Insomnia #2: Common Prescription Medications

Although good sleep hygiene is a prerequisite for the treatment of insomnia, many persistent cases of insomnia merit the use of targeted medication treatments. Medication choices should always be discussed with a qualified healthcare practitioner who has training in evidence-based practice. Melatonin is generally a good first choice natural supplement and can be used for all ages but has varying levels of success. Many psychotropic medications used for psychiatric diagnoses have the additional benefit of also improving insomnia.

Trazodone is a serotonin modulator that works well as a sedative. Although technically an antidepressant, it is rarely used for this purpose due to its milder effects on depression but is often used off-label as primary or adjunctive treatment for insomnia. It is generally safe and well-tolerated; however, individual responses vary, and in very rare cases, it can cause priapism (prolonged and sustained erection), which requires emergency treatment. Hydroxyzine is an antihistamine often used off-label for as-needed anxiety or insomnia, but users over 65 should exercise caution due to its anticholinergic effects, especially at higher doses. Daytime use may cause excessive daytime sedation.

Doxepin is a tricyclic antidepressant (TCA) that is also FDA-approved for insomnia at very low doses and is the most sedating and antihistaminergic of the tricyclics. It generally has minimal side effects at sub-therapeutic doses, and more common TCA side effects such as dry mouth, urinary retention, weight gain, constipation, and a higher risk of arrhythmias are dose-dependent and highly unlikely at the doses used for insomnia. Users should closely monitor for excessive next-day sedation. Mirtazapine is an atypical antidepressant known for its sedative properties, particularly at lower, subtherapeutic doses. Despite its strong sedative properties, users should be aware of an increased risk of appetite stimulation, weight gain, restless legs, and orthostatic hypotension. Citalopram tends to be more sedating than most of its selective serotonin reuptake inhibitor (SSRI) counterparts due to antihistaminergic properties and is thus often prescribed for nightly dosing. SSRI medications are first-line antidepressants due to tolerability and milder side effect profiles, yet Citalopram has a higher risk of weight gain compared to most of its counterparts, and doses above 40 mg daily are contraindicated due to an increased risk of QT prolongation (abnormal heart rhythm). Those with preexisting cardiac conditions or risk factors should exercise caution with Citalopram.

Controlled substances such as benzodiazepines, Ambien, and Lunesta should never be prescribed first-line for insomnia due to strong addictive properties and elevated risk of dependence, as well as many other adverse effects including drowsiness, confusion, ataxia, impaired driving ability, reduced coordination, and cognitive impairment. Physicians should avoid prescribing these substances except in extraordinary circumstances, and only after a thorough discussion of benefits versus risks, review of drug-drug contraindications, and long-term effects on patient care. Non-pharmacological options such as cognitive-behavioral therapy for insomnia (CBT-I) should be considered as alternative or adjunctive treatments.