Sleeping pills for insomnia: Which ones work best?

Lack of sleep can have serious consequences—a higher risk of type 2 diabetes, obesity, heart disease, and other health conditions. It can also raise the risk of falling, particularly among older women, and increase the likelihood of having a car accident if you drive. Insomnia might also leave you feeling anxious, depressed, or irritable. Paying attention, learning, or remembering can become difficult.  

Yet, in an effort to combat the condition, there is concern that sleeping pills are overprescribed. Drugs like Lunesta and Ambien have been heavily advertised both to doctors and consumers, which may have led to excessive and overly casual use.  

At the same time, studies have found that chronic insomnia is undertreated, and that fewer than half of the people who need help actually get it.

Four prescription drugs used to treat insomnia—eszopiclone (Lunesta and generic), ramelteon (Rozerem and generic), zaleplon (Sonata and generic) and zolpidem (Ambien, Ambien CR, Edluar, Zolpimist, and generic)—are effective but not necessarily better than behavioral therapy or older, less expensive drugs for many people who need a sleep aid.  

Older prescription sedatives called benzodiazepines, such as estazolam (generic only), triazolam (Halcion and generic), and temazepam (Restoril and generic), might work just as well as the newer sleeping pills. Nonprescription drugs containing an antihistamine—for example, diphenhydramine (the active ingredient in Benadryl, but also sold as a sleep aid under the brand names Nytol and Sominex and as a generic) or doxylamine (Unisom and generic)—might help if you have suffered insomnia for just a night or two. Antidepressants, particularly trazodone, are also commonly prescribed for insomnia.

All insomnia medicines can cause side effects like daytime sleepiness, dizziness, unsteadiness, and could actually worsen your insomnia. Sleep-walking, sleep-driving, sleep-eating, memory lapses, and hallucinations have also been reported. The risk of developing a dependency on the drugs is also a problem. People who are age 55 or older should be cautious about taking sleeping pills because they are at higher risk of all the side effects from these medicines.

Sleeping pills should generally not be used long-term for chronic insomnia. If you have just one or two nights where you can't fall or stay asleep, it's better to try something else besides medication.

That said, people with persistent, chronic insomnia—three or more nights a week for months—should seek treatment. First to rule out whether your insomnia is due to other sleep disorders, medical conditions you have, or medications you take.

Studies have found that improving your sleep habits and making other changes like doing relaxation training, setting and sticking to consistent bedtimes and wake-up times, regular exercise, quitting smoking, cutting back on caffeine and alcohol, keeping your bedroom quiet and dark, and not watching TV or using computers in bed can relieve insomnia.

If those don’t seem to help and you and your doctor decide a prescription sedative is an option to try, our analysis of the newer drugs led us to recommend generic zolpidem as a Best Buy. This is the less expensive, generic version of the drug Ambien. Seven pills cost $16 to $17, depending on the dose and where you buy it.

Insomnia is defined as having difficulty falling asleep or staying asleep, which can lead to sleepiness and other problems during the daytime. Normal sleep is generally considered getting 7 to 9 hours a night, although this varies from person to person; some might feel fine with as little as 4 hours of sleep while others might need up to 10. Older people may often sleep less, but might nap more during the day.

Insomnia can be mild to severe, and the sleep issues vary from person to person. Some people only have trouble falling asleep, while others fall asleep easily but awake during the night, and still others have trouble both falling asleep and staying asleep. These sleep disturbances can lead to daytime fatigue and feeling irritable and anxious.

Insomnia can range from short-term—a night or two for up to two weeks—to chronic, which is difficulty sleeping several nights a week for at least a month. Some people fall in between and have intermittent bouts of insomnia.

Most of us have experienced short-term insomnia at some point in our lives. It can be caused by a number of things—stress, jet lag, or poor sleep habits. It can last up to a couple of weeks but usually passes in a few days.

Intermittent short-term insomnia is more bothersome. People with this type are prone to bouts of insomnia from time to time. The episodes might last a few days to a few weeks, sometimes triggered by events, or arising spontaneously.

Chronic insomnia—trouble getting to sleep at least three nights a week for at least a month, and usually much longer—is even more serious. If your insomnia has persisted for this long, you should see your doctor for an evaluation. He or she might help you identify an underlying cause, and possibly order blood or other tests such as a sleep study.

Symptoms of insomnia

• Difficulty falling asleep–tossing and turning for an hour or more
• Waking up during the night and not being able to get back to sleep
• Feeling unrefreshed upon waking
• Daytime fatigue, irritability, poor concentration or anxiety

Who is at risk for insomnia?

Insomnia is quite common. Up to 40 percent of adults have difficulty falling or staying asleep within any given year, and up to 15 percent say they have chronic insomnia, according to the National Heart, Lung, and Blood Institute (NHLBI).

Insomnia can affect people of any age, including children. But women are more likely to suffer from it than men. Older people are also more likely to have trouble sleeping. This is usually because they are more likely to have other illnesses (or just aches and pains) that disrupt sleep, or to be taking medicines that make getting a good night’s rest difficult.

African-Americans also face a heightened risk of insomnia, according to the NHLBI. Compared to Caucasians, African-Americans, in general, take longer to fall asleep, don’t sleep as well, and tend to take more naps.

Several other factors are also associated with an increased risk of insomnia. They include:

• High level of stress
• Depression or sudden changes in life that cause significant distress, such as divorce or death of someone close
• Working at night
• Traveling to different time zones
• Illnesses or disorders that interfere with sleep
• A sedentary, inactive lifestyle

If your problems sleeping are because of pain, hot flashes, heartburn, frequent urination, or waking up short of breath, your insomnia might be due to an underlying condition. Asthma, bladder and prostate problems, fibromyalgia, heart failure, gastroesophageal reflux disease (GERD), menopause, and sleep apnea can all interfer with sleep. Other conditions, such as hyperthyroidism and Parkinson and Alzheimer disease, are also associated with sleep disorders. Treating the condition might help relieve your insomnia.

Medications that can interfere with sleep include allergy and cold medicine, beta-blockers, certain pain relievers, steroids, and asthma medicine, such as theophylline. In addition, alcohol, caffeine, and tobacco or other nicotine products can trigger insomnia.

Insomnia sufferers may get relief by treating an underlying illness or stopping a medication that might be causing the insomnia. But don’t stop or switch a medication without talking to your doctor first. Studies have found that improving your sleep habits can also help relieve chronic insomnia.  

Poor sleep habits and how to correct them

Over-the-counter products

Although some people find them helpful in the short-term, nonprescription antihistamines should not be used over a long period for chronic insomnia because they can cause next-day drowsiness, daytime sleepiness, confusion, constipation, dry mouth, and urinary retention.

Is it safe to take over-the-counter sleeping pills like Unisom long term?

Cognitive behavioral therapy

One group of nondrug treatments—collectively known as cognitive behavioral therapy or CBT—has proved to be quite effective in treating insomnia. This involves getting help from a therapist to learn a new set of behaviors regarding sleep. For example, you might be prohibited from watching TV in bed, or be directed to get up at the same time every day. Or you might have your actual time in bed restricted while you “relearn” to associate being in bed with sleep.

You might also learn relaxation techniques and mental tricks to help you get to sleep. Generally, CBT involves three to six one-hour sessions with a trained therapist, plus directions for at-home activities.

Studies have found behavioral therapy to be effective—it helps 70 to 80 percent of people with chronic insomnia—and it appears to be at least as effective as sleeping pills. In some studies, a combination of the two has helped people the most.

For many people, behavioral therapy can provide a long-term solution for insomnia, as opposed to sleeping pills that treat only the symptoms but don’t address the underlying issues. If you see a primary-care doctor or therapist for chronic insomnia and they prescribe pills without mentioning behavioral therapy as an option, you should mention it. If they don’t know anything about it, finding a physician who does. 

Another option for treatment is prescription medications. We evaluate four currently available prescription sleeping pills for our analysis. They are:

Three of the four newer sleeping medications—zolpidem (Ambien and generic), eszopiclone (Lunesta and generic), and zaleplon (Sonata and generic)—work the same way, by affecting a chemical in the brain called gamma-aminobutyric acid, or GABA. The remaining medicine, Rozerem, works differently. It affects the receptor in the brain for the hormone melatonin.

Zolpidem CR contains the same medicine as Ambien but stays active in the body for a longer period. The dissolvable tablet, Edluar, and the oral spray, Zolpimist, also contain the same medication as Ambien, but those are designed to work more quickly.

Two other medications—doxepin (Silenor) tablets and low-dose zolpidem (Intermezzo) dissolvable tablets—are approved by the Food and Drug Administration for treating insomnia. Neither were included in the analysis that forms the basis of our report, so their effectiveness or safety have not been as thoroughly evaluated as the other sleeping pills.

Intermezzo is a low dose of zolpidem, but it has been studied only against a placebo, so it’s unclear how it compares with regular-strength zolpidem. Intermezzo’s side effects are the same as regular-strength zolpidem.

Newer sleeping pills vs. benzodiazepines

We refer to these drugs as new or newer sleeping pills to distinguish them from an older group of sedatives and anti-anxiety drugs called benzodiazepines. The larger class of benzodiazepines—which includes such drugs as alprazolam (Xanax and generic), diazepam (Valium and generic), and lorazepam (Ativan and generic)—are used primarily to treat anxiety. But the FDA has approved some benzodiazepines to treat insomnia. Those include estazolam (generic only), flurazepam (Dalmane and generic), quazepam (Doral), temazepam (Restoril and generic), and triazolam (Halcion and generic).

The newer drugs we examine have been found to be generally as effective as the benzodiazepines approved for treating insomnia. But it’s not clear whether the newer drugs are more effective or cause fewer side effects.

Several studies indicate that benzodiazepines cause more day-after sleepiness and grogginess, and are associated with a higher risk of dependency and rebound insomnia (when the insomnia returns after the person stops taking the medication and might even be worse for a few days). But overall, few studies have directly compared the newer insomnia drugs with benzodiazepines, and many researchers and doctors think it’s unclear whether the newer drugs are more effective or safer.

It’s also important to note that benzodiazepines remain very useful in some circumstances—specifically when treating people who have an anxiety disorder that also causes sleep problems. In this case, a benzodiazepine may in fact be your doctor’s first choice for you. Some people tolerate these medicines well, experience few of the side effects mentioned above, and can use them safely on an intermittent basis.

Trazodone

Other medicines are also used to treat insomnia. Among prescription drugs, one antidepressant in particular, trazodone (generic only) is widely prescribed for insomnia even for people who don’t have depression. Trazodone is available as an inexpensive, generic drug but it is rarely prescribed these days for depression. For short-term use, studies indicate it helps people with depression fall asleep and stay asleep. Unfortunately, there is very little evidence that it is effective in treating insomnia in people who have not been diagnosed with depression. In the one study to test trazodone against a placebo and a newer sleep drug (Ambien), trazodone came out only slightly better than placebo and was not as helpful as Ambien.

Trazodone: Common sleep drug is little-known antidepressant

Some do's and don'ts about sleeping pills

All of the newer drugs are effective in helping people fall asleep faster. In general, they will help you fall asleep in about 30 to 50 minutes (or 8 to 20 minutes faster than a placebo). But that can vary widely, depending mostly on the severity of your insomnia.

A key difference among the drugs is the length of time they remain active in your body. In theory, the shorter-acting sleeping pills—zaleplon (Sonata) and ramelteon (Rozerem)—should be better for getting to sleep, but not for staying asleep. Eszopiclone (Lunesta) is the longest-acting and zolpidem falls in the middle range.

Individual responses to the drugs also vary, with some people having a substantial improvement in how long they sleep without waking and others continuing to wake up during the night. In general, these sleeping medications stay active longer in older people, which increases the risk for side effects. This is why the lowest dosages are recommended for elderly people. You and your doctor’s choice might be based on those factors, matched against your insomnia symptoms, your overall health status, and your age.

But for the average person needing short-term help for insomnia, we have chosen only one of these drugs—zolpidem—as a Best Buy. Zolpidem is the generic version of brand-name Ambien. The generic contains the same active ingredient as the brand-name drug and is much less expensive. At a cost of $16 to $17 for seven pills, depending on dose and strength, zolpidem is less expensive than the other brand-name sleeping pills as well.

Our choice of zolpidem is based not just on this price advantage, but also because the evidence shows it helps people fall asleep and stay asleep, and next day drowsiness is unusual (see the effectiveness table below). Thus, if you are getting a first-time prescription for one of the new sleeping pills, or if you have been taking one, we urge you to talk with your doctor about trying generic zolpidem.

The other forms of zolpidem—sustained-release (Ambien CR), dissolvable tablet (Edluar), and the oral mist spray (Zolpimist)—are more expensive and offer little if any advantage to make the higher cost worth it.

So far, the evidence is weak that Ambien CR is any better than zolpidem. While studies have found it increases sleep duration a bit more when compared with regular zolpidem (Ambien), the difference in the available studies is not that great and there aren’t any head-to-head trials that have directly compared the two. And for people whose main problem is getting to sleep, Ambien CR probably offers no advantage at all.

Edluar and Zolpimist are designed to act more quickly than other forms of zolpidem, but there is very little evidence directly comparing these newer drugs with the other insomnia drugs. Edluar has been shown to help people fall asleep more quickly than regular zolpidem tablets. But it does not appear to offer any other advantages.

One study compared a single dose of Edluar with a single dose of zolpidem in people who were monitored in a sleep laboratory. Those who took Edluar fell asleep about 10 minutes faster than those who took zolpidem. But there was no difference between the groups in how long they stayed asleep, or in how long they thought they had slept. There also was no difference between the groups in reports of next-day effects, such as drowsiness.

No studies have compared Zolpimist with the other insomnia drugs. The FDA’s approval of Zolpimist was based on studies showing that it is bioequivalent to zolpidem—meaning that the drugs are so similar that their effects with regard to efficacy and safety can be expected to be the same.

The effectiveness table below presents some general comparisons of the other drugs, though the numbers come from different studies, making precise comparisons difficult. As you can see, zolpidem (Ambien and generic) and zaleplon (Sonata and generic) tend to act more quickly in the body and thus appear more effective at helping you fall asleep. In one study that directly compared the two drugs in the same group of patients, Sonata was slightly better than zolpidem—by about 17 minutes on average—in bringing sleep about. Other studies, however, have consistently found zolpidem better than Sonata at producing longer duration sleep. Also, people taking zolpidem have reported “better quality” sleep than those taking Sonata.

Regarding zolpidem and sleep duration, there are mixed results. Studies that directly compared zolpidem with a placebo found that the medication did not produce longer sleep. The analysis that forms the basis of our report pooled the results of trials and also found no evidence overall that zolpidem increased sleep duration.

However, three other studies did find longer sleep duration with zolpidem compared with zaleplon and placebo. But these trials were designed to evaluate zaleplon, so it is difficult to conclude from them that zolpidem clearly produces longer sleep duration.

Lunesta acts a bit more slowly in the body and is slightly less effective at helping you get to sleep. While in theory—because of its slower action—Lunesta may be more likely to help you stay asleep, direct comparisons of Lunesta with the other drugs are lacking on this measure. One notable study found Lunesta effective (better than a placebo) and safe for up to six months of use. The other drugs may well produce equal results if six-month studies of them were conducted. But remember, none of these medicines—including Lunesta—ought to be used on a regular basis for that long.

Rozerem is a newer drug and there is less evidence available on its effectiveness. It acts differently in the body than the other drugs and appears, based on the available evidence, to be somewhat less effective than the others in helping people fall asleep.

Side effects

As mentioned, all of the drugs can cause side effects. The three most important are:

• Next-day drowsiness
• Rebound insomnia
• Dependency and abuse

On next-day drowsiness, the evidence is quite clear: Ambien CR and Lunesta both cause more of it than the other drugs. In the few comparison studies to date, fewer people who took zolpidem experienced this side effect.

Rebound insomnia occurred in some people taking zolpidem, Ambien CR, and Lunesta, but not Sonata or Rozerem. But the problem is usually short-term. In studies, it disappeared by the second or third night after the drug was stopped.

It’s also not clear how much of a risk of rebound insomnia zolpidem poses. The studies that indicated zolpidem might cause rebound insomnia were actually focused on evaluating zaleplon, and other studies did not find evidence of rebound insomnia in people who took zolpidem.

All of the newer medicines are less likely to cause dependence and abuse problems than benzodiazepines—and that may be their biggest advantage. However, there have been reports of abuse and dependence with zolpidem. Most have occurred among people who had problems with drug or alcohol dependence in the past. So far, there have been fewer similar reports with the other newer sleep drugs. But that could be because Ambien has been available much longer and is used by millions more people than the other drugs. Ambien first became available in 1992, while the next new sleep drug (Sonata) didn’t come along until 1999.

Notably, because it works differently, Rozerem is not considered to have the potential for abuse and dependence that the other new insomnia medicines have. That could be an advantage for use in treating people who have dependency problems or a history of drug abuse.

All of the newer sleeping pills cause minor side effects at about the same rate. None offers an advantage over the others in this regard. The most common are headaches and dizziness. But only about 2 to 6 percent of people stop using the drugs because of these problems.

Sleep-walking, amnesia, and hallucinations appear to be very rare when any of these medicines are taken as they should be. However, the reports of these problems should be a warning that excessive use and especially excessive doses in the middle of the night can raise the risk of serious problems. Combining sleeping pills with alcohol, even just a drink or two, is not a good idea and raises the risk of side effects.

Age, race, and gender differences

The new insomnia medicines are as effective in older adults as they are in younger people. But they cause more side effects in older people. For that reason, older adults should use a lower dose. In general, the recommended starting dose of all the drugs (except Rozerem) in older adults is half the usual dose. Also, studies have shown that all sleeping drugs, not just the new ones, increase the risk of hip fracture in older people, because they can lead to falls.

Table 3. Common side effects of newer sleeping pills

Recent changes in dosing amounts

The FDA has lowered the starting dose by half for zolpidem, zolpidem extended-release (Ambien CR and generic), and eszopiclone (Lunesta and generic) because levels of the drugs in the body can remain high enough the morning after taking them to impair the ability to drive or carry out other activities requiring mental alertness. To reduce the risk of next-day impairment, the FDA recommends that people use the lowest dose—5 mg for Ambien, Edluar, and generics, 6.25 mg for Ambien CR and generics, and 1 mg for Lunesta and generics.

If the low dose does not relieve your insomnia, ask your doctor if increasing the dose makes sense for your health situation. Although the FDA has not lowered the starting dose for over-the-counter sleeping aids, such as diphenhydramine, it said that those products should not be considered safer than prescription sleeping pills when it comes to next-morning alertness and driving.

When used only for a night or two, the risk of side effects appears to be minimal, with the benefit of the drug outweighing any potential harm. But when you take one of the newer sleeping pills every night or almost every night for months or years, your risk of adverse events, such as a fall or accident, increases. This might be especially true for the elderly.

For the average person needing short-term help for insomnia, we have chosen only one drug—zolpidem—as a Best Buy. Zolpidem is the generic version of brand-name Ambien. The generic contains the same active ingredient as the brand-name drug and is much less expensive. At a cost of $16 to $17 for seven pills, depending on dose and strength, zolpidem is less expensive than the other brand-name sleeping pills as well.

Our choice of zolpidem is based not just on this price advantage, but also because the evidence shows it helps people fall asleep and stay asleep, and next day drowsiness is unusual (see the effectiveness table below). Thus, if you are getting a first-time prescription for one of the new sleeping pills, or if you have been taking one, we urge you to talk with your doctor about trying generic zolpidem.

The other forms of zolpidem—sustained-release (Ambien CR), dissolvable tablet (Edluar), and the oral mist spray (Zolpimist)—are more expensive and offer little if any advantage to make the higher cost worth it.

Our evaluation is primarily based on an independent scientific review of the evidence on the effectiveness, safety, and adverse effects of the newer sleeping pills. A team of physicians and researchers at Oregon Health & Science University Evidence-Based Practice Center conducted the analysis as part of the Drug Effectiveness Review Project, or DERP. DERP is a first-of-its-kind multi-state initiative to evaluate the comparative effectiveness and safety of hundreds of prescription drugs.

A synopsis of DERP’s analysis of the insomnia drugs forms the basis for this report. The synopsis was based on DERP’s analysis as well as a search for recent trials, systematic reviews, and FDA information. A consultant to Consumer Reports Best Buy Drugs is also a member of the Oregon-based research team, which has no financial interest in any pharmaceutical company or product.

The drug costs we cite were obtained from a healthcare information company that tracks the sales of prescription drugs in the U.S. Prices for a drug can vary quite widely, even within a single city or town. All the prices in this report are national averages based on sales of prescription drugs in retail outlets. They reflect the cash price paid for a month’s supply of each drug in March 2014.

Consumer Reports selected the Best Buy using the following criteria. The drug had to:

–Be approved by the FDA for treating insomnia.

–Be as effective as other insomnia medicines.

–Have a safety record equal to or better than other insomnia medicines.

–Have an average price for a 7- and 15-day supply that was not higher than the other insomnia medicines.

The Consumers Reports Best Buy Drugs methodology is described in more detail in the Methods section at CRBestBuyDrugs.org.

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