Using Melatonin or Benadryl to Sleep? Read this.

When I started my career in science journalism 17 years ago, I followed the work of a handful of now iconic health writers. One of them was Tara Parker-Pope, Well’s founding editor, who wrote this newsletter for more than a decade. I marveled, and still do, at her ability to unpack complex health topics with ease.

As Tara has moved on to a new opportunity, I am honored to be stepping in for now. Over the coming weeks, I’ll be bringing you science-based advice on a number of issues. If there is anything you’re especially curious about, you can also email me at [email protected]

The first topic I’m tackling is a big one: sleep, or a lack thereof. The stress of the pandemic has left me tossing and turning at bedtime, and if I awaken in the middle of the night, I often start ruminating on Covid-related worries or my to-do list for the next day, unable to nod off again. I’m not the only one: In a 2021 systematic review, researchers reported that 36 percent of people in the U.S. and 12 other countries have experienced sleep problems during the pandemic, and, according to a 2021 report from the American Psychological Association, 32 percent of U.S. adults reported changes in sleeping habits because of pandemic stress.

Like many people with insomnia, I’ve turned to sleep aids. During much of the pandemic, I was taking over-the-counter antihistamines — drugs sold under the brand names Benadryl, Sominex and ZzzQuil. But when I saw my primary-care nurse practitioner last summer, she warned me that these medications aren’t recommended for long-term use and suggested that I switch to melatonin, a hormone that regulates the body’s sleep cycle. I’ve been taking it nightly ever since, with varying degrees of success. (Last night was a bad one. After a middle-of-the-night bathroom trip, I began worrying about the note from my son’s school saying he’d recently been exposed to the coronavirus.) But the world of sleep aids is clearly a confusing one.

The first thing to know is that not all sleep medications are the same. “The myth is, ‘It doesn’t matter which one you choose, they all work the same way, they all do the same thing.’ They don’t,” said Dr. Andrew D. Krystal, a psychiatrist at the University of California, San Francisco, who specializes in sleep disorders. Some drugs, like zaleplon (Sonata), decrease the amount of time it takes to fall asleep, he said; while others, such as suvorexant (Belsomra), block signals in the brain that cause you to wake up. The hormone melatonin, as well as prescription drugs like ramelteon (Rozerem) that act on melatonin receptors, help regulate the body’s internal clock but don’t necessarily help you stay asleep.

The best drug for you will largely depend on what causes your insomnia. “It really is about choosing the right medication for the patient,” said Dr. Aruna S. Rao, a neurologist at Johns Hopkins Medicine. If your problem is that you can’t fall asleep at bedtime, then a drug that prevents you from waking in the middle of the night may not help. If you fall asleep easily but can’t sleep toward the end of the night, then drugs that wear off within a few hours, like zaleplon (Sonata), aren’t going to do you much good, either.

Many people, too, have sleeping problems that won’t be resolved with any sleeping pill. One such condition is sleep apnea, which afflicts 22 million people in the United States and causes frequent wake-ups, said Dr. Grace Pien, a pulmonary, critical care and sleep medicine physician at Johns Hopkins Medicine. Sleep apnea is best managed with a machine that provides continuous positive airway pressure (CPAP), not with medication.

Another issue is that many sleep aids don’t have convincing data behind them. The over-the-counter antihistamines I used to take, which contain diphenhydramine, “were never really systematically studied for their effects on sleep,” Dr. Krystal said. They’re recognized for their allergy benefits but are often used as a sleep aid because they cause drowsiness, he added. The few studies that have been done on diphenhydramine suggest that it doesn’t help much at all: Clinical practice guidelines from the American Academy of Sleep Medicine say the antihistimine’s benefits, in terms of extra sleep, are “below the level of clinically significant improvement.”

Sleep aids can also have side effects, some of them serious. A 2017 study found that, when compared with older adults who did not take sleeping medications, those who took sleep aids of any kind recommended by their doctor were 34 percent more likely to suffer a fall, perhaps because the drugs affected their balance or incited clumsiness. Another study found that people who had recently, for the first time, been prescribed sleep medications such as temazepam, trazodone or zolpidem (Ambien) were 90 percent more likely to be involved in car crashes, and that their increased risk was on par with that of driving drunk. Some research even suggests that the long-term use of hypnotic drugs such as nordazepam, clonazepam (Klonopin), flurazepam (Dalmane) and zolpidem (Ambien) can more than double the risk of dementia.

Some sleeping pills can also cause physical dependence — a condition where people need higher doses over time to get the same effect, or when they stop taking the medication and experience withdrawal symptoms or have even more difficulty than usual falling asleep. According to Dr. Pien, dependence is possible with zolpidem (Ambien), zopiclone (Imovane) and zaleplon (Sonata), and even more likely with benzodiazepine pills like flurazepam (Dalmane), temazepam (Restoril), quazepam (Doral) and triazolam (Halcion). People can also experience a psychological form of dependence with many sleeping pills, Dr. Rao added, making them feel unable to sleep without the medication.

Zolpidem (Ambien), in particular, has earned an unsavory reputation for its bizarre ability to cause people to drive or eat while half asleep. (One woman would find candy wrappers near her bed and Popsicle sticks next to the refrigerator when she woke up.) Zolpidem can also cause next-day drowsiness, especially among women and older adults, whose bodies slowly break down the drug, possibly because they have lower levels of the hormone testosterone, which plays a role in metabolizing the drug. Consequently, recommended doses of zolpidem for people over 65 have always been lower than for younger adults, and in 2013, the Food and Drug Administration began requiring zolpidem manufacturers to lower its recommended doses for women, too. Nevertheless, in 2018, researchers used survey data to show that about two-thirds of women and people over 65 were still taking the higher doses.

The bottom line: Sleep aids can help in the short term, but you need to take the right one for your needs. So instead of randomly choosing one like I did, talk to your primary care physician or a sleep specialist to get a more tailored recommendation, Dr. Pien said. And remember that as with any medication, they do pose risks.

There are also drug-free alternatives that might even work better for you. Cognitive behavioral therapy, which can help people develop better sleeping habits, is widely considered the most effective treatment for chronic insomnia. Even small lifestyle changes can help as well: going to bed at the same time each night, putting electronics away well before bedtime, and not looking at the clock in the middle of the night, Dr. Pien and Dr. Rao said.

Perhaps I don’t need melatonin after all. I do need to stop doomscrolling on my phone right before I go to bed. That might help with my anxiety dreams, too.

Understanding trauma

PTSD entered the Diagnostic and Statistical Manual of Mental Disorders in 1980 as an official diagnosis, in response to symptoms that Vietnam War veterans were exhibiting. Today, people in combat still report high rates of the disorder. As Russia continues to wage war against Ukraine and more citizens enter combat, researchers expect cases of PTSD to emerge in the coming years.

But, as Dani Blum reported this week, civilians are affected by post-traumatic stress, too. The trauma most likely to cause PTSD is rape, with combat trauma a “close second,” Dr. Shaili Jain, the author of “The Unspeakable Mind,” told Dani. That’s why Dr. Jain and other experts say that understanding PTSD is vital.

Read more about why people with PTSD still aren’t being treated:
A Private War: Why PTSD Is Still Overlooked

Do you have motherhood advice to share?

Well is working on a special feature for Mother’s Day, and we want your help. Moms can get lots of unsolicited advice, starting even before a child is born. And once the kid arrives, all bets are off. From feeding an infant to disciplining an unruly teen, people seem to think that everything is up for discussion.

Being on the receiving end can be exhausting. But every so often, you get a gem — actual helpful advice that gets you through the phase or the year or, if you’re really lucky, the whole of parenthood. That’s what we want to hear about now. Is there a nugget of wisdom, a turn of phrase or a parenting hack that you’ve returned to again and again?

Use the form here to share your tips:
What’s the Best Advice You’ve Received About Motherhood?

The Week in Well

Here are some stories you don’t want to miss:

Debra Kamin reported on divorced parents’ disagreements over vaccinating their children.

Gretchen Reynolds investigated whether 30 minutes of daily exercise is enough.

Pilar Guzmán interviewed Susan Cain about her new book, “Bittersweet.”

Tara Parker-Pope answered: Do home Covid tests expire?

And of course, we’ve got the Weekly Health Quiz.

Let’s keep the conversation going. Follow Well on Twitter, or write to me at [email protected]

Stay well!