Sleep
The Risks of Using Antipsychotics for Insomnia
Antipsychotics are FDA-approved drugs that treat mental illness, although some people take them atypically to treat insomnia. These drugs often make people feel drowsy, but there is little research to show they actually help people stay asleep. The benefits of taking an antipsychotic for insomnia generally do not outweigh the risks, which include:
- Blood Clots
- Dizziness, drowsiness, confusion, disorientation
- A higher risk of falls and injuries
- Weight gain
- High cholesterol
- Diabetes
- Muscle twitches, tremors, spasms
In most cases, non-antipsychotic treatments can significantly improve insomnia and its effects.
When Antipsychotics for Insomnia are Appropriate
In some cases, the use of antipsychotics to treat insomnia may be appropriate. The American Psychiatric Association advises considering anti-psychotics to treat insomnia only if:
- You have a serious mental illness that keeps you from sleeping, such as bipolar disorder with mania.
- Other treatment options have not been successful.
- Your lack of sleep is causing severe distress.
Typical Antipsychotics
Most typical, or first-generation, antipsychotics have sedating effects. Typical antipsychotic medications also tend to decrease muscular actions created by psychiatric disorders, like anxiety and obsessive-compulsive disorder, which also may improve sleep. Sleep cycles, including REM-sleep, are not altered by antipsychotics, although total sleep time may increase. Tolerance to the sedating effect of these drugs may develop during treatment. Examples of typical antipsychotics include:
- Haloperidol – known to be sedating
- Chlorpromazine – known for both extreme sedation and anti-anxiety properties
Atypical Antipsychotics
The atypical, or second-generation, antipsychotics are less prone to inducing sedation although some atypical antipsychotic drugs are still associated with extreme tiredness and may shift sleep patterns. Tolerance to the sedating effect of these drugs may develop during treatment and withdrawal may result in insomnia. Commonly prescribed atypical antipsychotics include:
- Quetiapine (Seroquel) – known for extreme sedation and sometimes prescribed for anxiety or sleep disorders
- Olanzapine (Zyprexa) – sedation is a common side effect
- Aripiprazole (Abilify) – sedation is a common side effect
- Risperidone (Risperdal) – has been known to cause both tiredness and insomnia depending on the individual. People taking Risperidone for schizophrenia more commonly experience insomnia, while those taking it for bipolar mania are more likely to experience tiredness.
Summary of Sleep Medications and Disorders
Additional Medications Related to Sleep
- Prazosin (Minipress): a medication primarily used to treat high blood pressure, symptoms of an enlarged prostate, and PTSD treatment for nightmares/terrors.
- Orexin: hypocretin is a neuropeptide that regulates arousal, wakefulness, and appetite.
- Armodafinil (Nuvigil): FDA-approved to treat excessive daytime sleepiness associated with obstructive sleep apnea, narcolepsy, and shift work disorder. It is commonly used off-label to treat attention deficit hyperactivity disorder, chronic fatigue syndrome, and major depressive disorder.
