Sleeping pills and the alternatives

More than 10 million prescriptions for sleeping pills are given each year in England, but medication only offers short-term relief.

Non-drug treatments have been under-used, but sleep experts say they offer the best long-term solutions to chronic insomnia.

Professor Kevin Morgan of Loughborough University’s Sleep Research Centre says that sleeping tablets treat the symptoms of insomnia, not its causes.

He has been researching psychological treatments for insomnia, focusing on behavioural change and self-help to promote better sleeping patterns.

It was always assumed that if people had insomnia alongside a more serious condition, then curing that illness would cure the insomnia. Nowadays, however, insomnia is generally treated as a separate illness.

Before your GP can make a diagnosis, you may be asked to keep a sleep diary, in order to record bedtimes, wake times, hours slept and quality of sleep each morning.

“Sleep diaries are an invaluable insight into the patient’s sleeping habits. If continued during therapy, they're a useful way of monitoring the outcome of treatment,” says Professor Morgan.

If insomniaisdiagnosed, the main treatments are:

1. Sorting out 'sleep hygiene'

Lifestyle, particularly your sleeping habits, have a big impact on your quality of sleep. Addressing so-called "sleep hygiene" should be the first step in any insomnia treatment.

Sleep hygiene is a list of lifestyle dos and don'ts. It has proved to be effective in stopping insomnia from getting worse, and making it easier to benefit from further treatment.

“It's a useful first step in treatment, and sends the important message that behaviour and lifestyle choices can influence sleep quality,” says Professor Morgan.

Habits such as drinking too many caffeine-based drinks (including coffee, tea and some energy drinks) or exercising too close to bedtime will affect your sleep.

“If you have a sleep problem, it’s worth looking at your personal habits. It could be that your sleep is being ruined by your regular espresso before bed,” says Professor Morgan.

“Sleep is fragile,” he says. “You’ve got to look after it.”

2. Cognitive behavioural therapy (CBT)

Once sleep hygiene has been addressed, and there’s no improvement in your insomnia, CBT is the next step. It's a package of treatments that usually includes sleep restriction, stimulus control, cognitive therapy and relaxation techniques.

Sleep restriction: Some people with insomnia may benefit from a sleep restriction programme that allows only a few hours of sleep during the night, at first. Gradually, the time is increased until you achieve a more regular night's sleep.
Stimulus control: This therapy rebuilds the association between the bedroom and sleep by limiting the amount of time you spend awake in bed. “The environment can stimulate behaviour,” says Professor Morgan.
Cognitive therapy: Thought-blocking therapies are used to reduce anxiety about not falling asleep. Professor Morgan says: “Cognitive therapy can help break this vicious circle by teaching you a different way of worrying. Do your worrying at a different time, write down your fears and discipline yourself not to worry about things around bedtime.”
Relaxation therapy: There are specific effective techniques that can reduce or eliminate anxiety and body tension. As a result, the person's mind stops racing, the muscles relax and restful sleep can follow.

3. Sleeping tablets

GPs are advised to turn to hypnotic drug therapy only after considering non-drug therapies, such as those outlined above.

Benzodiazepines (such as Temazepam or Loprazolam) and the newer "Z medicines" (such as Zopiclone or Zolpidem) are the preferred drugs for insomnia.

Both types of drugs work in a similar way. If one doesn’t work, swapping to the other is unlikely to have a different effect.

“These drugs are very effective sleep inducers,” says Professor Morgan. “They work immediately, they’re not toxic and they've been shown to be safe in overdose.”

However, they're only recommended for the short-term treatment of insomnia ‐ up to four weeks.

“Very few insomnia cases only last four weeks,” says Professor Morgan. “Most clinical insomnias are chronic, so most of these drugs are prescribed for longer than they should.”

In any case, the drugs lose their effectiveness over time because the body gets used to them. By that stage, the person has become psychologically dependent on them.