Sleep is often considered sacred. Still, sleep disorders affect many people. About 40% of the general population experience symptoms of temporary insomnia and between 10 and 20% suffer from chronic insomnia, according to a study published in 2015 in Sleep Medicine and from High Authority for Health (HAS). While there are simple and effective methods, such as having a healthy lifestyle, falling asleep at a set time, exercising daily – but not before bedtime – or even avoiding the consumption of stimulants, they are not always enough. In severe cases, the two main treatments are cognitive behavioral therapy (CBT) and prescription sleeping pills.
The best known are the benzodiazepine hypnotics, such as loprazolam, lormetazepam, estazolam and nitrazepam. The therapeutic effects of these sedatives are attested by meta-analyses that bring together dozens of scientific studies. They allow for a reduction in the time to fall asleep and an increase in total sleep time and could also improve the state of depressed patients suffering from insomnia, although this aspect is still debated within the scientific community.
Risk of addiction and addiction
However, benzodiazepines cause many side effects, including memory problems, decreased alertness or even drowsiness, behavioral problems, and the risk of falling in the elderly. “These molecules are pro-GABA (for gamma-aminobutyric acid), i.e. molecules that globally slow down the brain, non-specifically: They reduce slow, deep, paradoxical sleep and, in high doses, slow down the brain so much that they can cause a coma,” explains Professor Isabelle Arnulf, neurologist and department head at the Pitié-Salpêtrière hospital (AP-HP).
Prolonged use of these sleeping pills can also cause tolerance – which leads to a decrease in efficacy and/or an increase in doses – and above all a strong dependence which worries doctors. And even though benzodiazepine use has declined in recent years, France was still Europe’s second-most consuming country in 2015, and also saw a sharp increase during the anxiety-provoking lockdown period. So many reasons why HAS recommends that treatments ideally last only 4 to 6 weeks and 12 at most.
But in recent years, benzodiazepines have been overshadowed by non-benzodiazepine sleeping pills called “z-drugs” (zopiclone, zolpidem, zaleplon, and eszopiclone). Overall less potent than their elders, they induce more natural sleep and allow for a more rapid return to wakefulness. A study published in 2019 in The American Journal of Psychiatry further suggests that the use of zolpidem in depressed patients suffering from insomnia would reduce suicidal thoughts. Again, these results, while encouraging, remain preliminary and will need to be confirmed. Their persistence in the body also appears to be shorter than that of benzodiazepines, which causes fewer side effects. However, because they are also “pro-GABA” molecules, they share the same flaws at high doses. And when given to elderly people or people with kidney or liver problems, they cause benzodiazepine-like side effects: addiction, risk of falls, cognitive impairment and drowsiness, according to published studies. in 2017 in the magazine PLOS One et in 2020 y BMC Medicine. Their prescription must therefore, also in this case, be limited in time.
New generations always asking themselves questions
A new generation of sleeping pills is starting to emerge. Among them, daridorexant (quviviq) an antagonist of hypocretin/orexin, a brain neurotransmitter that is in a sense the conductor of awakening. Already marketed in the United States, it was authorized in May 2022 in Europe and should be available soon in France. This drug aims to combat hyperarousal insomnia by creating a more natural sleep: slow, deep and paradoxical. It also allows for a better morning awakening, as it is eliminated from the body more quickly than other sleeping pills. “This is a major breakthrough in the field of insomnia, which is overlooked by pharmaceutical companies and pharmaceutical agencies, while chronic insomnia is a real disease,” enthuses Professor Isabelle Arnulf. C “is the first novelty for thirty years! Although, as with any novelty, we will have to wait for it to be used by a very large number of people to better understand its safety”. Daridorexant, on the other hand, cannot treat the causes of insomnia if these are related to depression, an anxiety disorder or the mechanisms of restless legs, warns the specialist.
Be that as it may, taking sleeping pills remains a reflex for many French people, with the risk of self-medication, when we have known for some time that the use of drugs alone is not enough to act on the factors that perpetuate insomnia, as evidenced by a study Posted in The American journal of psychiatry en… 2002. So should we care about the phenomenon? “It is clear that drugs do not solve all the problems associated with insomnia, confirms Professor Emmanuel Mignot, a leading narcolepsy specialist and longtime director of the prestigious Stanford University (USA) sleep center. But, if users sleep better and feel better, then I don’t see the problem.” The specialist is well aware of the side effects, however he is surprised by a recurring prejudice against psychiatric drugs. “If one person has clogged arteries, they’ll take statins and no one will argue with them, but if another person is depressed and on antidepressants, we’re more likely to be judged,” he explains, before recalling his general philosophy on drugs: “They bring benefits, but you have to be careful of excesses and the fact that sometimes we prescribe too much without it being necessary.”
