By Lead writer: Rachel Grumman
September 10, 2008

Chances are, someone you know takes a sleeping pill. One in four Americans takes a sleep aid every year, according to the National Sleep Foundation, and the numbers are even higher for women—one in three uses some sort of sleep medication a few times a week.

Why do women have such trouble sleeping? The reasons are as numerous as the passel of pills on the market: anxiety, depression, chronic illness, restless legs syndrome, sleep apnea, everyday exhaustion...the list goes on and on. No wonder so many sleep aids are available.

But sleeping pills, while often quite helpful, are largely misunderstood. Many stop working after a few hours, for instance, and most should never be mixed with other meds. So if you take one of these drugs now—or plan to in the future—there are important questions you need to ask. Here, the answers.

Q: Should I try over-the-counter drugs before a prescription pill?

A: Many sleep experts arent fans of OTC sleep aids because the meds dont usually help people with significant insomnia. And many—like Nytol, Simply Sleep, Sominex, and Unisom—contain antihistamines (similar to the allergy medicine Benadryl) that can have side effects like dry mouth and eyes and next-day grogginess, says Donna Arand, PhD, clinical director of the Kettering Sleep Disorders Center in Kettering, Ohio. OTC sleep aids are best for people who have occasional sleep problems. Note: Women who breast-feed should avoid them, as should the elderly, who sometimes are more sensitive to the effects of antihistamines.

Q: How do I know if I need a sleeping pill?

A: More than a third of Americans experience occasional insomnia, which is defined as a few nights of restlessness, poor sleep, or trouble falling asleep. The general rule of thumb: If insomnia lasts a month and doesnt get better, talk to your doctor, says Frisca L. Yan-Go, MD, director of the Sleep Disorders Center at Santa Monica–University of California, Los Angeles, Medical Center and Orthopaedic Hospital. She may recommend a pill for a short period, but dont be surprised if she suggests some tests or other nondrug treatment options first.

For starters, your doc may have you visit a sleep specialist to rule out sleep apnea, a common breathing disorder that wakes sufferers several times a night, sometimes without them even knowing it. If you have apnea, you may need a sleeping device that gently forces air into your windpipe.

If you dont have apnea, some docs recommend cognitive behavioral therapy (CBT): You work with a trained therapist to change how you think about sleep and learn sleep-inducing techniques (like how to set up your sleep space and what to do before bedtime). Some studies say CBT is as effective as pills—if not more—and has no side effects.

"Often people attribute everything bad that happens to them, including being angry and crabby, to lack of sleep," says Dr. Arand. "It puts such a burden on sleep that not sleeping gets blown out of proportion." CBT changes that kind of distorted thinking and in some cases is prescribed along with a pill.

Next Page: What if I still can't fall asleep?

[ pagebreak ] Q: If I take a prescription pill and still cant fall asleep, can I take another?

A: If youre taking a short-acting drug, such as Sonata, Rozerem, or Ambien—and its still early in the evening—you can take another pill. Short-acting medications kick in and then fade out, which is why they are prescribed for people who have trouble falling asleep. "They last about three or four hours, so you could take another pill up until about 3 a.m. because it would metabolize before you wake up," says Ana Krieger, MD, a sleep specialist at New York University. (The timing depends on your sleep schedule, of course, and its always wise to check with your doctor, she adds.) Longer-acting drugs like the time-released Ambien CR or Lunesta—for people who have trouble falling and staying asleep—shouldnt be taken more than once a night.

Q: Is it safe for me to take a sleeping pill at 11 p.m. if I had a glass of wine or a cocktail around 6 p.m.?

A: Its probably OK, doctors say, but the sleeping pill wont work as well as it should. Heres why: "Alcohol becomes a stimulant about three to four hours after you drink it, so youre actually working against your sleep medication," Arand says. "Its a terrible combination." (Watch a video about the effect of alcohol, caffeine, and cigarettes on sleep.)

Never drink and then immediately take a sleep aid. Why? Alcohol acts like a sedative at first, so youd essentially be getting a double dose of sedatives. This can dangerously slow your heart rate and lead to dizziness, fainting, and shallow breathing, which can deprive your body of oxygen and damage brain cells. Worst case: You may even stop breathing altogether.

Because everyone metabolizes food and alcohol at different rates, there are no safety absolutes when it comes to the minimum number of hours you should wait between consuming alcohol and taking a sleeping pill, experts say. "But if youre at a dinner party and really want a drink, have the alcohol early," Dr. Krieger says. "Then eat dessert without any alcohol and wait as long as possible before taking your sleeping pill."

Next Page: Will I have nightmares?

[ pagebreak ] Q: Can sleeping pills give me nightmares?

A: Not usually, Arand says, "but some sleep meds can suppress dream recall." When you stop taking them, the dreams (and possibly nightmares) may return. The mechanism isnt fully understood, but once theres a withdrawal—even just when the dosage wears off during the night—vivid dreams can occur.

Q: Can I safely take sleeping pills for several months?

A: There are no known long-term health risks with most sleep aids, but some are more addictive than others. "The newer medications like Ambien CR, Sonata, Rozerem, and Lunesta have been approved by the Food and Drug Administration without a limit on how long they can be prescribed," Arand says. "They have a small addiction potential, and some have been shown to be effective up to one year." The older sleeping pills with secobarbital (Seconal) and pentobarbital (Nembutal) pose a much higher risk of addiction.

Tolerance is a common problem with all sleeping pills: After taking them for a while, you need more than the usual dose to help you sleep, which may lead you to think youre addicted. If the drug doesnt seem to be working as well as it used to or if youre taking more than your prescribed dosage, tell your doctor; she can change or adjust your medication.

Q: Ive been taking sleeping pills for several months. Whats the best way to wean myself off?

A: With your doctors help, gradually step down your meds. Generally, you want to reduce drugs by one clinical dose per week: If youre taking 10 milligrams of traditional Ambien a night, start taking 5 mg a night for a week, Arand recommends. Next, cut that pill in half and take that amount for a week. Then, stop taking the drug altogether. Medications in pill (not capsule) form that arent time-release versions are OK to split. (You can split Ambien, for instance, but not Ambien CR.)

Q: Ive heard of rebound insomnia. Is it really harder to fall asleep and stay asleep without pills if Ive taken them a few times?

A: You might have some trouble, Dr. Krieger says, though its less likely with the newer pills—these include Rozerem, Sonata, and Lunesta. "Give it a few days to adjust after you stop taking the medication," Arand explains. If you still cant sleep, talk to your physician. Rebound insomnia is one of the reasons some experts recommend CBT over sleep medications.

Q: If I dont want to use sleeping pills, are natural remedies worth trying?

A: Yes, but dont expect miracles. Melatonin, a sleep hormone your body makes naturally, and the herb valerian may be helpful (both are available at drugstores), but some experts feel theres a lack of research to back up the effectiveness of these supplements. Plus, theyre not regulated like drugs, so you dont always know what youre getting.

That said, if you want to try melatonin, take 0.2 to 1 mg about four hours before bedtime: "Its safe to take every day," Dr. Krieger says. "As we age, our bodies secrete less of it, so taking a supplement can be helpful." Melatonin may be particularly beneficial when you travel several time zones to the east (like Europe) and have trouble falling asleep. As for valerian, theres no recommended dosage, and its not clear how the herb works. Before using any supplements, check with your doctor; combining them with other medications—sleeping pills or otherwise—can be risky.

This content was first published in Health magazine, September 2008