Chemical Sleep

This week is 'sleep week' on Mind and Soul - so what do we have to say about pills that help us sleep. Are they right/wrong, safe/unsafe and maybe even unholy/redeemed?

What has the best research evidence?

Interestingly, this is not a tablet - but good old Cognitive Behavioural Therapy. We will get to the chemicals later.

Don't worry - I'm not suggesting that CBT cures everything, but one of the main issues in insomnia is rumination and worrying thoughts going round your head - things that CBT can help with. There is a specially adapted form of CBT for insomnia and good resources exist. There are some examples below. They take the best of sleep self-help (see our other articles this week) and add in some cognitive techniques.

• Sleep-io - a new digital CBT resource free from some NHS areas. www.sleep.io. NHS Scotland is also rolling out a similar free package nationally in the next few months with other NHS areas likely to follow.
• Overcoming Insomnia - a self-help book from the well-respected 'overcoming' series https://amzn.to/2U8j3LC
• A series of self-help worksheets from some international experts in Canada cci.health.wa.gov.au/Resources/Looking-After-Yourself/Sleep

The other important thing to remember is to have a good physical check up. Sleep Apnoea can affect anyone, even people who are not overweight. The insomnia it causes can often be treated by a CPAP machine or similar aid.
 

What are the 'options'

There are many prescription drugs that help with sleep. But let's start off with the main fact -  none of them are lisenced for LONG TERM use. They have lisences for "short-term insomnia" or sometimes no lisence for this use at all (they just have sedative side-effects). So 'options' is probably the wrong word - but these are some of the ones you will see prescribed.

There is also no drug that starts exactly 15 minutes after you take it and lasts the perfect 8 hours. You havae the choice of an initial sleep effect then maybe early waking vs. lasting longer into the night but with a hangover in the morning.

Sedating Antihistamines
Remember the old advice not to operate heavy machinery if you had taken your hay-fever medication? This is because things that act on histamine are sedating as well as antiallergenic. Examples are Promethazine and Chlorpheniramine. The good thing about them is that they are not chemically addictive.

The Z-drugs
These are among the most commonly prescribed for short-term insomnia. Zopiclone, Zolpidem, etc - they are meant (emphasis on 'meant') to be less addictive than benzodiazepines (the next option). They do have addictive properties however.

Diazepam and other 'Benzos'
These became very popular in the 1970s as they were so much safer than the barbiturates they replaced, then very unpopular as people realised how addictive they were. Withdrawal effects can be very nasty. They do have a clear place however, in part while waiting for other treatments to work.

Sedating Antipsychotics
Some antipsychotics, as well as acting on dopamine, act on histamine and so have a sedative effect. Common examples used in low doses for sleep are Quetiapine, Olanzapine and Chlorpromazine. Sleep can be useful if you are in a psychotic relapse and your brain is full of psychotic thoughts - as sleep can be a release.
However, long term, anything that acts on histamine can also cause weight gain. High doses can also make you sleepy and less active in the day. Likewise, we know that long term use of antipsychotics is associated with metabolic problems such as high cholestrol, diabetes and heart conditions.

Sedating Antidepressants
Similar to antispychotics, some antidepressants have sedative side-effects. Examples are the 'tricyclic' group of drugs like Amitriptyline, some older antidepressants like Trazadone and some newer ones like Mirtazipine. The primary use should be for depression but, again, sleep can be a release if you are depressed and lying awake at night with a head full of negative thoughts. However, the sleep is not a natural one and 'hang-over' effects are common due to the longer half-life of these drugs.
There was great excitement a decade or so ago when a new antidepressant called Agomelatine was lisenced - it acts on serotonin (the chemical thought to be important in depression) but also on melatonin (the sleep hormone) and it certainly seemed to give a fairly natural sleep. However, it has later been found to have rare but serious liver side-effects in some people and so is not used until after many other medications have been tried.

Melatonin
This is the natual sleep hormone secreted by the pineal gland during hours of darkness, so putting it in a tablet has been the holy grail of sleep medication makers. There is no doubt it transforms the quality of life for some people, especially in my experience people who have severe Aspergers Syndrome or similar conditions. However, for most people its effect wears off and we need to use it for a few months then slowly withdraw it, hoping that the body's natural melatonin production kicks in. It's UK licensing is complex and changing, so do read the small print for this one.

Should I take them?

There is no right or wrong answer here as it is a very individual thing. Lack of sleep by itself will not kill you and you will sleep to some degree eventually. However, lying awake at night is very unpleasant, as is being tired all day.

• Are they safe - yes, mostly, especially if a doctor is supervising the prescription
• Do they cause a natural sleep - no, the 'sleep architecture' will be abnormal and you will likely wake not feeling refreshed
• Is short term use OK - yes, it can be a chance to develop good routines and 'reset' your body clock
• Are they better than endless mental distress - yes, as long as you follow the above advice

Are they suitable for Christians? I think they are neutral - neither good nor bad. They are artificial,  but maybe they can be 'redeemed' if they help us stay sane, help us live day to day and start us on a journey to finding natural patterns of sleep and mental health.

** Please note, this is intended as an introductory article and one based on common practice in the UK. These medications are used by many GPs and we want you to be informed. However, there is a growing specialty of Sleep Medicine that is finding out more and more. Full overnight sleep-studies are available as well as lots more detail on the medications mentioned above and a growing range of digital and therapy approaches. You GP should be a great help - and the non-tablet resources should be pursued first, but if you suffer from really chronic insonmia, then do ask for a specialist referral.