Sleep is often considered sacred. And yet, sleep disorders affect many people. About 40% of the general population complains of temporary insomnia symptoms and between 10 and 20% suffer from chronic insomnia, according to a study published in 2015 in Sleep Medicine and by the High Authority for Health (HAS). If there are simple and effective methods, such as having a healthy lifestyle, falling asleep at a fixed time, exercising daily – but not before bedtime -, or even avoiding the consumption of stimulants, they are not always enough. In the most 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 bringing together dozens of scientific studies. They allow a reduction in the time to fall asleep and an increase in the total time of sleep and could also improve the state of depressive patients suffering from insomnia, even if this aspect is still debated within the scientific community.
Risk of dependence and addiction
Nevertheless, benzodiazepines cause many side effects, including memory problems, reduced vigilance or even drowsiness, behavioral problems and the risk of falling in the elderly. “These molecules are pro-GABA (for gamma-aminobutyric acid), that is to say molecules that globally slow down the brain, in a non-specific way: they reduce slow, deep and paradoxical sleep and, at high doses, slow down the brain so much that they can cause a coma”, explains Professor Isabelle Arnulf, neurologist and head of department at the Pitié-Salpêtrière Hospital (AP-HP).
Prolonged use of these sleeping pills can also cause tolerance – which leads to a decrease in effectiveness and/or an increase in doses – and above all a strong dependence that worries doctors. And even if the consumption of benzodiazepines has been falling in recent years, France was still the second most consuming country in Europe in 2015 and even experienced a sharp increase during the anxiety-provoking period of confinement. So many reasons why the HAS recommends that treatments last only 4 to 6 weeks ideally, and 12 at most.
But in recent years, benzodiazepines have been upstaged by non-benzodiazepine sleeping pills called “z-drugs” (zopiclone, zolpidem, zaleplon and eszopiclone). Overall less powerful than their elders, they induce a more natural sleep and allow a quicker return to wakefulness. A study published in 2019 in The American Journal of Psychiatry also suggests that the use of zolpidem in depressed patients suffering from insomnia would reduce suicidal thoughts. Here again, these results, although encouraging, remain preliminary and will have to be confirmed. Their persistence in the body also seems shorter than that of benzodiazepines, which causes fewer side effects. However, since they are also “pro-GABA” molecules, they share the same defects at high doses. And when given to people who are elderly or have kidney or liver problems, they cause side effects similar to benzodiazepines: addiction, risk of falling, cognitive impairment and drowsiness, according to published studies. in 2017 in the magazine PLOS One and in 2020 in BMC Medicine. Their prescription must therefore, here again, be limited in time.
New generations who always ask questions
A new generation of sleeping pills is beginning to emerge. Among them, daridorexant (quviviq) an antagonist of hypocretin/orexin, a cerebral neurotransmitter which is in a way the conductor of awakening. Already marketed in the United States, it was authorized in May 2022 in Europe and should soon be available in France. This drug aims to fight against insomnia by hyperarousal by setting up a more natural sleep: slow, deep and paradoxical. It also allows a better morning awakening, since it is more quickly eliminated by the body than other sleeping pills. “This is a big step forward in the field of insomnia which was neglected by pharmaceutical manufacturers and drug agencies, while chronic insomnia is a real disease, enthuses Professor Isabelle Arnulf. C “is the first novelty for thirty years! Even if, as with any novelty, we will have to wait for it to be used by a very large number of people in order to better understand its safety”. Daridorexant cannot, on the other hand, treat the causes of insomnia if these are linked to depression, an anxiety disorder or restless leg mechanisms, 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 a long time that using only drugs is not enough to act on the factors perpetuating insomnia, as evidenced by a study published in The American journal of Psychiatry in… 2002. So should we worry 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 long-time director of the prestigious sleep center at Stanford University (United States). But, if users sleep better and feel better, then I don’t see the problem.” The specialist is well aware of the side effects, he is nevertheless surprised by a recurring bias against psychotropic drugs. “If a person has clogged arteries, he will take statins and no one will find fault with it, but if another is depressed and takes antidepressants, we will allow ourselves to be judged more easily”, he illustrates, before to recall his overall philosophy with regard to drugs: “They bring benefits, but one must be wary of excess and of the fact that we sometimes prescribe too much without it being necessary.”