Therapy More Effective Than Pills For Sleep Problems

The reasons behind this increase are not entirely clear, and there are probably several contributing factors, explains Johan Reutfors , psychiatrist and associate professor at the Centre for Pharmacoepidemiology at Karolinska Institutet, who researches the use of sleep medication.

"During this period, we have seen several major changes that likely play a role. The proportion of young people diagnosed with neurodevelopmental conditions, such as ADHD, has increased significantly, and smartphones have become a part of our daily lives. It has also become easier to prescribe melatonin," he says.

The rise in sleep problems among young people is confirmed by psychologist Li Åslund , who researches adolescent sleep difficulties and who is releasing a book this autumn entitled Teenage Sleep.

"Both National and international studies show that many young people today get less sleep than previous generations. The issue is particularly widespread among children with neurodevelopmental disorders (NDDs), where up to 75 per cent experience recurring difficulties falling asleep or staying asleep. These issues can be linked to biological factors, but also to behaviour patterns, anxiety and trouble winding down in the evening," she says.

A similar trend can be seen in our neighbouring countries Norway and Denmark. Where the use of sleep medication among young people has also increased, but not nearly as much. That is something Johan Reutfors has observed in his research.

"Sweden's rate is two to three times higher than that of our Scandinavian neighbours. This pattern also seems to apply for other other types of psychiatric medications, such as antidepressants," he says.

Why is that?

"We do not know yet, but we are trying to find out. Sweden has more child and adolescent psychiatrists than Norway and Denmark, while primary care plays a stronger role in our neighbouring countries. I am curious about how this affects things. It is also possible that NDD diagnoses have increased more in Sweden, which could lead to more prescriptions."

Is it concerning that a relatively large proportion of young people are being medicated?

"We need to monitor this development. Melatonin, which is the main drug prescribed to young people, is not currently associated with any clear health risks. But there is still a lot we do not know - for instance, whether it might affect pubertal development," says Johan Reutfors.

Li Åslund agrees.

"Young people with sleep problems should always be offered psychological and behavioural support as a first step, such as fixed routines, adapted sleeping environment, and wind-down strategies. For children with NDDs, parent education can be a valuable complement, as structure and clear boundaries often make a big difference. Unfortunately, access to psychological treatment is uneven in Sweden. Many families face long waiting times, which may lead to medication being prescribed instead," she says.

Different kinds of sleeping pills

Durin the first half of the 20th century, barbiturates were the dominant type of sleep medication. They were effective but dangerous, with a high risk of dependence or overdose. A number of high-profile deaths among global celebrities - including Marilyn Monroe and Jimi Hendrix - helped raise awareness of the risks.

A new type of drugs called benzodiazepines began to take over in the 1960s. They were widely used as sedatives, anti-anxiety medication, sleep aids and anticonvulsants. Although safer than barbiturates, it eventually became clear that benzodiazepines were also addictive.

The next step in the development came in the 1990s with the introduction of so-called Z-drugs. Chemically similar to benzodiazepines, they are processed more quickly by the body, meaning their effects wear off by morning. Patients avoid feeling drowsy and affected during the day, which was a problem with previous medicines. But even Z-drugs could lead to dependence, as it later turned out.

Barbiturates, benzodiazepines and Z-drugs all work in the same way: by stimulating the brain's GABA signalling. GABA is a key neurotransmitter that helps slow down brain activity. Today, barbiturates have long since been phased out. The use of benzodiazepines as sleep aids has been declining for several decades and is now down to fractions of a percent of the population. Over the past decade, the use of Z-drugs has also decreased about a third.

Melatonin is on the rise

Instead, another type of sleep medication is on the rise: melatonin, the hormone that regulates our circadian rhythm. Although known for a long time, it has only recently become widely used as a sleep aid. As Z-drug use declined in Sweden, melatonin consumption surged.

Another category of sleep medication is antihistamines - closely related to allergy medication, which may seem odd. The explanation lies in the fact that the hormone histamine helps regulate both our allergic reactions and our circadian rhythm.

In addition to these main categories of sleep medication, other types are also used. In psychiatry, a range of medicines are prescribed off-label for sleep - that is, the medication is actually intended for something else.

"There are, for example, certain antidepressants and antipsychotics that are also used for their sleep-inducing effects. We are seeing signs that this is becoming more common," says Johan Reutfors.

In his clinical work as a senior consultant in psychiatry in Region Stockholm, he meets many patients who suffer from both sleep difficulties and other mental health issues, such as anxiety, depression, or PTSD.

"It is very common among patients with mental health issues to also suffer from sleep difficulties. Yet there is limited knowledge about how different medications interact - for example, SSRIs and sleep aids."

In a study published last year, Johan Reutfors and his colleagues showed that nearly half of all patients diagnosed with depression were treated with sleep medication within a year of diagnosis. More strikingly, almost half of those were still on sleep medication three years later - even though in most cases, Z-drugs are only recommended for short-term use.

"Many who have become accustomed to sleeping with the help of medication may come to rely on the pills and may be afraid to try without them. That is unfortunate," says Johan Reutfors.

Joar Guterstam conducts research on addiction at Karolinska Institutet's Department of Clinical Neuroscience and is a senior consultant at Beroendecentrum Stockhom, Region Stockholm (Region Stockholm's Addiction Centre). He is pleased that the use of addictive sleep medication has decreased significantly.

"It is the result of targeted work within healthcare. I have met many patients who have become dependent on benzodiazepines and Z-drugs. While only a small proportion develop addiction problems- around two to three per cent -when these drugs are widely used, many individuals are affected," he says.

For those struggling to stop using sleep medication on their own, good support is available within the healthcare system, Joar Guterstam emphasises.

"But the strongest argument against benzodiazepines and Z-drugs is actually tolerance - which affects most patients. After a relatively short time, the brain adapts and the effect fades. It is often said that, on average, a patient sleeps just as poorly after a month on these drugs as before treatment - only now, the individual also needs a pill," he says.

Melatonin and Antihistamines: Safer but Less Potent

The two main advantages of melatonin and antihistamines - the sleep medications that have largely replaced benzodiazepines and Z-drugs - are that they rarely lead to tolerance and carry no risk of addiction, explains Joar Guterstam. The downside of these new medications is that they are not as effective in the short term.

"When you measure time to fall asleep and sleep quality in studies, the effects are not particularly impressive. But for some, they do provide some help."

In many cases, the placebo effect may play a significant role, he observes. The anxiety about not being able to fall asleep may lessen when you have taken a pill.

"There is a misconception that poor sleep is dangerous. The body does not really work that way. It is good at compensating, for example by sleeping more deeply when needed. It is really unfortunate that this idea prevails, as the fear itself becomes a major obstacle to falling asleep," says Joar Guterstam.

He agrees with Johan Reutfors that the rapidly increasing use of melatonin among young people is not unproblematic.

"We tend to be restrictive with medications for young brains that are still developing. Even though melatonin seems fairly benign, it is not as well-researched as one might think. We do not want to find ourselves in a situation in 10-20 years' time where we ask, 'What on earth were we thinking?'"

Many people view sleep medication as a well-established and effective category of pharmaceuticals, but according to Joar Guterstam, there are still no particular good alternatives. Research into new substances is ongoing, as the potential market is enormous. A few years ago, considerable hope was invested in medicine targeting the orexin system - another brain mechanism connected to wakefulness and sleep. These medications have now been approved and launched, but they have not become a major success.

CBT is better in the long run

However, there is a treatment that yields very good results for sleep problems, both short and long term, and does not risk causing dependency.

"Cognitive behavioural therapy for insomnia, CBT-I, is highly effective and the results last. When we followed up ten years after treatment, we found that patients were still sleeping well," says Kerstin Blom , psychologist and researcher at Karolinska Institutet's Department of Clinical Neuroscience. She has, among other things, participated in developing the CBT-I programme used at Internet Psychiatry in Region Stockholm.

Sweden lacks national guidelines for treating insomnia, but in European guidelines, as well as in many local guidelines within Swedish healthcare, CBT-I is recommended as the first-line treatment option.

Compared to other options, CBT-I has proven to be just as effective as benzodiazepines and Z-drugs in the short term, and significantly better in the long term.

Nevertheless, pharmacological treatment for sleep problems remains about a thousand times more common than CBT-I. In 2024, around 600 patients in Sweden received internet-based CBT-I treatment, according to the Swedish Internet Treatment Registry (SibeR) - compared to more than 870,000 who took sleeping pills.

"We do not know how many receive CBT-I through other channels, for instance at health centres or in conjunction with other psychotherapy, but there is reason to believe the numbers are note significantly higher," says Kerstin Blom.

Limited availability is, of course, one explanation for these modest figures. The introduction of internet-based therapy has expanded psychiatric capacity, but not enough to meet the demand. There is also a lack of awareness about CBT-I in healthcare, Kerstin Blom adds.

"The view of sleep problems is often not entirely up to date, which means people are not aware of the available solutions. Previously, most sleep difficulties were seen as secondary to other conditions, such as pain or depression. The focus was on treating the underlying issue, assuming the insomnia would resolve itself."

Today, research shows that sleep problems should be treated, regardless of underlying causes, she explains. In fact, CBT for insomnia also helps alleviate depression in patients suffering from both, whereas treatment for depression does not significantly improve insomnia.

What does CBT-I involve?

"The most important component is something called sleep restriction, though it should really be called bed restriction. This means you set a fixed wake-up time, calculate how much you sleep on average per night, and then limit your time in bed to match that. If, after a week, you are sleeping at least 85 per cent of your time in bed, you can gradually go to bed earlier," says Kerstin Blom.

It is tough at first for patients who might sleep only four hours a night and are therefore only allowed to lie in bed, for example, between 2am to 6am. But then the reward follows. When sleep adjusts - which varies from person to person but often takes just a few weeks - most experience more consolidated, high-quality sleep, perhaps for the first time in years.

Other elements of the treatment include relaxation techniques and psychoeducation, meaning patients learn about both the condition and the treatment.

"In addition, we conduct behavioural experiments. For many with insomnia, worry about not sleeping is a central feature. It causes hyperarousal, which in turn prevents sleep. For example, there may be catastrophic thoughts about not being able to work after a sleepless night. We test this."

Kerstin Blom hopes that CBT-I in various forms will be made available to more people in future. One step in that direction is a new self-help version that her colleagues are now evaluating.

"However, without therapist support, it unfortunately fizzles out for many, som some human contact may be needed. In those cases, a self-help programme for insomnia seems sufficient for many."