Prescriptions sleeping pills are common. As many as four percent of U.S. adults ― that’s nearly 10 million people ― use them, according to a 2013 estimate from the U.S. Centers for Disease Control and Prevention.
But they also come with some fairly alarming potential side effects. The medication guide for Ambien, for example, warns that potential side effects may include aggressive behavior, confusion, depression, hallucinations and “suicidal thoughts or actions.”
Given this, who should take sedative-hypnotic medications, the class of drugs to which popular medications like Ambien and Lunesta belong? And how frequently do the drugs actually cause these problems?
A new study published in the American Journal of Psychiatry says that answer is rather elusive.
The new research reviewed previous medical studies to try to quantify exactly how much taking a hypnotic increased someone’s risk of suicidal thoughts or behavior. The researchers confirmed that prescription sleep aids were linked to increased cases of suicide, but then things got more complicated: None of the studies involved in the review distinguished between suicidal thoughts or behavior that were caused by abuse or misuse of the drugs and those caused by taking the drug properly.
In other words, the side effect warning may be based on cases in which the drug was abused or in cases where there was a preexisting mental health condition. Or not. The research doesn’t make this clear.
The research on sleeping pills and suicide is flawed
The new study looked back at all previously published research linking suicide or suicidal thoughts with 11 different hypnotic drugs currently approved by the Food and Drug Administration for the treatment of insomnia. The study also included FDA safety reviews or commentaries about those 11 insomnia drugs, as well as detailed FDA reports of hypnotic-related suicide deaths dating back to the 1970s.
The evidence suggests that the increased risk of suicide among people taking hypnotics was anywhere from 2 to 24 times higher than the risk of suicide in people not taking sleep aids.
Risk of suicide or having suicidal thoughts associated with the prescription sleep aids appeared to be highest in the first few days of starting on the medication, which in some cases was accompanied by other unusual behaviors like sleep walking, confusion, hallucinations or paranoia.
Another big question the evidence has not answered: To what extent can preexisting symptoms of depression affect someone’s risk of suicidal thoughts or behavior?
“Does taking a sleep medication alone make you suicidal? Or only if you are also experiencing or are at risk for depression?” asked study coauthor Peter Rosenquist, vice chair of the department of psychiatry and health behavior at Augusta University in Georgia. “This is a major limitation of nearly all the studies.”
“Does taking a sleep medication alone make you suicidal? Or only if you are also experiencing or are at risk for depression?”
Several of the studies that Rosenquist and his colleagues reviewed for this research looked back at outcomes of groups of individuals who had taken these various prescription sleep aids, but whether or not they had depressive symptoms or previous episodes of alcohol or substance abuse was not consistently accounted for.
He explained that another caveat is that the studies that have been done showed that rates of suicide were higher in people who took prescription sleep aids, but not necessarily that one was the cause of the other.
“We can all agree that it’s better to be safe than sorry. But association doesn’t necessarily prove causation,” he said.
What all this means for people on prescription sleep aids
These warnings may sound threatening, but they should not be taken to mean that prescription sleep aids can’t help people.
Prescription sleep aids still can have very real benefits for some people used in the right circumstances, Rosenquist said. But ― based on the evidence available ― it’s important for anyone either considering or taking prescription sleep aids to be aware of the risks and the precautions that you can take, he said.
Here’s what you need to know:
1. If you struggle with depression, taking sleep aids can be dangerous.
It’s well established that insomnia and depression have a complicated (and often intertwined) relationship. And if you’re being treated for both, it’s important that your doctors are all on the same page about your treatment.
The evidence doesn’t say that already having symptoms of depression compounds suicide risk if you take hypnotics, W. Vaughn McCall, another coauthor of the study and chair of the department of psychiatry and health behavior at the Medical College of Georgia at Augusta University, told HuffPost. But overdoses of sleeping pills can kill.
“The pill [may be used as a] means to complete a decision that has already been made,” he said.
2. The first few days of taking hypnotics are the most dangerous.
Be especially on the lookout for any unusual side effects as soon as you start taking a prescription sleeping pill.
“Our review shows that the period of greatest documented risk is in the first few days of taking the medication,” Rosenquist said.
Warning signs the medication is not working the way it should including sleepwalking, depressed mood, and if you feel worse or have suicidal thoughts. If you experience any of the above apply, STOP taking the drug and call your doctor, Rosenquist said.
3. Hypnotics can be deadly in combination with other drugs (and alcohol!).
Even if each drug is taken at the prescribed dose, hypnotics can be deadly if you’re taking them at the same time as other medications (or alcohol). Heath Ledger’s accidental deadly overdose in 2008 is a tragic example.
Make sure your doctor knows about any other drugs you’re taking if he does prescribe a sleeping pill ― and make sure he or she gives you the OK to take those medications at the same time.
4. Heed the labels’ warnings.
It may seem obvious, but it’s worth repeating: prescription sleep aids should be used as directed.
Do NOT take more than the recommended dose.
Do NOT take after you’ve had alcohol.
Do NOT mix with other drugs unless you’ve gotten the go-ahead from your doctor.
Go to sleep within 15 minutes of taking the medication ― and stay in bed for the recommended amount of time it takes for the drug to wear off (typically seven to eight hours).
The bottom line: These drugs are potent pills. Use only under the direction of your doctor and heed the warnings.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.
Sarah DiGiulio is The Huffington Post’s sleep reporter. You can contact her at firstname.lastname@example.org.