A comprehensive review of insomnia medications: insomnia, early awakening, and easy awakening. Which medications are more suitable for you?

Nowadays, there are not only many kinds of drugs for treating insomnia. But also different drugs focus on different insomnia symptoms. Some people just take diazepam when they can’t sleep, and some even rely on alcohol to help them sleep… Based on my own experience and combined with the consensus of guidelines. In this article we bring a comprehensive review of insomnia medications

Do I have insomnia?

Many people believe that being unable to fall asleep or sleeping well is insomnia. So they seek medical treatment and take medication to improve the condition. However, occasional difficulty falling asleep or restless sleep does not constitute insomnia.

There are four types of insomnia:

Difficulty falling asleep: Having trouble falling asleep and taking a long time to fall asleep

Difficulty maintaining sleep: difficulty falling asleep or sleep being easily interrupted

Early awakening: Sleep duration is shorter than that of the average person. Waking up early and often having difficulty falling asleep again

Not getting enough sleep (not being able to wake up): Even if you get enough sleep at night. You still feel very tired during the day

If you have any of the above symptoms more than 3 times a week. Which affects your daytime daily routine and mood, and the impact lasts for more than 3 months, it constitutes “insomnia”.

Therefore, insomnia or poor sleep caused by periodic stress and anxiety does not constitute insomnia, so there is no need to worry.

Depending on the duration of insomnia, there are two types:

Short-term insomnia: lasts for a few days or weeks, but symptoms do not exceed 3 months, and the cause is simple and identifiable.

Chronic insomnia: occurs at least three times a week and symptoms persist for more than three months, usually with complex and difficult-to-identify causes.

What are the signs and symptoms of insomnia?

Difficulty falling asleep at night, waking up in the middle of the night or too early, feeling restless after waking up, daytime fatigue, sleepiness, irritability, anxiety, difficulty concentrating, memory loss, headaches or tension, gastrointestinal discomfort, and anxiety about sleeping…

When should I see a doctor or take medication?

Insomnia symptoms persist for more than 3 months, or insomnia is severe in a short period of time.

What are the principles for taking anti-insomnia medication? When should it be taken? How long should it be taken? What precautions should be taken?

Currently, there are four major categories of drugs commonly used to treat insomnia in China, namely benzodiazepines (BZDs), new non-benzodiazepines (Non-BZDs), melatonin-like drugs , and antidepressants .

To make it easier for everyone to remember and understand, I have presented the indications, half-lives, dosages, etc. of common drugs in these four categories in tabular form.

It should be noted that the drugs approved for insomnia in China include benzodiazepines (BZDs) and new non-benzodiazepines (Non-BZDs), melatonin-type drugs, antidepressants, etc. They are only approved for the treatment of depression in China, but because they have sedative and hypnotic effects, it is also common for them to be used off-label in cases of anxiety, depression and insomnia.

With so many insomnia medications available, how should I choose? Which medication is right for me?

Anti-insomnia drugs are special because they have both high benefits and high risks. Some are even regulated as psychotropic drugs. Therefore, no matter which type of drug you use, you must know the principles of their use before using them (due to the wide variety of types, the principles of use of BZDs and Non-BZDs are emphasized):

1. For drugs of the same type, those with shorter half-lives are preferred.
2. Take the lowest dose, only 1 tablet a day
3. Take intermittently, 2-4 times a week
4. The total duration of use should not exceed 4 weeks
5. Avoid sudden discontinuation of medication and reduce the dose gradually

(1) If you are suffering from simple insomnia and do not have anxiety or depression:

Non-benzodiazepines (Non-BZDs) are the first choice, which can selectively stimulate the α1 subunit of the γ-aminobutyric acid receptor and exert a hypnotic effect;

Second-choice benzodiazepines (BZDs) are non-selective agonists of γ-aminobutyric acid receptors, with multiple effects including sedation, hypnosis, anxiolysis, anticonvulsant, and muscle relaxant.

Benzodiazepines are known to be prone to drug tolerance and addiction. Because sudden discontinuation can cause rebound insomnia and withdrawal symptoms, they are not the first choice for insomnia. If used, short- to medium-acting medications, such as estazolam, alprazolam, and lorazepam, should be chosen for short-term use.

New non-benzodiazepine drugs, how to choose for different insomnia conditions?

Difficulty falling asleep (time to fall asleep > 30 minutes): Eszopiclone, zopiclone, zaleplon , zolpidem

Difficulty maintaining sleep (≥ 2 awakenings): Eszopiclone, zopiclone, zolpidem

Short total sleep time (<6.5 hours): Eszopiclone, zopiclone

(2) Insomnia patients with anxiety or depression states/symptoms:

It can be combined with antidepressants with sedative and hypnotic effects. Drugs represented by trazodone are suitable for anxious patients with comorbid insomnia. When used in combination with short-acting new non-benzodiazepine drugs, it can improve insomnia and anxiety symptoms.

(3) Traditional Chinese Medicine

Treating insomnia with traditional Chinese medicine requires careful attention to the specific symptoms. Its advantage is that it addresses the entire body, without the addictive drawbacks of chemical medications. Its disadvantage is that it takes longer to take effect, and unlike chemical medications, it doesn’t induce sleepiness immediately, making it more suitable for gradual treatment.

If you have trouble falling asleep, your head plays a movie while you lie in bed, and you recall the day’s events, along with dry mouth and thirst, and sweat easily at night, this is a case of restlessness. Common Chinese patent medicines include Anshen Dingzhi Pills and Baizi Yangxin Pills.

If symptoms include frequent dreams, waking easily, losing temper over trivial matters, and losing control of emotions, this is a case of liver fire rising. Common Chinese patent medicines include Longdan Xiegan Pills and Bailemian Capsules.

If symptoms include short sleep duration, waking up easily at two or three in the morning, and difficulty falling asleep after waking, this is a case of kidney yin deficiency. Common Chinese patent medicines include Anshen Bunao Liquid and Wuling Capsules.

Only by first clarifying the syndrome type and then treating it accordingly can you achieve twice the result with half the effort.

(4) Melatonin food supplements (non-drugs)

Melatonin is a substance in the body that regulates sleep timing. It is secreted by the pineal gland within the thalamus. Melatonin is secreted more at night, promoting sleepiness, and less during the day, promoting wakefulness. Abnormal or decreased melatonin secretion can affect sleep duration. Generally, melatonin is used to alleviate difficulty falling asleep due to jet lag or circadian rhythm disturbances.

The two most frequently asked questions about melatonin are: Is it safe? And is it effective in treating insomnia?

Many people resort to melatonin when they suffer from insomnia. Most commercially available melatonin supplements are in regular foods or health foods, including popular sleep gummies. These are actually melatonin, which is safer than medications. It works by increasing melatonin levels in the body, forcing you to feel sleepy. It’s suitable for those who work shifts or experience jet lag. However, melatonin is a hormone secreted by the human body, and frequent supplementation can suppress normal melatonin levels, leading to a dependence on exogenous melatonin.