Psych Meds 101: Medications for Sleep

The Psych Meds 101 series on my perspective as a mental health nurse, former pharmacist, and person with depression. This final post in the series focuses on sleep meds.

While some of these meds are primarily for sleep, many have other uses as well. The choice of medication for any given person will be based on their diagnosis among other factors, and sleep meds may no longer be necessary once the underlying mental illness is well controlled.

Rx/OTC medications

Benzodiazepines

I covered these in more detail in my previous post on anti-anxiety meds. The choice of benzo will depend on whether you want it more for getting to sleep or staying asleep (i.e. shorter or longer-acting). I’ve found clonazepam, which is long-acting, to be helpful in the past when I was having problems with waking up early.

Oxazepam and temazepam do not have the same degree of anti-anxiety effect as other benzos, but they are useful for sleep because their half-lives match up pretty well with a night of sleep. They’re also cleanly metabolized, meaning they don’t leave any active metabolites sticking around that can cause a hangover-type effect. The key thing to be aware of when using benzos for sleep is that if you use them regularly, you will develop a tolerance and they’ll become less effective.

Z-drugs

The so-called Z-drugs include zopiclone and zolpidem. Their main therapeutic use is as sleep meds. Like benzos, they act on GABA receptors (GABA is a calming neurotransmitter), but they act at a different site and cause different changes in the receptor. As a result, they’re less likely to result in dependence, tolerance, or withdrawal symptoms. I’ve had moderate success taking zopiclone in the past, but I’ve needed 15mg rather than the most common dose of 7.5mg.

Anti-histamines

Histamine does a number of things in the body, but in the brain it promotes wakefulness. Blocking H1 histamine receptors results in a sedative effect. Most over-the-counter sleep meds contain diphenhydramine, which is the same ingredient in Benadryl to treat allergies. A downside of H1 histamine blockers is that they can cause weight gain when used long-term.

A lot of the prescription medications that may be used for sleep block H1 receptors in addition to whatever their primary therapeutic purpose might be. The antidepressant trazodone is used more often for sleep than as an antidepressant. It’s used for sleep generally at doses of 50-150mg; for an antidepressant effect, the dose needs to be higher.

Tricyclic antidepressants like amitriptyline are quite sedating, as is mirtazapine. Interestingly enough, mirtazapine is most sedating at lower doses, and at higher doses becomes more activating. For me, the sweet spot seems to be at 30mg. Antipsychotics affecting H1 receptors may also be used for sleep, such as methotrimeprazine and quetiapine. The extended-release formulation of quetiapine can be useful if early morning awakening is a problem.

Anticonvulsants

Gabapentin is an option but not necessarily the most effective one. It would tend to be most appropriate for someone who would also benefit from its other therapeutic effects, e.g. for neuropathic pain or anxiety.

Prazosin

Prazosin isn’t a sleep medication per se; however, for people with PTSD, it can help tone down nightmares and thus improve sleep. It blocks alpha-1 adrenergic receptors, slowing down some of the sympathetic nervous system fight-or-flight-related activity.

Supplements

There are a variety of non-drug options that are worth considering. Tryptophan is an amino acid that is a precursor for serotonin production. It’s the substance in turkey that’s associated with drowsiness, and it can be taken as a supplement to promote sleep. Herbal teas, particularly those containing chamomile, may be helpful.

Melatonin

The pineal gland in the brain naturally produces the hormone melatonin, which regulates the circadian rhythm, i.e. sleep-wake cycle. For some people, melatonin supplements work well, such as people whose circadian rhythm gets disrupted by things like shift work. For other people, taking melatonin doesn’t do much of anything; I happen to fall into this category.  

Ramelteon is a drug that stimulates the same receptors as melatonin does, but I’ve never actually seen it used; melatonin is cheaper and more readily available.

Valerian root

This is a herbal product that may have some sort of activity at GABA receptors, although it’s not clear what exactly this is. There isn’t a lot of evidence to back up its effectiveness, but it’s worth being aware of as a non-drug option. I’ve tried it and personally didn’t find it helpful.

Other strategies

There are also certain substances that it may be best to avoid; caffeine is an obvious one, but perhaps not so obvious is alcohol. Alcohol may help you get to sleep, but it decreases sleep quality and makes it more likely you will wake up during the night. Sleep hygiene is very important, but I’ll address that in another post. Cognitive behavioural therapy for insomnia (CBT-i) is a key non-drug form of insomnia treatment.

While ideally, we wouldn’t need sleep meds, the reality of mental illness is that most of us will have problems with sleep at one time or another. Given how hugely damaging poor sleep is to mental health, I’ll take sleep meds over insomnia hands down. As with any kind of medication, knowledge is power, and knowing our options puts us in a position to make the best decision in our own specific circumstances.