Sleeping pills are one of the most requested medications by people these days and they often have no
idea how any of the pills work and entrust their physician to choose the right one. The problem is many
physicians, including psychiatrists make choices that are not the best and with a better understanding of different options for sleeping pills you can make a more informed decision with your doctor.
Here is a list of the different options and the information that is good to know
Ambien/Lunesta/Sonata-These are all very similar to commonly known pills like xanax and valium. They do have some differences and tend to be specifically used for insomnia. Essentially all benzodiazepines and their derivatives are like putting alcohol into a pill. They act on the same receptors as alcohol does. This means if you drink alcohol regularly these are not a good choice. If you have an addictive personality these are not good as they are addicting. They act on GABA receptors in the brain. The good thing is that if they are used for VERY sporadic use, they do provide a good quality of sleep and does not disrupt normal sleep stages and will not eliminate the restful stage 3 sleep or effect REM sleep which many others tend to do. Bottom line: If you do not drink and have never been addicted and want something to use a few times a month-this is your pill
Trazodone-A newer antidepressant with sedating qualities at lower doses. Interesting pharmacological profile and receptor binding that is good to understand even as a lay person as it illustrates that less is sometimes more when it comes to drugs. Lower doses have more potent effects on sleep than higher doses (above 200) They act on alpha 1 and serotonin 5HT2A/C receptors which along with many functions act to help sleep quality, increase ability to fall asleep and to stay asleep. It lacks any antihistamine effects so if you are someone who has chronically been taking OTC benadryl or tylenol PM which are purely anti-histamines, then this is a good option since it will effect a completely different receptor profile which will maximize your chance at response. They are not addictive so are a good choice for alcohol drinkers or prior addicts and they can have good antidepressant activity if used at doses of 200mg or higher so you can avoid needing to take a seperate antidepressant if depression is a component of the insomnia. Can cause lack of orgasm and decrease libido but there is no weight gain or other side effects in women. Men are at a small risk for an erection that won’t go away.
Elavil-An old tricyclic antidepressant with potent antihistamine effects. Essentially you could take beneadryl and have the same effect. High toxicity if taking too many and has a lot of weight gain associated with it. It eliminates REM sleep and changes sleep architecture. Low doses have no antidepressant activity and higher doses are often not tolerated as they have severe anticholinergic effects-urine hesitation, dry mouth, feeling warm, constipation, blurry vision. They can be good for migraines so if insomnia without depression and a component of migraines this is a potentially a good choice.
Remeron-A newer antidepressant with potent antihistamine effects and 5HT2A/C effects. Lacks the alpha 1 effects of trazodone. It is another good option with no addictive potential as long as you do not take benadryl or OTC PM medications as since it relies on antihistamine activity to produce a lot of its sedation, it will have much less effect if you are already taking antihistamines. Can cause weight gain and increased appetite. However it lacks sexual problems so if you want to have no problems with orgasms or sex drive and you need something that you can take nightly then this is a great option. ALso is a potent antidepressant so if there is a component of depression, this is often the choice to go with.
Ativan/valium/xanax/klonopin/restoril-these are classic benzodiazepines that act on GABA receptors and have a more broad effect than the ambien/lunesta/sonata medication. They are highly addictive and they can change REM sleep and decrease stage 3 restful sleep. Good choice if you have an underlying anxiety disorder in which these will be useful for but otherwise not a great option for regular or short-terms use. ESpecially if you drink or have had a past addiction.
Michael Yasinski MD