Is sleep induced by a hypnotic (sleeping pill) as restorative as sleep without medication?

From the Guidelines

Sleep achieved with sleeping pills is generally not considered as restorative as natural sleep. While medications like zolpidem and eszopiclone can help improve sleep outcomes, such as sleep onset latency, total sleep time, and wake after sleep onset, as shown in a clinical practice guideline from the American College of Physicians 1, they often suppress important sleep stages, particularly deep sleep and REM sleep, which are essential for cognitive function, memory consolidation, and emotional processing.

Some key points to consider when evaluating the restorativeness of sleep achieved with sleeping pills include:

• Low-quality evidence showed that both eszopiclone and zolpidem improved global outcomes in the general population, and low- to moderate-quality evidence showed that eszopiclone, zolpidem, and doxepin improved sleep outcomes, such as sleep onset latency, total sleep time, and wake after sleep onset 1.
• Moderate-quality evidence showed that suvorexant, an orexin antagonist, improved treatment response and sleep outcomes in mixed general and adult populations 1.
• However, evidence on harms was limited, and observational studies have shown that hypnotic drugs may be associated with infrequent but serious adverse effects, such as dementia, serious injury, and fractures, as well as daytime impairment, “sleep driving,” behavioral abnormalities, and worsening depression 1.

For better sleep quality, it's preferable to address underlying sleep issues through non-pharmacological methods, such as cognitive behavioral therapy for insomnia (CBT-I), maintaining consistent sleep schedules, creating a comfortable sleep environment, limiting screen time before bed, avoiding caffeine and alcohol in the evening, and regular exercise. If medication is necessary, it's best used short-term (as recommended by the FDA for 4 to 5 weeks) while developing better sleep habits, and patients should not continue using the drugs for extended periods without further evaluation 1.

From the Research

Sleep Quality with and without Sleeping Pills

• The quality of sleep achieved with sleeping pills may not be as restorative as sleep without pills, according to studies on the effects of medication on sleep architecture 2.
• Research suggests that certain antidepressants can improve sleep and return sleep architecture to its restorative function, while others may derange sleep architecture and decrease restorative sleep 2.
• Cognitive-behavioral therapy for insomnia (CBT-i) is a non-pharmacological treatment that can produce results equivalent to sleep medication, with no side effects and a tendency for sleep to continue to improve long past the end of treatment 3, 4.

Comparison of Sleep Quality

• Studies have shown that CBT-i can be an effective treatment for insomnia, with moderate to large effect sizes for the reduction of insomnia severity post-treatment 5.
• The effects of CBT-i on comorbid symptom severity, such as depression and PTSD, have also been found to be significant, with medium to large effects indicating that CBT-i is an effective add-on treatment for improving mental health 5.
• In contrast, the use of sleeping pills may not provide the same level of restorative sleep, and may even have negative effects on sleep architecture and overall health 2.

Mechanisms of CBT-i

• Research has identified changes in dysfunctional beliefs about sleep as a cognitive mediator of insomnia symptom improvement following CBT-i 6.
• The temporal precedence of mediator changes, however, cannot be established, and further studies are needed to fully understand the mechanisms of CBT-i 6.