Sleeping Pills Not Working? Here’s What You Need to Know

By Wallace Mendelson MD

Reviewing the Situation

Consider whether a medical illness is contributing to poor sleep:

A number of illnesses or changes in life can disturb sleep, among them:

  • Gastric reflux
  • Irritable bowel syndrome
  • Arthritis
  • Asthma or chronic pulmonary disease
  • Congestive heart failure
  • Headaches
  • Parkinson’s disease
  • Benign prostatic hypertrophy
  • Chronic pain conditions
  • Changes in life including menopause

Consider the effect of other medicines on sleep:

A variety of drugs for various medical or psychiatric illnesses can disturb sleep, among them:

  • Thyroid hormone
  • Steroids
  • Some antidepressants
  • Beta-blockers for high blood pressure or heart rhythms
  • Alpha blockers for high blood pressure or enlarged prostate
  • ACE inhibitors for high blood pressure
  • Cholinesterase inhibitor drugs used for memory loss
  • Some statin medicines for high cholesterol
  • Nicotine replacement patches or inhalers
  • Caffeine-containing over-the-counter medicines for a headache or alertness

Consider other sleep and body rhythm disorders, including:

Sleep apnea: The obstructive form of sleep apnea results from the periodic collapse of the upper airway during sleep, blocking airflow to the lungs. During these episodes, blood oxygen levels decline and carbon dioxide rises; ultimately a protective mechanism causes a person to have an arousal, and then return to sleep. These arousals are so brief that they are not usually remembered as a true awakening the next day, but the cumulative effect of having many of these is a sense of having slept poorly and awakening unrefreshed. It is often associated with snoring, though many people snore but do not have sleep apnea.

Consider what else is going on in life:

Waking and sleep are connected. Just as disturbances of sleep can affect a person’s daytime life, upsetting events or ongoing conflicts during the day will make sleep more difficult. Even though a person knows this logically, when sleep is disturbed there’s often a tendency to consider it in isolation and to seek help for the sleep as if it were a world apart from everything else. Of course, this isn’t so. Medicines can help to some degree, but it’s not realistic to expect ongoing good quality sleep, with or without a pill, if there are major ongoing conflicts during the day (or night — for instance, when sharing a bed with a person at the center of the conflict). These kinds of situations need to be addressed, and one good way to do this is in psychotherapy.

Changing Doses or Medicines

If a person is troubled by a side effect that doesn’t go away, for instance, an unpleasant taste, or persistent sleepiness in the morning, opting for a different medicine is an appropriate choice. If the issue is that a medicine doesn’t seem to be helping sleep, it’s natural to think about taking a higher dose, but it is rarely successful. Most currently available sleeping pills have a very narrow dose range.

Psychotherapy

Non-medicine talking therapy is an important alternative — and complementary– approach to insomnia. Although many forms of psychotherapy have been used over the years, the one with the most well-recognized evidence of efficacy is known as cognitive behavior therapy for insomnia (CBT-I). The general notion is that although there can be many initial triggers for poor sleep, for instance, an upsetting event or illness in a susceptible individual, there are other factors that can make it worse or perpetuate it, and these factors can be addressed. Some of these may be behavioral (such as keeping irregular sleep hours), while others can be psychological (anxiety about sleep) and cognitive (inaccurate beliefs about sleep). CBT-I has multiple components, reflecting the many factors that can contribute to insomnia. It typically involves 4–6 one hour sessions with a therapist over the course of 6–8 weeks. During this time several different approaches are used:

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