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Treatment-Resistant Insomnia: When Sleeping Pills Don’t Work

Medically Reviewed by Brunilda Nazario, MD on July 19, 2021

Insomnia is the most common sleep disorder. But there are effective treatments for it. Doctors might start by recommending lifestyle changes that could improve your sleep. Or they might refer you for talk therapy for insomnia. Some doctors prescribe sleeping pills first or prescribe them along with or after lifestyle changes and talk therapy. Doctors recommend sleeping pills for short-term use just to get your sleep back on track.

If you’ve tried those things and they didn’t work, you may have treatment-resistant insomnia. That means that even though you’ve taken sleeping pills for 3 months or more, you still don’t get enough sleep or you don’t get good sleep.

But you haven’t reached the end of the line. There are steps that you and your doctor can take to get you to sleep again.

Why It’s Important to Manage Insomnia

Too little sleep can make it hard to focus and learn or remember things. It can also put you in a terrible mood and make it hard to get along with your family and co-workers.

Over time, ongoing poor sleep can be a risk factor for many health conditions including:

A growing body of research suggests sleep deprivation could also play a role in the development of dementia.

Taking a Second Look

If you still can’t sleep with sleeping pills, some recommendations advise doctors to go back to the drawing board. Even though they probably checked for all these things the first time around, they may want to check again to make sure you don’t have certain habits, take other medications, or have other health conditions that could be keeping you awake at night. The doctor may also check that you’re taking the right dose of sleep medication. Finally, the doctor might want to make sure that you have realistic expectations of the sleeping pills.

Habits That Might Make Insomnia Worse

Living with insomnia, you might have developed some habits that aren’t helping you sleep. In a small study of people who had treatment-resistant insomnia, almost all of them had picked up behaviors that could make their insomnia worse.

A few unhelpful habits you might pick up to cope with insomnia include:

Drinking. You may drink to make yourself sleepy or to ease the stress and anxiety of living with insomnia. It’s true that a drink or two can make you sleepy. But heavy drinking can keep you from sleeping through the night or prevent you from getting truly restful sleep. People who have alcohol use disorder often have insomnia.

Caffeine. When you don’t sleep at night, you may turn to coffee or energy drinks to power through the day. But too much caffeine, or caffeine too late in the day, can make it hard to get to sleep again that night. And the cycle continues.

“Catching up” on sleep. When you don’t sleep well at night, you might want to nap during the day or sleep in on the weekends. These extra ZZZs may feel good in the moment, but sleeping outside of your normal bedtime hours could make it harder to nod off at night.

Mental Health and Insomnia

Your feelings about your insomnia are a lot harder to control than your caffeine intake. But they can also make your insomnia worse. Think about it: You’re having trouble sleeping, so you worry about how you’re going to function the next day, and those worries keep you awake. The next day, you worry about whether you’ll get any sleep that night. You may even dread going to bed. Then, that anxiety builds up to keep you awake again that night.

Many people who have treatment-resistant insomnia also have symptoms of mental health disorder. Depression can make it hard to fall asleep or stay asleep at night, and it can make you sleepy during the day. On the flip side, ongoing insomnia can make you feel depressed. You can see how the two conditions feed off each other.

Other Sleep Disorders and Insomnia

Other undiagnosed sleep disorders, such as restless legs syndrome and sleep apnea, can interfere with sleep, too. In a small study of people who didn’t respond to sleeping pills, many had undiagnosed sleep apnea. This sleep disorder causes you to temporarily stop breathing in your sleep. When this happens, you wake up, catch your breath, and then go back to sleep. The result is broken sleep that isn’t restful.

Once your doctor diagnoses you with both conditions, you can get treatment for both and hopefully get back to sleep at night.

Next Steps

Your doctor’s exam might lead to new lifestyle recommendations or treatments for other overlooked conditions. If you don’t have habits or health conditions that explain the problem, you might get a new prescription. For example, your doctor may prescribe a medicine that’s usually for another condition, such as epilepsy or depression, but also happens to help with sleep.

You could also get a referral to a sleep psychologist, who can explore how negative thinking and behavior -- that you may not even notice -- could be keeping you awake at night. Relatively few people know about talk therapy for sleep, but it can be very effective.

You may also look into alternative therapies for insomnia. For example, researchers are testing electroacupuncture for people who don’t get help from sleeping pills.

WebMD Medical Reference

Sources

SOURCES:

Journal of Clinical Sleep Medicine: “Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults.”

BMJ Open: “Electroacupuncture for treatment-resistant insomnia: study protocol for a randomised, controlled, assessor-blinded, pilot clinical trial.”

Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem: “Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders.”

Current Opinion in Psychiatry: “Impact of Sleep on the Risk of Cognitive Decline and Dementia.”

The Journal of Nervous and Mental Disease: “Persistent Insomnia in Chronic Hypnotic Users Presenting to a Sleep Medical Center.”

MDEdge Psychiatry: “Treatment-resistant insomnia: Ask Yourself 8 Questions.”

Sleep Foundation: “Alcohol and Sleep,” “The Relationship Between Depression and Sleep.”

Cleveland Clinic: “Are You Making Your Insomnia Worse?”

Sleep Medicine Clinics: “Insomnia and Obstructive Sleep Apnea.”

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