Making sense of sleeping pills and minor tranquillisers

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What should I know before taking any drugs?
What sort of drugs are used for anxiety or sleeping problems?

The benzodiazepines
When and how should benzodiazepines be used?
What are the different types of benzodiazepines?
What are the possible side effects?
Dependence or addiction to benzodiazepines
What are the withdrawal symptoms?

Drugs for anxiety only
What other drugs can be used for anxiety?  
What else can I do to tackle my anxiety?

Drugs for sleeping problems only
The ‘Z’ drugs: zolpidem, zopiclone and zaleplon
Chloral hydrate and related drugs
Antihistamines
How can I improve my sleep without drugs?

References
Useful organisations
Useful websites
Further reading

This booklet is aimed at anyone interested in learning more about the drugs prescribed for sleeping problems and/or anxiety. It explains why these drugs may be prescribed, what their effects are (including side effects), who should avoid them, what happens when people want to withdraw from them, and what the alternative treatments might be.

What should I know before taking any drugs?

Drug names
Drugs can have two types of names: their general (generic) name and the trade names given by the drug companies (starting with a capital letter). The same drug can have several different trade names. In this booklet, drugs are listed using their generic name, with the trade name/s after it in brackets.

Informed consent
The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent, properly, you need to have enough information to understand the nature, likely effects and risks of the treatment, including its chance of success, and any alternatives to it. Generally, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isn’t final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. However, there are times when treatment can be given without consent – see Mind rights guide 3: consent to medical treatment for more details.

Patient information leaflets
If you are prescribed medication as an outpatient, or from your GP, it should come with a patient information leaflet (PIL) in accordance with a European Union directive. As an inpatient, you may have to ask for it, specifically. If you do not receive this information with your medicine, or accidentally throw the PIL away (it’s usually a very small piece of paper), you should ask for it from the person who makes up your prescription.

The PIL contains information such as: the trade and general (generic) names of the drug; the strength of the medicine and the form it takes – for example, tablets; who should take it; what conditions the drug is licensed to treat; any cautions you should be aware of before taking it, such as conditions which mean you should take a reduced dose or not take it at all; how to take it and when; possible side effects; the expiry date of the drugs and how to store them.

It should also contain a full list of all the ingredients, including the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatin, cellulose, and colourings. This information is important because some people may be allergic to one or other of the ingredients, such as lactose or gluten or a colouring. Gelatin is unacceptable to some people because it is an animal product.

Some of the information is quite hard to understand, and the Commission on Human Medicines (formerly the Committee on Safety of Medicines) has been looking at ways of making it easier. They have produced a leaflet Taking medicines – some questions and answers about side effects which you can find on their website or request by telephone, or may be available in your local pharmacy. There is more information on medicines and their use, in the form of Medicines Guides, available from the Medicines Information Project website (See Useful websites for details of both these organisations.)

The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist.

Getting more information from your doctor or pharmacist
Many people would like to have the information about their proposed treatment before they are given the prescription for it, and not after they have got it from the pharmacist and taken it home. The following are issues you might like to discuss with your doctor when she or he gives you a prescription for a drug:

• What is the name of the drug, and what is it for?
• How often do I have to take it?
• How long will I have to take it for?
• If I am taking any other drugs, will it be all right to take them together?
• Will I still be able to drive?
• What are the most likely side effects, and what should I do if I get them?
• Do I have to take it at any particular time of day?
• Is it likely to make me sleepy?
• Should I take it with food?
• When I want to stop taking it, am I likely to have any problems with withdrawal?

You may well think of other questions you wish to ask.

You should also consider talking to your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs (this is when a drug changes the effect of other drugs you are taking; making them less effective, or causing additional side effects). Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.

Since January 2006, a new scheme has been in place called the ‘Medicines Use Review’. People who regularly take more than one prescription medicine, or take medicines for a long-term illness, are encouraged to go to pharmacists who are operating the scheme, for a full discussion of their medicines and any problems they may have with them. The Medicines and Healthcare products Regulatory Agency (MHRA), who are responsible for overseeing the licensing of medicines, have produced a guide to the scheme, which is available on the Department of Health website. (See Useful websites.)

Side effects and withdrawal symptoms
If you have troublesome side effects, or withdrawal symptoms when you stop taking your medication, you can report them yourself to the MHRA under the Yellow Card scheme. You can do this on their website or by phoning them (see Useful organisations) or on a form which you can get from your pharmacy. You can also see a full list of side effects reported on the MHRA website. You can also report symptoms with the help of a health professional if you prefer.

Drug misuse and the law
Some of the drugs discussed in this booklet are controlled drugs. This means that the rules for storing them, and writing and dispensing prescriptions, are stricter than for other drugs. Of the drugs discussed in this booklet, the benzodiazepines, zolpidem, and meprobamate are classified as class C drugs. Barbiturates are classified as class B.

People who pass on any of the prescribed drugs mentioned above to relatives or friends may not realise it, but they are committing a criminal act and are liable to serious penalties in the form of imprisonment or fines.

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What sort of drugs are used for anxiety or sleeping problems?

This booklet covers the group of drugs called benzodiazepines which may be prescribed both for anxiety and sleeping problems. It also includes drugs that are prescribed solely for anxiety, or solely for sleeping problems. The drugs mentioned are sometimes referred to as sleeping pills, minor tranquillisers, sedatives or anxiety-busters; doctors may also call them anxiolytics or hypnotics.

None of these drugs should be used for long-term treatment, either for anxiety or for sleep.

All of the drugs mentioned have a sedative effect and carry a warning about driving and operating machinery, and it’s very important to take this seriously. Research has shown that users of benzodiazepines and zopiclone were more likely to have a road traffic accident. Research looking at a number of different studies of benzodiazepines suggests that the short increase in sleep time they offered was not worth the increased drowsiness and dizziness that followed, and the increased risk of road accidents and falls.

When should drugs be used for anxiety?
None of the drugs listed for anxiety are suitable for long-term use. Because there is a serious risk that dependency will develop, they should be used only for severe anxiety which is seriously affecting someone’s ability to live a normal life. They should not be taken for more than four weeks, and preferably should not be taken every day. In many cases, anxiety states are appropriately treated with antidepressants which may be taken continuously, for longer periods (see below).

When might sleeping pills be helpful?
Sleeping pills can be helpful for short-term sleeping problems when the cause of the problem is understood: often, short-term sleeping difficulties are related to an emotional problem such as bereavement, or to serious illness. Sleeping pills, whether benzodiazepines or other types, should not be used for more than three weeks, and preferably for no more than a week. It’s also best not to take them every night.

Sleeping pills rarely help long-term sleep problems. Instead, doctors should investigate and treat the underlying problems. Sleeping pills may be used to try and break a bad sleep habit, but other techniques, such as cognitive behaviour therapy (CBT), have been found to be more effective for some people. In some instances, your doctor may be able to refer you to a specialist sleep laboratory, which can assess your insomnia and sleep patterns. (See Mind’s booklet, How to cope with sleep problems, for more information.)

Guidance by the National Institute for Health and Clinical Excellence (NICE), issued in 2004 (see Useful websites), reinforces the message that sleeping drugs should only be prescribed for severe insomnia and for short periods of time, and only after considering other forms of treatment, including CBT. (See Mind’s booklet Making sense of cognitive behaviour therapy (CBT).

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The benzodiazepines

Benzodiazepines are minor tranquillisers, and therefore sedatives, and some of them are used to treat anxiety and sleeping problems. They are also widely used in alcohol withdrawal programmes. (They also have other uses, not covered in this booklet.)

Benzodiazepines increase the effect of a brain chemical called GABA (gamma amino butyric acid). GABA reduces brain activity in the areas of the brain, responsible for rational thought, memory, the emotions, and essential functions, such as breathing. Therefore benzodiazepines are very effective for treating anxiety, as well as acting as sedatives or sleeping pills. However, their widespread action is also responsible for other unwelcome effects. They may also cease to be effective after about four months, as the brain gets used to having higher levels of GABA.

When and how should benzodiazepines be used?

Because of the risk of people becoming dependent on these drugs, and finding it difficult to withdraw from them, benzodiazepines should be used only for the short-term treatment of severe anxiety or severe insomnia. They are not for long-term use.

According to the British National Formulary (BNF):

• Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
• The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable.
• Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or extremely distressing.

In addition, a report by the Royal College of Psychiatrists suggests that the drugs should not be prescribed regularly for longer than one month and, ideally, should be taken only as required and with a gap every few days. Treatment should always be at the lowest possible dose, for the shortest possible time. The maximum treatment period includes the time for withdrawal.

The best way to use benzodiazepines, whether for acute anxiety or for severe sleeping problems, is as a one-off dose for one occasion, and not as continuous treatment; that way they are likely to be most effective, and you are very unlikely to become dependent on them.

Although benzodiazepines are effective in treating anxiety states, it’s clear that there are situations when their use is not justified. In bereavement, for example, tranquillisers may prevent people from grieving properly.

Children
None of these drugs is recommended for children, except in rare cases of acute anxiety or insomnia caused by fear or sleep-walking, when diazepam (Valium) may be used.

Older people
The doses should be reduced in older people.

Medical conditions
Use benzodiazepines with caution if you have any of the following conditions: respiratory disease (chest and lung problems); muscle weakness (especially a condition called myasthaenia gravis); a history of alcohol or drug abuse; marked personality disorder (a psychiatric diagnosis).

The dose should be reduced for those with liver or kidney problems or porphyria (a rare, inherited illness).

You should not take them at all if you have severe respiratory disease, sleep apnoea (breathing problems during sleep), or severe liver disease. They should not be used if you have a long-lasting psychosis or, on their own, if you are depressed.

During pregnancy and breastfeeding
Avoid benzodiazepines during pregnancy and while breastfeeding. Benzodiazepines used at the end of pregnancy cause drowsiness in the newborn baby, floppy muscles, breathing problems, hypothermia (low body temperature), and withdrawal symptoms that include abnormal sleeping patterns, high-pitched crying, tremor, vomiting and diarrhoea. Some research suggests that the use of benzodiazepines during pregnancy may be associated with long-term problems in children, such as dyslexia, dyspraxia (a movement disorder) and attention hyperactivity deficit disorder (ADHD). There may be physical problems, including cleft palate, urinary tract abnormalities, and heart and stomach abnormalities.

Breastfeeding your baby while taking benzodiazepines is not a good idea because the drug comes through the breast milk.

Using benzodiazepines with antipsychotics
Benzodiazepines are often used together with antipsychotic drugs to treat schizophrenia, or similar conditions. They may be prescribed, short-term, to help with over-excitement, agitation and severe psychotic disturbance, to aid rapid tranquillisation. It’s better than giving a high dose of antipsychotic drugs, which have a risk of severe side effects.

Using benzodiazepines with other drugs
Benzodiazepines may interact with other drugs and change their effects, or make either drug less effective, or cause additional side effects; for example, taking tranquillisers with medication that already makes you sleepy will increase the sedative effect. If your doctor or psychiatrist suggests prescribing one of these drugs for you, you should make sure they know about any other medication you are taking, including over-the-counter (non-prescription) remedies and herbal remedies. Alcohol increases the sedative effect of these drugs.

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What are the different types of benzodiazepines?

Short-acting and long-acting
The main difference between the different benzodiazepines is the length of time the drugs are active in the body. There are basically two types: short-acting drugs, which have a short half-life; and long-acting drugs, which have a long half-life. The half-life is the time it takes for the amount of the drug in the body to be reduced by half.

The shorter the half-life, the faster the drug will be eliminated from your system, and so the body has less time to adapt to the loss of the drug: because of this, there is a greater risk of withdrawal symptoms. The longer the half-life, the more slowly the drug will be eliminated from the body, and the more likely you are to experience a hangover effect after taking them.

The actual rate at which drugs are eliminated from the body will vary from individual to individual. Some people absorb and dispose of substances more quickly than others, and this process slows down as people get older. Drug levels therefore tend to build up in older people, who should be given lower doses of most drugs, as a rule.

Also, generally speaking, those that are short-acting are used as sleeping pills, and those that are long-acting are used for anxiety; but the different types are not clear-cut, and drugs prescribed for anxiety will help you sleep if taken at night (for example, diazepam [Valium]), while sleeping pills will calm you if taken during the day.

The different benzodiazepines
Below is a table providing information about the different benzodiazepines usually prescribed for anxiety and to aid sleep.

It’s important to note that, usually, the dose should be halved in older people.

Benzodiazepines are usually only available on the NHS under their generic (general) name, with the exception of diazepam, which is also available under its trade name/s (given by the drug company). The trade names of the drugs are included, in brackets, after the generic name.

Of the sleeping pills, nitrazepam and flurazepam are relatively long-acting and may give a hangover effect the next day. Loprazolam, lormetazepam, and temazepam are all short-acting and produce little or no hangover. However, they are more likely to produce withdrawal symptoms. Benzodiazepines that are normally used for anxiety, such as diazepam (Valium), may also be used as sleeping pills.

Note: flunitrazepam (Rohypnol) and clorazepate (Tranxene) have been taken of the market in the UK, although they may still be available through unregulated sources.

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What are the possible side effects?

All drugs have side effects, although some people are more vulnerable than others. The most common side effects of the benzodiazepines are drowsiness, light-headedness, confusion, unsteadiness (especially in older people, for whom it may lead to falls and fractures), memory problems and muscle weakness. In some people, they may increase hostility, aggression or anxiety, instead of doing the opposite.

Less common side effects are headaches, vertigo (dizziness), low blood pressure, changes in saliva production, digestive disturbances, sight problems (such as double vision), problems speaking clearly, tremor, changes in sexual desire, incontinence (loss of bladder control) and difficulty urinating. Blood disorders and jaundice have also been reported.

These drugs may impair judgement and slow down your reaction time, which affects your ability to drive and to operate machinery. The hangover effect of a night-time dose may affect your driving the following day. If they are taken with alcohol, the impact of the drink is increased.

If these drugs are taken for more than a short time, people may find it more difficult to concentrate, and begin to lose confidence in themselves and their abilities. They may feel dulled, slow, isolated, unreal and unable to respond emotionally to pleasure or pain. They may develop weight problems, and feel irritable and impatient. The drugs can also be addictive.

Dependence or addiction to benzodiazepines

Dependence is a combination of psychological and physical need for the drug. It ranges from mild psychological dependence, or nervousness about stopping a drug, to severe withdrawal symptoms if the drug is reduced or stopped.

You would probably need to take benzodiazepines regularly, for at least a fortnight, for dependence to develop; although taking sleeping pills for as little as three or four nights can be habit-forming. The longer you remain on the drugs, the greater the risk of physical dependence. You are also likely to become psychologically dependent; in other words, to feel very unsure about how you will manage without them. It’s therefore important to reduce the drugs very gradually, in most cases.

People on benzodiazepines for more than a short period of time may become tolerant and experience withdrawal, even before reducing or coming off them, as the drugs lose their effectiveness. Strictly speaking, this means you need more and more of the drug to achieve the desired effect; but it’s rare for people on these drugs to increase their own dosage, unless they are already abusing alcohol or other drugs.

What are the withdrawal symptoms?

It’s important to recognise that individual responses to drugs differ, and you may not experience all the symptoms listed below. Some of them resemble the original complaint, so doctors may be tempted to continue prescribing the drug.

Symptoms may include: increased anxiety and depression, insomnia, nightmares, restlessness and inability to concentrate, panic attacks and agoraphobia (fear of crowded places), cravings for the tablets, loss of interest in sex, loss of appetite and of body weight, muscle tension, tight chest, palpitations, sweating, trembling or shaking, dizziness, headaches, feeling sick, blurred vision, sore eyes, increased sensitivity to light, noise, touch and smell, tinnitus (ringing in the ears), sore tongue and metallic taste, face and neck pain, tingling in the hands and feet, abdominal cramps, unsteady legs.

Severe withdrawal symptoms can include: muscle twitching, burning sensations in the skin, severe depression, hallucinations, paranoia and delusions (baseless fears and beliefs), confusion, memory loss, fits, depersonalisation (feeling strange in familiar surroundings), derealisation (feeling out of touch with reality). (It has been suggested that symptoms of depersonalisation and derealisation are defence mechanisms, which reduce the body’s reactions to stress by slowing down the responses.)

If you withdraw from benzodiazepines abruptly, it may cause: confusion; psychosis (symptoms such as seeing or hearing things others don't); fits; rapid heartbeat; a condition resembling delirium tremens (caused by alcohol withdrawal), which can trigger a rapid heartbeat, sweating, high blood pressure, tremors, hallucinations and agitated behaviour.

Withdrawal symptoms may develop at any time up to three weeks after stopping a long-acting benzodiazepine, but may occur within a few hours of stopping a short-acting one. Short-acting benzodiazepines (which are most likely to be taken as sleeping pills) can be particularly difficult to come off if you have been taking them for a long time, and it’s recommended that people should switch to diazepam, which has the longest half-life, at an equivalent dose, at the start of their withdrawal.

How long symptoms last varies. Some may continue for weeks or months. Experiences and reactions will differ, but if you have been relying on benzodiazepines for many years, not only is it likely take a long time to withdraw from them completely, but you will need to re-learn normal coping skills for dealing with tension and stress. This can take some time, and would probably depend on what kind of support systems you have. For more information on drug withdrawal, see Mind’s booklet, Making sense of coming off psychiatric drugs. Also see above for details on how to report withdrawal symptoms.

Antidepressants
Many people become depressed after coming off tranquillisers, and you may be offered antidepressants. A recent Dutch study concluded that serotonin specific re-uptake inhibitor (SSRI) antidepressants were of limited use in treating depression in these circumstances. Because of this, and the fact that antidepressants also bring the risk of side effects and withdrawal problems, you need to consider this option carefully.

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Drugs for anxiety only

What other drugs can be used for anxiety?

Buspirone (Buspar)
This can be used to treat anxiety, but is for short-term use only. It does not help with the symptoms of benzodiazepine withdrawal.

Cautions: people with liver or kidney problems should use this with caution. Anyone who is pregnant, breastfeeding, who has epilepsy, or severe liver or kidney problems should not use it. It may affect your ability to drive or perform other skilled tasks and can also increase the effects of drinking alcohol.

Side effects: most common: feeling sick, dizziness, headache, nervousness, light-headedness, excitement. Less common: rapid heartbeat, palpitations, chest pain, sweating, dry mouth, drowsiness, fatigue, confusion, fits.

Dose: 15–30mg per day (5mg three times per day, increased, as necessary, every two to three days); maximum 45mg per day. It is not suitable for children. Form: tablets

Beta-blockers
Beta-blockers, such as propranolol, are sometimes used to treat the physical symptoms of anxiety such as rapid heart beat, and may also be useful for relieving some of the symptoms of withdrawal, such as palpitations and tremor. These are not psychiatric drugs and don’t produce psychological symptoms; however, they may produce their own adverse effects, such as sleep problems and nightmares. There’s no problem of dependence or withdrawal symptoms but, because of their effects on the heart and blood pressure, withdrawal should be done gradually, and through slowly reducing the dose.

Meprobamate
Meprobamate is licensed for short-term use in anxiety. The BNF says: ‘Older drugs such as meprobamate and barbiturates are not recommended – they have more side-effects and interactions than benzodiazepines, and are much more dangerous in overdosage.’

Cautions: it should be used with caution, in people who have respiratory disease, muscle weakness, epilepsy, a history of drug or alcohol abuse, marked personality disorder, liver or kidney disease, in older people, and in pregnancy. It should not be used for people with severe respiratory disease or porphyria, or while breastfeeding.

It’s not suitable for children.

Side effects: similar to those of the benzodiazepines, but more common. Drowsiness, digestive disturbances, low blood pressure, pins and needles, weakness, headaches, excitement and visual disturbance. Rarely: blood disorders and rashes.

Dose: 400mg, three to four times per day. Older people should halve the dose. Form: tablets

Antidepressants
Some forms of anxiety, such as obsessive-compulsive disorder, panic disorder and some phobias, may be treated with SSRI antidepressants. These may be prescribed for much longer periods than other drugs, but unfortunately they have their own withdrawal problems, and should be withdrawn slowly in the same way as benzodiazepines (see above and also Making sense of coming off psychiatric drugs ). Another disadvantage of antidepressants is that their possible side effects include anxiety and sleep disturbances. SSRIs have been associated with suicide and violent episodes in some people. (See Making sense of antidepressants.)

Antipsychotics
Antipsychotics are sometimes used in low doses for severe anxiety, because of their sedative action, but long-term use should be avoided. (See Making sense of antipsychotics (major tranquillisers).)

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What else can I do to tackle my anxiety?

When faced with a threatening situation, the body automatically gears itself up to fight or to run away (the ‘fight or flight’ reflex). The body reacts this way, even when the danger is not a physical threat. As the muscles tense, you need more oxygen, so breathing becomes faster and deeper, or comes in gasps. The heart beats faster to send the blood to where it’s needed and away from other organs. Digestion slows down and the mouth becomes dry. Sometimes, this can lead to a panic attack. People experiencing panic attacks may think they are having a heart attack, dying, or going mad. (See Mind’s booklets Understanding anxiety, and How to cope with panic attacks.)

Breathing techniques and relaxation
You can learn special breathing techniques to promote calmness or use muscle relaxation exercises to reduce levels of anxiety. You can also use your imagination, in a positive way, to create mental images and situations that give you a sense of wellbeing and to ‘transport’ you to a place, that for you, symbolises peace and relaxation; for example, a meadow or a beach. You can find more details of these techniques in the Mind guide to relaxation.

Talking treatments
You can ask your GP about counselling or other therapies such as CBT, which can help you to deal with the problems underlying and surrounding your anxiety. The treatment works by providing an opportunity for you to talk in a way that assists you to understand yourself better. It can then help you to work out a more positive and constructive way of living. The organisations listed under Useful organisations can provide details of counsellors and other therapists. Some will operate a sliding scale of fees, which takes into account people’s financial situation. (See, also, Understanding talking treatments.)

Complementary and alternative therapies
Complementary and alternative therapies have proved to be particularly helpful when people are experiencing stress-related symptoms, anxiety and depression. They can help people relax and feel better. Therapists emphasise the connection between mind and body, and are not concerned with merely treating symptoms.

There are many different therapies, including homeopathy, herbal medicine, acupuncture, aromatherapy, reflexology, meditation, and various types of massage. (See the Mind guide to… series of booklets.) Therapies using art, music, drama, dance or creative writing may also prove invaluable. (See Mind’s factsheet Arts therapies.)

Exercise
Exercise, such as walking and swimming, can be helpful. It helps you to develop better breathing techniques, and also encourages the body to produce endorphins. These are natural morphine-like chemicals, which help you cope with shock, pain and stress. (See the Mind guide to physical activity.)

Diet
Caffeine, alcohol and smoking can all contribute to panic attacks, and should be avoided. Healthy eating, on the other hand, can have the opposite effect. Some of the symptoms of withdrawal are similar to the effects of low blood sugar; therefore it can help to avoid foods with a high sugar content, which can cause wide fluctuations in blood sugar. Instead, eat more complex carbohydrates, such as wholemeal bread, pasta, fruit and vegetables.

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Drugs for sleeping problems only

The ‘Z’ drugs: zolpidem, zopiclone and zaleplon

Zolpidem tartrate (Stilnoct), zopiclone (Zimovane) and zaleplon (Sonata) were introduced more recently than the benzodiazepines. They are a bit different from benzodiazepines and were designed to try and get over some of the problems associated with the older drugs; but they act in the same way. Problems of dependence and withdrawal are just as likely to occur with these ‘hypnotic’ drugs, and guidelines for use of all of them say that they should be given at the lowest effective dose, for the shortest possible time, and they should be withdrawn gradually. They are short-acting and have little or no hangover effect.

NICE (National Institute for Health and Clinical Excellence) has made the following recommendations about the use of zaleplon, zolpidem and zopiclone to treat insomnia.

• Doctors should consider using non-medicine treatments, and then, if they think that a hypnotic medicine is the appropriate way to treat severe insomnia that is interfering with normal daily life, they should prescribe one for only short periods of time and strictly according to the licence for the drug.
• Because there is no firm evidence of differences in the effects of zaleplon, zolpidem, zopiclone and the shorter-acting benzodiazepines, NICE recommends that doctors should prescribe the cheapest drug, taking into account the daily dose required and the cost for each dose.
• Treatment should only be changed from one of these hypnotics to another if side effects occur that are directly related to the medicine.
• If treatment with one of these hypnotic medicines does not work, the doctor should not prescribe one of the others.

The British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders, consider that the Z drugs are preferable to benzodiazepines because they are more likely to be free of significant hangover effects the next day.

These drugs should not be given to people with sleep-related breathing problems (obstructive sleep apnoea), neuromuscular weakness, or during pregnancy or breast-feeding. The same cautions apply as for the benzodiazepines (see above).

Zolpidem (Stilnoct)
Side effects: diarrhoea, feeling or being sick, dizziness, headache, daytime drowsiness, weakness, memory problems, dependence, nightmares, restlessness at night, depression, reduced alertness, confusion, gait disturbances or unsteadiness, falls, double vision, upset stomach, changes in libido, skin rashes, and paradoxical excitement or hostility.

Dose: for a maximum of 4 weeks. 10mg at bedtime. Older people 5mg. Not suitable for children. Form: tablets.

Zopiclone (Zimovane)
Side effects: bitter or metallic after-taste, mild stomach upset (including feeling or being sick), dry mouth, dizziness, headache, drowsiness. More rarely: irritability, aggressiveness, confusion, depression, difficulty remembering new information, hallucinations, nightmares, skin rashes, light-headedness, and loss of coordination.

Dose: for a maximum of 4 weeks. 7.5mg at bedtime. Older people 3.75mg. Not suitable for children. Form: tablets.

Zaleplon (Sonata)
Zaleplon appears to have less hangover effect than other sleeping pills, but is also less effective in keeping people asleep. It may be helpful for people who have difficulty falling asleep, but will be less helpful for people who wake frequently. A study of zaleplon in older people showed that they got to sleep more quickly and stayed asleep for longer after zaleplon than after a placebo (dummy pill), and there seemed to be no significant hangover effects next day.

Side effects: loss of memory, tingling sensations, drowsiness, painful periods, loss of energy. Less commonly: feeling sick, loss of appetite, feeling weak, loss of coordination, confusion, loss of concentration, depression, feeling detached from things, dizziness, hallucinations, disturbances of smell, hearing, speech and vision, sensitivity to light, and paradoxical excitement or hostility (discontinue the drug if this occurs).

Dose: for a maximum of 2 weeks. 10mg at bedtime, or after going to bed if difficulty falling asleep. Older people 5mg. Not suitable for children. Form: tablets

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Chloral hydrate and related drugs

The drugs in this group are chloral hydrate (Welldorm), triclofos sodium and clomethiazole (formerly spelt chlormethiazole). These used to be given to children, but nowadays giving children sleeping drugs is not recommended. Nor is there any convincing evidence and that these drugs are particularly useful in older people and so they are not actually used very often as sleeping pills any more.

They should be used with caution for people who have a history of drug or alcohol abuse, and marked personality disorder. Contact with the skin should be avoided.

Chloral hydrate and triclofos sodium
Side effects: feeling or being sick, bloated stomach and wind, feeling unwell, unsteadiness, confusion, rashes, headache, light-headedness, ketonuria, excitement, nightmares, delirium (especially on sudden withdrawal), dependence on prolonged use. Triclofos causes fewer gastrointestinal disturbances than chloral hydrate.

Dose: depends on preparation used; liquid versions of chloral hydrate should be freshly mixed. Form: oral solution, tablets.

Clomethiazole (chlormethiazole, Heminevrin)
This should be prescribed only for older people (and only for the short term), and for very short-term use in younger people who are going through alcohol withdrawal. Regular use is undesirable and likely to cause dependence.

Cautions: it should not be used in alcoholic patients who continue to drink. It should be used with caution in people with heart or chest diseases (confusion may develop caused by insufficient oxygen), history of drugs abuse, personality disorders, liver or kidney disease. It is not suitable for children.

Side effects: nasal congestion and irritation, eye irritation, and headache. More rarely: excitement, confusion, dependence, stomach upsets, rashes, severe allergic reaction and alterations in liver function.

Dose: 1-2 capsules or 5-10ml syrup at bedtime. Form: capsules, sugar-free syrup.

Barbiturates
Barbiturates were used as sedatives before benzodiazepines became available. They are rarely prescribed now. The BNF (British National Formulary) says, ‘the intermediate-acting barbiturates have a place only in the treatment of severe intractable insomnia in patients already taking barbiturates; they should be avoided in the elderly’, and that the use of the long-acting barbiturate pentobarbital, as a sedative, is unjustified.

Antihistamines
Two antihistamines, diphenhydramine (Dreemon, Medinex, Nightcalm, Nytol) and promethazine (Phenergan, Sominex) are available over the counter without a prescription, to treat insomnia. Antihistamines are primarily used for treating allergic reactions and conditions such as hay fever. They can be used for short-term sleeping problems, because they cause drowsiness, which is their main side effect. Diphenhydramine is also available as Panadol Night and Medised for Children, combined with paracetamol, to treat temporary insomnia with night-time pain.

These drugs are long-acting and so often leave a hangover the following day. They may be slow to act, and their sedative effect may diminish after a few days.

Cautions: they should be used with caution for men with an enlarged prostate, people with problems urinating (urinary retention), glaucoma (an eye disease), liver disease, epilepsy and porphyria (a rare, inherited problem). They should not be used during pregnancy or while breastfeeding. If you are in any doubt about whether they are suitable for you, or if you are taking any other medication, including herbal remedies, you should discuss this with the pharmacist before you buy them.

Side effects: dizziness, restlessness, headaches, nightmares, tiredness and disorientation. Occasionally, and especially in older people: blurred vision, dry mouth, urinary retention, confusion, and excitement (also, especially in children). More rarely: loss of appetite, stomach discomfort, palpitations, low blood pressure, disturbances of heart rhythm, shaking, muscle spasms, tic-like movements, blood disorders, and sensitivity to sunlight.

Diphenhydramine
Dose: 50mg (2 tablets) 20 minutes before going to bed (Medised for Children: see patient information leaflet for age-appropriate dosage). Form: tablets, oral liquid.

Promethazine
Dose: 25mg at bedtime increased to 50mg if necessary. Not recommended for children under 2 years old; see patient information leaflet for age-appropriate dosage. Form: tablets, oral liquid.

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How can I improve my sleep without drugs?

There are some simple steps you can take to begin with:

• Make sure your bed and mattress are comfortable.
• Think about whether the level of light suits you.
• Make sure that you are not going to be disturbed by noise. Some people may find ear-plugs helpful.
• Go to bed only when you are feeling tired. If you don’t sleep within about 20 minutes, get up and relax in another room for a while before going back to bed.
• Don’t read or watch television in bed. These activities will only encourage you to stay awake; but some people may find that a radio on quietly for a short time will take their mind off intrusive thoughts which are keeping them awake.
• Avoid coffee, tea, and other caffeine-containing drinks in the evening. A herb tea such as valerian or camomile, or a hot, milky drink may help you to sleep.
• Some foods are known to make you sleepy; including lettuce, pumpkin seeds, turkey, nuts, oats. Avoid sugary foods at night.
• Don’t eat a large meal too late in the day: eating gives you an energy boost, which may keep you awake.
• Get enough exercise during the day; fit people sleep better.
• Try to relax before you go to bed, so that you are not preoccupied with daytime concerns. Yoga and meditation could prove helpful; a bath is usually relaxing too.
• Avoid alcohol. Although alcohol is sedating and may help you get to sleep initially, it interferes with sleep later on in the night. Because it’s a diuretic (increasing urine production) it may cause you to wake up to use the toilet or because you are thirsty. After long-term use, it disturbs sleep patterns and causes insomnia.
• A herbal remedy such as valerian may help.
• Some people are helped by lavender, or a hop pillow.

There are many possible causes for sleeping difficulties – including stress, ill health, old age or emotional difficulties – and there are various ways of tackling them. These include changes to lifestyle, holistic approaches, such as homeopathy or herbal remedies, or talking treatments, such as counselling or CBT. Information about sleep problems and ways of improving sleep are included in Mind’s booklet, How to cope with sleep problems.

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References

Association of road-traffic accidents with benzodiazepine use F. Barbone et al (The Lancet 352, 1331, October 24 1998)
Benzodiazepine Equivalence Table (June 2001) (www.benzo.org.uk/bzequiv.htm)
Benzodiazepines: how they work and how to withdraw (The Ashton Manual) C. H. Ashton (University of Newcastle 2001)
Benzodiazepines: risks, benefits or dependence: a re-evaluation (The Royal College of Psychiatrists Council Report CR59 January 1997)
Benzodiazepines: the still unfinished story Professor C. H. Ashton’s speech to the Beat the Benzos Campaign Launch Conference, Croydon (November 2000)
British National Formulary 54 (British Medical Association and Royal Pharmaceutical Society of Great Britain 2007)
‘Chronic benzodiazepine use in general practice patients with depression: an evaluation of controlled treatment and taper-off: report on behalf of the Dutch Chronic Benzodiazepine Working Group’ F. G. Zitman, J. E. Couvée (British Journal of Psychiatry 2001, 178, 317-324)
‘Cut down on tranquilliser prescriptions, GPs warned’, The Guardian, 11 February 2004.
Meta-analysis of benzodiazepine use in the treatment of insomnia A. M. Holbrook, R. Crowther, A. Lotter et al (Evidence-Based Mental Health 3, 81, August 2000)
New drug evaluation: zaleplon (NHS Northern and Yorkshire Regional Drug and Therapeutics Centre 2000)
New product evaluation: zaleplon (Sonata) (Trent Drug Information Services 2000)
Prescribing guidelines (5th ed) M. Dunitz (The Bethlem and Maudsley NHS Trust 1999)
Prescription cost analysis England 2006, The Information Centre, 2007.
Psychotropic drug directory S. Bazire (Quay Books 1999)
Short-term zaleplon use effective in older patients with chronic insomnia J. K. Walsh et al (Clinical Drug Investigations 20, 143-149, 2000)
Reasons for a diazepam (Valium) taper Professor C. H. Ashton (University of Newcastle April 2001) (web: htttp://members/dencity.com/ashtonpapers/diazepam.htm)
‘Review: benzodiazepines increase sleep duration but also lead to adverse effects in adults with insomnia’ T. Furukawa (Evidence-Based Mental Health 2000, 3, 81)
Zaleplon, zolpidem and zopiclone for the management of insomnia: technology appraisal, NICE, 2004.

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Useful organisations

Battle Against Tranquillisers
PO Box 658, Bristol BS99 1XP
tel. 0117 966 3629
web: www.bataid.org
Helps people who take benzodiazepine tranquillisers or sleeping pills to withdraw from them as comfortably as possible. Telephone helpline. Carers support

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 01254 875 277
web: www.babcp.co.uk
Can provide details of accredited therapists. Full directory of psychotherapists available online

British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252 minicom: 0870 443 5162
web: www.bacp.co.uk
See website for details of local practitioners

The British Psychological Society
tel. 0116 254 9568
web: www.bps.org.uk
Publishes a directory of chartered psychologists across the UK

First Steps to Freedom
PO Box 476, Newquay TR7 1WQ
helpline: 0845 120 2916
web: www.first-steps.org
Charity helping those with anxiety disorders

The Institute for Complementary Medicine (ICM)
ICM Unit 25, Tavern Quay Business Centre, Sweden Gate, London SE16 7TX
tel. 020 7231 5855
web: www.i-c-m.org.uk  

The Medicines and Healthcare products Regulatory Agency
tel. 020 7084 2000
web: www.mhra.gov.uk
See the ‘Safety information’ section of their website, for reporting side effects and withdrawal problems to the MHRA, and see the ‘Committees’ section for the Commission on Human Medicines.

National Institute of Medical Herbalists (NIMH)
Elm House, 54 Mary Arches Street, Exeter EX4 3BA
tel. 01392 426 022
web: www.nimh.org.uk

Rethink Severe Mental Illness (formerly NSF)
tel. 0845 456 0455 advice line: 020 8974 6814
web: www.rethink.org
For everyone affected by severe mental illness

Samaritans
Chris, P.O. Box 9090, Stirling, FK8 2SA
helpline: 08457 90 90 90 minicom: 08457 90 91 92
email: jo@samaritans.org
web: www.samaritans.org
24-hour help

Sleep Matters Insomnia Helpline
tel. 020 8994 9874

United Kingdom Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: www.psychotherapy.org.uk
Umbrella organisation for psychotherapy in UK. Has a directory of psychotherapists in local areas

Victims of Tranquillisers
Helpline: 01202 311 689
Help, support and information to those who have suffered medical and legal problems resulting from tranquillisers and other psychoactive drugs.

Useful websites

www.benzo.org.uk
Benzodiazepine addiction, withdrawal and recovery site

www.dh.gov.uk
Department of Health – see their publications section for ‘Medicines use review’

www.foodforthebrain.org
Charity promoting optimum nutrition for mental health

www.insomniacs.co.uk
Advice on insomnia

www.medicines.org.uk/mip.aspx
Medicines Information Project

www.nice.org.uk
For the latest suggested guidance on prescribing treatments and the use of drugs

www.sleeping.org.uk
The British Sleep Society

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Further reading

Coming off psychiatric drugs: successful withdrawal from neuroleptics, antidepressants, lithium, carbamazepine and tranquillisers Peter Lehmann (ed) (Peter Lehmann Publishing 2004)
Drugs used in the treatment of mental health disorders: FAQs (fourth edition) Stephen Bazire (Academic Publishing Services 2004)
How to cope with panic attacks (Mind 2006)
How to cope with sleep problems (Mind 2005)
How to improve your mental wellbeing (Mind 2007)
How to stop worrying (Mind 2006)
Learn to sleep well kit (includes audio CD) Chris Idzikowski (Duncan Baird 2005)
Making sense of antidepressants (Mind 2006)
Making sense of antipsychotics (Mind 2007)
Making sense of cognitive behaviour therapy (Mind 2007)
Making sense of coming off psychiatric drugs (Mind 2005)
Mind troubleshooters: panic attacks (Mind 2007)
Mind troubleshooters: sleep problems (Mind 2007)
Mind troubleshooters: stress (Mind 2006)
The Mind guide to food and mood (Mind 2006)
The Mind guide to managing stress (Mind 2006)
The Mind guide to massage (Mind 2004)
The Mind guide to physical activity (Mind 2006)
The Mind guide to relaxation (Mind 2006)
The Mind guide to yoga (Mind 2004)
Mind rights guide 3: consent to medical treatment (Mind 2007)
Overcoming anxiety Helen Kennerley (Robinson 1997)
Relaxation: exercises and inspirations for wellbeing Dr Sarah Brewer (DBP 2003)
Your drug may be your problem: how and when to stop taking psychiatric medications Peter Breggin and David Cohen (Da Capo Press 2007)
Understanding addiction and dependency (Mind 2007)
Understanding anxiety (Mind 2006)
Understanding bereavement (Mind 2005)
Understanding depression (Mind 2007)
Understanding talking treatments (Mind 2005)
When panic attacks (book and audio CD) Aine Tubridy (Newleaf 2003)

For a catalogue of publications from Mind, send an A4 SAE to:
Mind Publications
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London E15 4BQ
tel. 0844 448 4448
fax: 020 8534 6399
email: publications@mind.org.uk
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This booklet was written by Katherine Darton

First published by Mind 2000. Revised edition © Mind 2008
ISBN 9781903567869
No reproduction without permission