Why the Best Insomnia Treatment Is Not A Drug Consumer Reports Best Buy Drugs compares the effectiveness and safety of the most common treatments

At-A-Glance Everyone has trouble sleeping from time to time—stressful life events like having to take a test the next day, or dealing with worries about home or work can keep you from falling asleep or staying asleep. Sleeping problems that happen once or twice a month can be annoying, but usually will resolve on their own. But when sleep problems are ongoing and cause you distress—occurring several nights a week for three months or more—it’s time to see your doctor. It could be a more serious matter and may be chronic insomnia (though your doctor may call it “insomnia disorder”). Up to 10 percent of adult Americans suffer from this problem, and it’s not something to be ignored. Besides making you feel lousy, not getting enough sleep over the long term has been associated with other problems: it puts you at a higher risk for type 2 diabetes and heart disease. It can also decrease cognitive function, and lower your productivity at work. Insomnia might also leave you feeling anxious, sad, or irritable, and it’s been linked to a worsening of symptoms for people with depression and anxiety. Getting treatment is important to improving sleep and may help with other health conditions. Frequently, doctors have relied on sleep medications like eszopiclone (Lunesta and generic); ramelteon (Rozerem and generic); zaleplon (Sonata and generic); zolpidem (Ambien, Ambien CR, Edluar, ZolpiMist, and generic); or other drugs like the antidepressant trazodone, to manage insomnia. In fact, previous CR Best Buy Drug reports looked closely at the differences among these medications—how much faster did they help people get to sleep? Which ones helped people sleep longer during the night? The answers to those questions, along with considerations about the safety and side effect profile of each drug and its cost, had guided our earlier reports and selection of a “Best Buy” among these drugs. New Research Changes Our Recommendations But three important changes have since occurred. First, the recognition among clinicians that while sleep drugs might provide some benefit in the short term, their modest benefits may not outweigh their risk over the long term. Our past reports on these treatments have found that the newer sedative medications add only between 8 to 20 minutes of sleep time, and none have been shown to improve how well people feel or perform the next day. And, they can also cause troubling side effects: next-day drowsiness, dizziness, and feeling unsteady—all of which can increase your risk of falls or accidents. Sleeping pills can also cause dependency and even worsen the symptoms of chronic insomnia if taken for long periods. Sleep-walking, memory lapses, and hallucinations are rare, but have been reported with Ambien, as have cases of driving or eating while asleep within a few hours of taking a sleeping pill. Plus, most of these medications have only been tested over short time periods and in highly select patients. So, little is known about their long-term safety and effectiveness, especially in older individuals, those with serious medical conditions, or with less severe sleep problems. Second, the release of a recent systematic review of insomnia treatments—drug treatments, behavioral therapy, and alternative therapies—by the federal Agency for Healthcare Research and Quality (AHRQ)—found strong scientific evidence that shows cognitive behavioral therapy (CBT) for insomnia is a consistently effective way to treat the problem. It works like this: a provider is trained to help teach you better sleep habits, develop regular sleep cycles, and suggest ways to change your behavior, using techniques such as sleep restriction and controlling stimulus, while also working to change the way you think about sleep. The report found CBT to be effective for most adults with chronic insomnia, and safer because there are few, if any, side effects. CBT might also potentially keep insomnia at bay longer than medication—even after the therapy ends. Several medical groups, including the American Academy of Sleep Medicine and the American College of Physicians, have suggested that when chronic insomnia is diagnosed, to try CBT first, instead of sleep medication alone. (Some people may benefit from both, however.) The AHRQ report also evaluated other types of medications—an older kind called benzodiazepines, sedative sleep drugs like zolpidem (Ambien and generic), and several antidepressants that can cause drowsiness as a side effect. The report found good evidence that when used for short periods the sedative drugs are effective at helping people fall asleep and stay asleep a bit longer. Overall, across some 14 studies, from 50 percent to 85 percent of people diagnosed with chronic insomnia, as well as those who have not, get some benefit from the drugs, compared to 19 percent to 48 percent of people who took a placebo instead of the active drug. However, the report found insufficient evidence that the benzodiazepine drugs, when compared to placebos, were helpful in combating insomnia. In addition, few studies adequately assessed the side effects the drugs can cause. The third shift in recent thinking derives from growing evidence that far too many people take sleep medicines for long periods—months or even years—leading to a kind of psychological addiction that can be both medically counterproductive and dangerous. That's why our Best Buy pick isn’t a drug at all.