Insomnia (Poor Sleep)
As many as one in three people can have some difficulty with sleeping. However, there are many things you can do to help yourself. This leaflet aims to show you some of them. For example, simple things like winding down before bedtime, avoiding certain foods and drinks, and a bedtime routine can help.
Further ways to promote sleep in more difficult cases include relaxation techniques, regular exercise and certain psychological therapies. Sleeping tablets are not the best way to help with sleep problems because you can get addicted to them and they often stop working if you take them regularly.
Understanding normal sleep
A normal night's sleep has three main parts:
- Quiet sleep. This is divided into stages 1-4. Each stage becomes more deep. Quiet sleep is sometimes called deep sleep.
- Rapid eye movement (REM) sleep. REM sleep occurs when the brain is very active but the body is limp, apart from the eyes which move rapidly. Most dreaming occurs during REM sleep.
- Short periods of waking for 1-2 minutes.
Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. In addition, several short periods of waking for 1-2 minutes occur about every two hours or so, but occur more frequently towards the end of the night's sleep. The graph below shows a typical normal pattern of sleep in a young adult.
Normally, you do not remember the times that you wake if they last less than two minutes. If you are distracted during the wakeful times (for example, a partner snoring, traffic noise, etc) then the wakeful times tend to last longer and you are more likely to remember them.
What is insomnia?
Insomnia means poor sleep. About one third of adults do not get as much sleep as they would like. Poor sleep can mean:
- Not being able to get off to sleep.
- Waking up too early.
- Waking for long periods in the night.
- Not feeling refreshed after a night's sleep.
If you have poor sleep, particularly over a long period of time, it can severely affect your life, as it can cause:
- Tiredness (fatigue) and loss of energy in the daytime.
- Poor concentration.
- Loss of interest in usual activities.
- Depression and anxiety.
- Inability to do things as well or as much as usual - for example, work, social activities, exercise. Errors might occur at work or whilst driving, which could have serious consequences.
- A worse quality of life.
What is a normal amount of sleep?
Different people need different amounts of sleep. Some people function well and are not tired during the day with just 3-4 hours' sleep a night. Most people need more than this. To need 6-9 hours per night is average. Most people establish a pattern that is normal for them in their early adult life. However, as you become older, it is normal to sleep less. For most people it takes less than thirty minutes to fall asleep.
So, everyone is different. What is important is that the amount of sleep that you get should be sufficient for you, and that you usually feel refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is: 'Difficulty in getting to sleep, difficulty staying asleep, early wakening, or non-restorative sleep despite adequate time and opportunity to sleep, resulting in impaired daytime functioning, such as poor concentration, mood disturbance, and daytime tiredness.'
Causes of insomnia
Poor sleep may develop for no apparent reason. However, there are a number of possible causes which include the following:
Concern about wakefulness
You may remember the normal times of being awake in the night. You may feel that to wake in the night is not normal, and worry about getting back off to sleep. You may clock-watch and check the time each time you wake up. This may make you irritated or anxious, and you are more likely to remember the times of wakefulness. You may then have an impression of having a bad night's sleep, even when the total amount of time asleep was normal.
Poor sleep is often temporary. This may be because of stress, a work or family problem, jet lag, a change of routine, a new baby, a strange bed, etc. Poor sleep in these situations usually improves in time.
Stress, anxiety or depression
You may find it difficult to switch off your anxieties about work, home or personal problems. Also, poor sleep is sometimes due to depression. Other symptoms of depression include a low mood, lethargy, poor concentration, tearfulness and persistent negative thoughts. Depression is common. Treatment of depression or anxiety often cures the poor sleep too.
This sometimes occurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly. You may wake up many times each night which may result in daytime tiredness. See separate leaflet called Obstructive Sleep Apnoea Syndrome. Note: most people who snore do not have sleep apnoea and they do sleep well.
Various illnesses keep some people awake. For example, illness causing pain, leg cramps, breathlessness, indigestion, cough, itch, hot flushes, mental health problems, etc.
These can interfere with sleep. There are three common culprits.
- Alcohol - many people take an alcoholic drink to help sleep. Alcohol actually causes broken sleep and early morning wakefulness.
- Caffeine - which is in tea, coffee, some soft drinks such as cola, and even chocolate. It is also in some painkiller tablets and other medicines (check the ingredients on the medicine packet). Caffeine is a stimulant and may cause poor sleep.
- Nicotine (from smoking) is a stimulant, so it would help not to smoke.
Street drugs (for example, ecstasy, cocaine, cannabis and amfetamines) can affect sleep.
Some medicines sometimes interfere with sleep. For example, 'water tablets' (diuretics), some antidepressants, steroids, beta-blockers, painkillers containing caffeine, and some cold remedies containing pseudoephedrine. Also, if you suddenly stop taking regular sleeping tablets or other sedative medicines, this can cause rebound poor sleep.
There is some evidence that the time we spend looking at electronic screens can affect our sleep. It may be that certain types of light from e-readers and electronic tablets can disrupt control of our natural day-and-night cycle. There are studies which suggest we may sleep better after reading a printed book or a particular kind of screen before bedtime. There are also some studies which show that in children and adolescents, more time using electronic devices in the daytime is linked to less good sleep at night. There is not yet enough evidence to make definite recommendations, but it may be worth considering.
Some people just need less sleep than others. If your sleep pattern has not changed, and you do not feel sleepy during the day, you are probably getting enough sleep. Older people and people who do little exercise tend to need less sleep. Some people think they should be able to nap during the day - and sleep eight hours at night!
A vicious cycle
Whatever the initial cause, worry about poor sleep and worry about feeling tired the next day, are common reasons for the problem to become worse.
Some people may also experience waking from sleep but then being unable to move or speak for a period of time. Some people experience the same problems when they are falling asleep. Read more about how sleep paralysis can affect you.
There are different definitions and classifications of poor sleep (insomnia) around, which can make things confusing. Doctors may classify insomnia into one of the following categories:
- Primary insomnia is insomnia that occurs when no illness or other secondary cause (comorbidity) is identified. Primary insomnia accounts for about one in five cases of long-term insomnia.
- Secondary (or comorbid) insomnia occurs when insomnia is a symptom of, or is associated with, other conditions. These can be medical or mental health conditions, or drug or substance misuse (as discussed above).
- Short-term if insomnia lasts between one and four weeks.
- Long-term (or persistent) if insomnia lasts for four weeks or longer.
By a combination of factors
Some authorities use the term 'chronic insomnia disorder'. To have this diagnosis, you would:
- Have problems sleeping for at least three nights a week for at least three months.
- Be distressed or have problems functioning due to your sleeping problem.
- Not have another condition which could affect sleep, ie mental or physical illnesses or another sleep disorder.
How can I sleep better?
- Avoid caffeine, smoking and alcohol, especially in the hours before bedtime.
- Avoid heavy meals or strenuous exercise shortly before going to bed.
- Go to bed and get up at the same time each day.
- Regular daytime exercise helps you feel more relaxed and tired at bedtime.
This section will discuss five topics which can help to promote better sleep:
- Understanding some facts.
- Sleep hygiene.
- Relaxation techniques.
- Daytime exercise.
- Psychological treatments called cognitive and behavioural therapies.
In effect, these can be used in a step-wise fashion. You need only go on to the next step if the previous step is not very helpful, but each step requires a greater degree of effort.
Understanding some facts
It is often helpful to understand that short periods of waking each night are normal. Some people are reassured about this and so do not become anxious when they find themselves awake in the night. Also, remember that worry about poor sleep can itself make things worse. Also, it is common to have a few bad nights if you have a period of stress, anxiety or worry. This is often just for a short time and a normal sleep pattern often resumes after a few days.
General tips for sleeping better (often called sleep hygiene)
The following are commonly advised to help promote sleep in people with sleep difficulties, and may be all that is necessary:
- Reduce caffeine - do not have any food, medicines, or drinks that contain caffeine or other stimulants for six hours before bedtime (see above). Some people have found that cutting out caffeine completely through the day has helped.
- Do not smoke within six hours before bedtime.
- Do not drink alcohol within six hours before bedtime.
- Do not have a heavy meal just before bedtime (although a light snack may be helpful).
- Do not do any strenuous exercise within four hours of bedtime (but exercising earlier in the day is helpful).
- Body rhythms - try to get into a routine of wakefulness during the day and sleepiness at night. The body becomes used to rhythms or routines. If you keep to a pattern, you are more likely to sleep well. Therefore:
- No matter how tired you are, do not sleep or nap during the day.
- It is best to go to bed only when sleepy-tired in the late evening.
- Switch the light out as soon as you get into bed.
- Always get up at the same time each day, seven days a week, however short the time asleep. Use an alarm to help with this. Resist the temptation to lie in - even after a poor night's sleep. Do not use weekends to catch up on sleep, as this may upset the natural body rhythm that you have got used to in the week.
- The bedroom should be a quiet, relaxing place to sleep:
- It should not be too hot, cold, or noisy.
- Earplugs and eye shades may be useful if you are sleeping with a snoring or wakeful partner.
- Make sure the bedroom is dark with good curtains to stop early morning sunlight.
- Don't use the bedroom for activities such as work, eating or television.
- Consider changing your bed if it is old, or not comfortable.
- Hide your alarm clock under your bed. Many people will clock-watch and this does not help you to get off to sleep.
- Mood and atmosphere - try to relax and wind down with a routine before going to bed. For example:
- A stroll followed by a bath, some reading, and a warm drink (without caffeine) may be relaxing in the late evening.
- Do not do anything mentally demanding within 90 minutes of going to bed - such as studying.
- Go to bed when sleepy-tired.
- Some people find playing soft music is helpful at bedtime. Try a player with a time switch that turns the music off after about 30 minutes.
- If you cannot get off to sleep after 20-30 minutes - then get up. If you can, go into another room, and do something else such as reading or watching TV rather than brooding in bed. Go back to bed when sleepy. You can repeat this as often as necessary until you are asleep.
These aim to reduce your mental and physical arousal before going to bed. Relaxation techniques may help even if you are not anxious but find it hard to get off to sleep. There are a number of techniques. For example, progressive muscular relaxation has been shown to help promote sleep. This technique consists of tensing and relaxing various muscle groups in sequence. See separate leaflet called Relaxation Exercises.
Your GP or a counsellor may be able to recommend a CD that takes you through deep-breathing exercises, and other methods to help you relax.
Regular daytime exercise can help you to feel more relaxed and tired at bedtime. This may help you to sleep better. (However, you should not do exercise near to bedtime if you have insomnia.) If possible, do some exercise on most days. Even a walk in the afternoon or early evening is better than nothing. However, ideally, you should aim for at least 30 minutes of moderate exercise on five or more days a week.
Moderate exercise means that you get warm and slightly out of breath. You do not need to go to a gym! Brisk walking, jogging, cycling, climbing stairs, heavy DIY, heavy gardening, dancing and heavy housework are all moderate-intensity physical exercises. See separate leaflet called Physical Activity For Health.
Behavioural and cognitive therapies
If you have severe persistent poor sleep, your doctor may refer you to a psychologist or other health professional for psychological treatments. These are various therapies which help re-train your brain and the way you feel, think or behave. Research studies have found that there is a good chance that behavioural and cognitive therapies will improve sleep in adults with insomnia. Increasingly, research has also shown that some of these therapies can be delivered digitally (ie through an app, online, etc).
There are various types of therapy and they include the following:
Stimulus-control therapy. This helps you to re-associate the bed and bedroom with sleep and to re-establish a consistent sleep/wake pattern.
Sleep restriction therapy. Very briefly, the principle of this treatment is that you limit the time that you spend in bed at night. As things improve, the time in bed is then lengthened. An example of the way that this may be done in practice is as follows:
- First, you may be asked to find out how much you are actually sleeping each night. You can do this by keeping a sleep diary.
- You may then be advised to restrict the amount of time that you spend in bed to the time that you actually sleep each night. For example, if you spend eight hours in bed each night but you sleep for only six hours then your allowed time in bed would be six hours. So, in this example, say you normally go to bed at 11 pm, get to sleep at 1 am and get up at 7 am. To restrict your time in bed to six hours, you may be advised to go to bed at 1 am but still get up at 7 am.
- You then make weekly adjustments to the allowed time in bed, depending on the time spent asleep. (You need to keep on with the sleep diary.)
- When 90% of the time spent in bed is spent asleep then the allowed time spent in bed is increased by 15 minutes, by going to bed 15 minutes earlier. In the above example, you would then go to bed at 12.45 am.
- Adjustments are made each week until you are sleeping for a longer length most nights.
Relaxation training. This teaches you ways of reducing tension. For example, this may include the progressive muscle relaxation technique as described earlier, plus various other techniques described earlier.
Paradoxical intention. This involves staying passively awake, avoiding any intention to fall asleep. It is used for people who have trouble getting to sleep (but not maintaining sleep).
Biofeedback. With this technique, you are connected to electrical sensors which give you feedback by sounds and lights to show you what your body is doing. This is to help you control certain body functions (such as muscle tension).
Cognitive therapy. Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger or fuel certain health problems, such as poor sleep. The therapist helps you to understand your thought patterns. In particular, to identify any harmful or unhelpful ideas or thoughts which you have that can contribute to you not sleeping well. The aim is then to change your ways of thinking and/or behaviour to avoid these ideas. Also, to help your thoughts to be more realistic and helpful. Cognitive therapy is often used in combination with a behavioural intervention (such as stimulus control, sleep restriction, or relaxation training); this is then called cognitive behavioural therapy (CBT).
What about sleeping tablets?
Sleeping tablets are not usually advised
The main types of sleeping tablets are in a class of medicines called benzodiazepines and a class called Z drugs. Read more about why benzodiazepines or Z drugs may be prescribed.
In the past, sleeping tablets were commonly prescribed. However, they have been shown to have problems and are now not commonly prescribed.
Possible problems with sleeping tablets include:
- Drowsiness the next day. You may not be safe to drive or to operate machinery.
- Clumsiness and confusion in the night if you have to get up. For example, if you have had a sleeping tablet, you may fall over if you get up in the night to go to the toilet. (Older people who take sleeping tablets have an increased risk of falling and breaking their hip.)
- Tolerance to sleeping tablets may develop if you take them regularly. This means that, in time, the usual dose has no effect. You then need a higher dose to help with sleep. In time, the higher dose then has no effect, and so on.
- Some people become addicted to (dependent on) sleeping tablets and have withdrawal symptoms if the tablets are stopped suddenly.
Sometimes a sleeping tablet is advised
If a sleeping tablet is prescribed, it is usually just a short course (a week or so) to get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents tolerance or dependence to the tablet from developing. Learn more about the role of sleeping tablets in insomnia.
Melatonin is, strictly speaking, not a sleeping tablet. Melatonin is a naturally occurring hormone made by the body. The level of melatonin in the body varies throughout the day. It is involved in helping to regulate the daily cycles (circadian rhythms) of various functions in the body. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia. The recommended duration of treatment is for three to ten weeks only.
Some antihistamines can make you sleepy and are sold over the counter for this purpose - for example, Nytol®. These should only be used for short periods of time. This is because if you use them for a long time insomnia can be worse when they are stopped. They can make you sleepy the next day. Also, there is not much evidence about how well they work.
Valerian and other herbal remedies are not recommended
Herbal remedies are used by some people to help with sleep. For example, valerian. However, research studies have shown that there is very little evidence to show that they work. Therefore, they are not recommended.
A final note
See a doctor if you feel that illness or medication is causing poor sleep. Treating any underlying condition that is causing the problem, if possible, can help to promote sleep. In particular, depression and anxiety are common causes of poor sleep and can often be treated.
What is sleep paralysis?
If you have sleep paralysis you are awake but you are unable to move your body (paralysis) and unable to speak when you wake up from sleep. Sometimes it can occur as you are falling asleep. If someone touches you or speaks to you, the paralysis is relieved and you are able to move again.
The paralysis may last for any time from a few seconds up to a minute or two. It does not affect your breathing and does not cause you any harm. After the episode of sleep paralysis you can move and speak normally. However, you are fully awake and so sleep paralysis can be very frightening.
How common is sleep paralysis?
Sleep paralysis is relatively common. About 1 in 5 people have at least one episode of sleep paralysis during their lifetime. Sleep paralysis can affect people of all ages but it's more common in teenagers and young adults. Sleep paralysis is also more common in people of African descent and people who have mental health problems.
Many people only experience sleep paralysis once or twice in their lives. Other people may experience regular episodes of sleep paralysis.
Sleep paralysis may be caused by sleep deprivation, irregular sleeping patterns or jet lag. You may also be more likely to have sleep paralysis if someone else in your family also has it.
What causes sleep paralysis?
Your muscles normally become very relaxed and paralysed at certain times when you're asleep. Sleep paralysis occurs when the same mechanism to stop your muscles occurs when you've woken up or when you're falling asleep. Sleep paralysis occurs when some aspects of REM sleep happen when you are awake. This means that you remain temporarily paralysed but are fully conscious.
Sleep paralysis can sometimes be a symptom of narcolepsy. Narcolepsy is a long-term (chronic) problem that affects your sleep. You feel excessively tired during the daytime but have disturbed night-time sleep. You can also have sleep attacks where you fall asleep during the day without any warning. See separate leaflet called Narcolepsy and Cataplexy.
What are the symptoms of sleep paralysis?
The main symptom of sleep paralysis is being unable to move or talk for a brief period. The paralysis usually occurs as you're waking up but can also sometimes happen when you're falling asleep.
You will be fully conscious during the period of sleep paralysis. An episode of sleep paralysis can therefore be very frightening. Breathing is not usually affected but it may be difficult to take a deep breath. After the sleep paralysis you can move and speak normally but you will often feel upset and anxious.
During an episode of sleep paralysis, you may also experience unusual experiences (hallucinations). If you have hallucinations, you see, hear, smell or feel something that isn't really there, such as thinking there is someone else in the room.
Is there any treatment for sleep paralysis?
The most important way to treat sleep paralysis is to make sure you:
- Have enough sleep.
- Have regular sleep patterns.
- Are relaxed and comfortable when going to bed.
Medicines can be prescribed by your doctor if you have frequent or severe episodes of sleep paralysis.
General sleep advice
It is very important to get into a good sleep routine and to make sure you have enough sleep. General advice to help improve your sleep pattern includes the following:
- Get enough sleep - most adults need between six and eight hours of sleep each night.
- Go to bed and get up at about the same times each day to create a good sleep routine.
- Make sure your bedroom is relaxing, quiet and dark, and not too warm or too cold.
- Making sure your bed is comfortable.
- Have regular exercise during the day but not in the few hours before you go to bed.
- Both caffeine and smoking can have a bad effect on sleep patterns. Therefore, cut down on caffeine (for example, coffee) and, if you are a smoker, stop smoking.
- Only drink alcohol in moderation if at all. Don't drink any alcohol before going to bed.
- Don't eat any food just before going to bed.
Treatments using medicines
Your GP may refer you to a sleep clinic if your symptoms are severe or you have any other problems with sleep.
If your sleep paralysis is frequent or severe, you may also be prescribed a medicine that is also used to treat depression. The medicine used to help sleep paralysis is usually a short course of a tricyclic antidepressant. Tricyclic antidepressant medicines that are often used to treat sleep paralysis include imipramine and clomipramine. The medicine will help to prevent episodes of sleep paralysis and will also help to prevent any hallucinations that may occur with sleep paralysis.
What is the outcome?
Sleep paralysis does not cause any long-term problems. Many people only experience sleep paralysis once or twice in their lifetime.
Episodes of sleep paralysis tend to become less frequent as you get older and they usually disappear. However, sometimes the sleep paralysis seems to have resolved but further episodes may then start again.
Why are doctors reluctant to prescribe sleeping tablets?
Doctors avoid prescribing sleeping tablets if possible due to the problems sleeping tablets can cause. In particular, the concern is that you could become dependent on sleeping tablets or addicted to them. Possible problems when taking sleeping tablets include the following:
- Drowsiness the next day. You may not be safe to drive a vehicle or to operate machinery. Evidence shows people who take sleeping tablets are more likely to be involved in road traffic accidents.
- Clumsiness, drowsiness, and confusion in the night (if you get up). These can occur - for example, if you have to get up in the night to go to the toilet. You may fall over and injure yourself. Some people have fallen down stairs due to the drowsiness caused by sleeping tablets. (Older people who take sleeping tablets have an increased risk of breaking their hip, as the result of a fall.)
- Risks. One study suggests that people who use sleeping tablets for a long time are more likely to develop dementia. (This has not been proven yet.)
- Tolerance. If you take benzodiazepines and Z drug sleeping tablets each night, your body becomes used to them. This means that, in time, the usual dose has no effect. You then need a higher dose for it to work. In time, the higher dose does not work and you need an even higher dose, and so on. It can take as little time as just a few days for tolerance to develop.
- Dependence. Some people become dependent on benzodiazepines or Z drugs. This means that withdrawal symptoms occur if the tablets are stopped suddenly. Withdrawal symptoms include anxiety, shaking, or just feeling awful. If you have taken a benzodiazepine or Z drug regularly for more than two to four weeks, you will need to come off it gradually, to avoid withdrawal symptoms.
- Addiction. Some people who are dependent on benzodiazepines or Z drugs may become addicted to them. If you are addicted to a medication, you have uncontrollable cravings for it and feel a need to take it. This can happen even after you have slowly withdrawn from it so that you are no longer dependent. Tolerance, dependence and addiction are different things. Some types of people seem more likely than others to become addicted to substances.
In some cases, however, sleeping tablets may be very helpful. In short courses for time-limited problems, they are safe to use. For example, if you have had a sudden shock or bereavement, sleeping can be a problem. A short course of sleeping tablets (for a week or two) may help you cope better in the daytime. Or if you have jet lag and are struggling with re-setting your internal time clock. Doctors advise that you take no more than two weeks of sleeping tablets at a time. If you just take the tablets for a week or two, you will not become dependent on them.
Are there different types of sleeping tablet?
Benzodiazepines and Z drugs
Benzodiazepines and Z drugs are sometimes used as sleeping tablets. Benzodiazepines include temazepam, loprazolam, lormetazepam, and nitrazepam. They are only available on prescription. Other related drugs called zaleplon (no longer available in the UK), zolpidem and zopiclone are also sleeping tablets. Strictly speaking, they are not benzodiazepines. They are known as the Z drugs. However, they act in a similar way (they have a similar effect to benzodiazepines on the brain cells).
These medicines are commonly used to treat allergies such as hay fever. However, drowsiness is a side-effect of some antihistamines - for example, promethazine. This 'side-effect' is useful in some people who have difficulty sleeping because of their allergy. An antihistamine is the active ingredient of some sleeping tablets that you can buy from pharmacies, without a prescription. Antihistamines are not as powerful as benzodiazepines or Z drugs at causing sleep. Also, they may cause a 'hangover' effect and some drowsiness in the morning. They may also cause rebound insomnia if you take them for a long time. For these reasons, current UK guidelines do not advise the use of antihistamines to be used solely as a sleeping tablet.
Melatonin is, strictly speaking, not a 'sleeping tablet'. Melatonin is a naturally occurring hormone made by the body. The level of melatonin in the body varies throughout the day. It is involved in helping to regulate the daily cycles (circadian rhythms) of various functions in the body. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia. The recommended duration of treatment is for three weeks to start with. If helpful, it can be used for a maximum of ten weeks in total.
In some countries melatonin is used to help with sleep problems related to jet lag. In the UK it is not currently licensed for this.
Chlormethiazole, chloral, and barbiturates are old-fashioned sleeping tablets. They are not commonly used these days, as benzodiazepines and Z drugs are usually preferred. Certain antidepressants are sometimes used to help with sleep, particularly if depression or anxiety is thought to be causing the problem.
What is the alternative to sleeping tablets?
Try to work out the reason for your sleeping difficulties. Where possible, correct this.
Your doctor or nurse may give you advice on how to tackle poor sleep naturally. They may also refer you for a type of talking therapy called cognitive behavioural therapy (CBT). CBT is a type of brain-training, which aims to teach your brain how to fall asleep.
If a sleeping tablet is prescribed
If your doctor prescribes a benzodiazepine or Z drug as a sleeping tablet for you, it will usually be only for a short time (a week or so). This is to help you get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents either tolerance to or dependence on the tablet from developing.
What if I am already taking a sleeping tablet regularly?
For various reasons, some people have become used to taking a benzodiazepine or Z drug sleeping tablet every night. As a rule, if you are taking one of these sleeping tablets each night, you should consider reducing or stopping them. However, in some people, problems of tolerance or dependence (see above) mean that it can be difficult to stop the tablet suddenly.
If you want to reduce or stop benzodiazepine or Z drug sleeping tablets, it is best to consult a doctor or nurse for advice. The sort of advice may include the following:
- Do it gradually and cut the dose down a little at a time. A switch to a different benzodiazepine (diazepam) may be advised. This is because it is easier to reduce the dose of diazepam gradually than it is with other benzodiazepines or Z drugs.
- It is best to wait until any life crisis has passed and your level of stress is as low as can be.
- Consider stopping the tablets whilst on holiday, when you have less pressure from work, family, etc.
- You are likely to have a period of worse sleep when you stop the tablets. Try to anticipate and accept this.
- Advice on coping strategies, and tips on how to improve your sleep pattern naturally.
See separate leaflet called Stopping Benzodiazepines and Z Drugs. However, stopping benzodiazepine or Z drug sleeping tablets is not practical in every case.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.
What are benzodiazepines and Z drugs?
Benzodiazepines are a group of medicines that are sometimes used to treat anxiety, sleeping problems and other disorders. Examples include diazepam, lorazepam, chlordiazepoxide, oxazepam, temazepam, nitrazepam, loprazolam, lormetazepam, clobazam and clonazepam.
Benzodiazepines work by affecting the way certain brain chemicals (neurotransmitters) transmit messages to certain brain cells. In effect, they decrease the excitability of many brain cells. This has a calming effect on various functions of the brain.
Medicines called zaleplon (no longer available in the UK), zolpidem and zopiclone are commonly called the Z drugs. Strictly speaking, Z drugs are not benzodiazepines but are another class of medicine. However, they act in a similar way to benzodiazepines. (They have a similar effect on the brain cells as benzodiazepines.) Z drugs have similar long-term usage problems as benzodiazepines.
What are benzodiazepines and Z drugs used for?
Benzodiazepines for anxiety
Symptoms of anxiety include: agitation, tension, irritability, the sensation of having a 'thumping heart' (palpitations), shakiness, sweating, excess worry, sleeping badly, poor concentration, fast breathing and sometimes a knotted feeling in the stomach and other muscles. There are various causes of anxiety. Sometimes it is a sudden life crisis such as a bereavement or redundancy. Some people have an anxious personality and feel anxious fairly often. Sometimes anxiety can be one of the symptoms of depression. Although most people will feel anxious at some time, sometimes the symptoms become prolonged and distressing. See separate leaflet called Anxiety.
Treatments for anxiety include: relaxation exercises, anxiety management courses and cognitive therapy and behavioural therapy. Simply talking things over with a friend, counsellor, or with members of a self-help group may also help. However, if symptoms become very severe, you may occasionally be advised to take a benzodiazepine medicine for a short time.
Benzodiazepines and Z drugs as sleeping tablets
A short course of a benzodiazepine or a Z drug may be prescribed if a medicine is felt necessary to help with sleeping difficulty (insomnia). However, there are other ways of helping to get a good night's sleep.
Other uses of benzodiazepines
A dose of a benzodiazepine is often given as a 'pre-med' to reduce anxiety before an operation. A large dose is commonly given as a sedative during medical procedures that may cause anxiety or discomfort. The medicine not only reduces anxiety but also has an amnesic effect. This means that you do not remember much about the procedure afterwards. Some benzodiazepines are occasionally used to treat muscle spasm and certain types of epilepsy as they can prevent fits (seizures). Others are used to help people who are dependent on alcohol and trying to stop.
How effective are benzodiazepines and Z drugs?
If you are not used to taking benzodiazepines or Z drugs, the first doses are usually good at easing symptoms of anxiety or promoting sleep. A benzodiazepine does nothing to remove any underlying cause of anxiety such as a life crisis. However, if your symptoms are eased, you may be able to cope better with any problems.
Benzodiazepines and Z drugs work best in situations where anxiety or sleeping difficulty is expected to last only a short while. They are not so useful if you have an ongoing anxious personality or long-term sleeping difficulty. However, a short course may help you over a particularly bad spell.
You can usually stop a benzodiazepine or a Z drug without any problems if you take it for just a short period of time (no more than 2-4 weeks).
Why should benzodiazepine and Z drugs be used only for a short time?
When benzodiazepines were first used they were thought to be safe. The problems with their long-term use were not known. In 1981, benzodiazepines were the most commonly prescribed medicines in western countries. It was because benzodiazepines worked so well to ease symptoms of anxiety and poor sleep that many people came back for more. Some people started to take them regularly.
However, it is now known that if you take a benzodiazepine or a Z drug for more than 2-4 weeks, you may develop problems (see below). Therefore, most doctors will now only prescribe benzodiazepines and Z drugs for a short period.
What happens if you use a benzodiazepine or a Z drug for longer?
If you take a benzodiazepine or Z drug regularly, the helpful effect on easing anxiety or in helping sleep usually lasts for a few weeks. However, after a few weeks, the body and brain often become used to the benzodiazepine or Z drug. The medicine then gradually loses its effect. The initial dose then has little effect. You then need a higher dose for it to work. In time, the higher dose does not work and you need an even higher dose and so on. This effect is called tolerance.
There is a good chance that you will become addicted to (dependent on) a benzodiazepine or a Z drug if you take it for more than four weeks. This means that withdrawal symptoms occur if the tablets are stopped suddenly. In effect, you need the medicine to feel normal. Possible withdrawal symptoms include:
- Psychological symptoms - such as anxiety, panic attacks, odd sensations, feeling as if you are outside your body, feelings of unreality, or just feeling awful. Rarely, a serious mental breakdown can occur.
- Physical symptoms - such as sweating, being unable to sleep, headache, tremor, feeling sick (nausea), the sensation of having a 'thumping heart' (palpitations), muscle spasms and being oversensitive to light, sound and touch. Rarely, convulsions occur.
- In some cases the withdrawal symptoms seem like the original anxiety symptoms.
The duration of withdrawal symptoms varies but often lasts up to six weeks and sometimes longer. Withdrawal symptoms may not start for two days after stopping the tablet and tend to be worst in the first week or so. Some people have minor residual withdrawal symptoms for several months.
Therefore, you may end up taking the medicine to prevent withdrawal symptoms but, because of tolerance, the medicine is no longer helping the original anxiety or sleeping problem. But note: you are unlikely to become dependent on a benzodiazepine or a Z drug if you take it for a short period only.
Some other possible problems with benzodiazepines and Z drugs
Even if you take a benzodiazepine or Z drug for a short time, you may feel drowsy during the daytime. Some people, especially older people, are at greater risk of having a fall and injury because of the drowsiness. If you drive, you may be more likely to be involved in a car crash. Some people have described themselves as being in a zombie state when they were taking a benzodiazepine on a long-term basis.
For a full list of possible side-effects whilst taking any tablet, read the leaflet that comes with the packet of tablets.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address:www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.
Benzodiazepines and Z drugs and the law
Benzodiazepines and Z drugs can sometimes be misused by people taking drugs for recreational purposes. The Misuse of Drugs Act was a law passed in 1971 in the UK to try to prevent the use of harmful drugs. It divides drugs into three categories - A, B or C, depending on how dangerous they are thought to be. Each of the categories then has different penalties for those convicted of use or supply. Benzodiazepines and Z drugs are classed as Class C drugs. This means it is illegal to be in possession of them if they have not been prescribed for you by a doctor. People found in possession illegally, or attempting to supply them to others, could face a fine or a prison sentence. There are also special rules for doctors prescribing them.
People on normal doses of benzodiazepines and Z drugs prescribed by their doctor do not need to inform the Driver and Vehicle Licensing Agency (DVLA). However, if you are taking higher doses than recommended, or taking them without prescription, your driving licence would be taken away.
What if I have been taking a benzodiazepine or a Z drug for a long time?
If you have been taking a benzodiazepine or a Z drug for over four weeks and want to come off it, it is best to discuss the problem with a doctor. Some people can stop taking benzodiazepines or Z drugs with little difficulty. However, many people develop withdrawal symptoms if they suddenly stop taking a benzodiazepine or a Z drug. To keep withdrawal effects to a minimum, it is often best to reduce the dose of the medicine gradually over a number of weeks or months before finally stopping it. Your doctor will advise on dosages, timescale, etc. See separate leaflet called Stopping Benzodiazepines and Z Drugs.
How should I stop taking a long-term benzodiazepine or Z drug?
If you have been taking a benzodiazepine or Z drug for over four weeks and want to stop it, it is best to discuss the problem with a doctor.
Some people can stop taking benzodiazepines and Z drugs without any difficulty, as they have only minor withdrawal effects which soon ease off. However, for a lot of people the withdrawal effects are too severe to cope with if the medicine is stopped suddenly. Therefore, it is often best to reduce the dose gradually over several months before finally stopping it. Your doctor can advise on dosages, timescale, etc.
Diazepam withdrawal plan
Often, coming off benzodiazepines and Z drugs is just a matter of very slowly reducing them. Sometimes, however, this isn't possible because of the type of tablet you are taking. In this situation a common plan is to switch from whatever benzodiazepine tablet or Z drug you are taking to diazepam. Diazepam is a 'long-acting' benzodiazepine that is commonly used. With diazepam, the dose can be altered very gradually and with greater ease compared to other benzodiazepines.
Your doctor will be able to prescribe the dose of diazepam equivalent to the dose of your particular type of benzodiazepine or Z drug. After this, you can decide with your doctor a plan of how to reduce the dose gradually. You and your doctor will make a plan you are both comfortable with. This can be flexible so you can come off your medication more quickly or more slowly depending on how you are feeling. A common plan is to reduce the dose by a small amount every 1-2 weeks. The amount the dose is reduced at each step may vary, depending on how large a dose you are taking to start with. Also, the last few dose reductions before finally stopping completely may be less than the original dose reductions, and done more gradually.
The gradual reduction of dose keeps any withdrawal symptoms to a minimum.
Occasionally other medication may be prescribed to help you cope with symptoms while you are coming off benzodiazepines. For example, you may be offered antidepressants if depression emerges whilst you are on a withdrawal programme. If anxiety is a problem, sometimes you may be prescribed a tablet called a beta-blocker, such as propranolol.
Some tips that may help
- Before coming off a benzodiazepine or a Z drug it may be best to wait until any life crisis has passed and your level of stress is as low as can be.
- Consider starting whilst on holiday, when you have less pressure from work, fewer family commitments, less stress, etc.
- Consider telling family or friends that you are coming off a benzodiazepine or a Z drug. They may give you encouragement and support.
- Consider joining a local self-help group. Advice and support from other people in similar circumstances, or who have come off a benzodiazepine or a Z drug, can be very encouraging.
- If you are taking other addictive medicines in addition to benzodiazepines, you may need specialist help for coming off the various medicines. Your doctor will be able to advise you or refer you on to local services which can help.
Other ways of tackling anxiety and sleeping problems
Benzodiazepines and Z drugs are not the long-term answer to anxiety or sleep problems.
If you have anxiety symptoms, there are other ways of tackling your symptoms - for example, learning to relax, or joining an anxiety management group. If anxiety symptoms persist or are severe, your doctor may advise on other treatments such as cognitive behavioural therapy (CBT).
A final note
Most people who have taken a benzodiazepine or a Z drug can successfully come off it. After switching to diazepam (described above), the pace and speed of withdrawal vary greatly from person to person. Go at a pace that is comfortable for you after discussion with your doctor. For many people, the gradual withdrawal and eventual stopping of diazepam take several months. However, some take up to a year to reduce the dose gradually before finally stopping it.
Further reading & references
- Insomnia - zaleplon, zolpidem and zopiclone for the management of insomnia; NICE Technology Appraisal Guidance, April 2004
- Insomnia; NICE CKS, April 2015 (UK access only)
- Consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders; British Association for Psychopharmacology (2010)
- Buysse DJ, Germain A, Moul DE, et al; Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 May 23;171(10):887-95. Epub 2011 Jan 24.
- Taibi DM, Landis CA, Petry H, et al; A systematic review of valerian as a sleep aid: safe but not effective. Sleep Med Rev. 2007 Jun;11(3):209-30.
- Sleep diary; American Academy of Sleep Medicine
- Buysse DJ; Insomnia. JAMA. 2013 Feb 20;309(7):706-16. doi: 10.1001/jama.2013.193.
- Luik AI, Kyle SD, Espie CA; Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review. Curr Sleep Med Rep. 2017;3(2):48-56. doi: 10.1007/s40675-017-0065-4. Epub 2017 May 8.
- Lemoine P, Zisapel N; Prolonged-release formulation of melatonin (Circadin) for the treatment of insomnia. Expert Opin Pharmacother. 2012 Apr;13(6):895-905. doi: 10.1517/14656566.2012.667076. Epub 2012 Mar 19.
- Qaseem A, Kansagara D, Forciea MA, et al; Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016 Jul 19;165(2):125-33. doi: 10.7326/M15-2175. Epub 2016 May 3.
- Sateia MJ, Buysse DJ, Krystal AD, et al; Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-349. doi: 10.5664/jcsm.6470.
- Hale L, Guan S; Screen time and sleep among school-aged children and adolescents: a systematic literature review. Sleep Med Rev. 2015 Jun;21:50-8. doi: 10.1016/j.smrv.2014.07.007. Epub 2014 Aug 12.
- Chang AM, Aeschbach D, Duffy JF, et al; Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci U S A. 2015 Jan 27;112(4):1232-7. doi: 10.1073/pnas.1418490112. Epub 2014 Dec 22.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr John Cox