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A hypnotic (from Ancient Greek Hypnos, sleep), also known as a somnifacient or soporific, and commonly known as sleeping pills, are a class of psychoactive drugs whose primary function is to sleep induction and to treat insomnia (sleeplessness). Some hypnotics are also used to treat narcolepsy and hypersomnia by improving sleep at night and thereby reducing daytime sleepiness. Certain hypnotics can be used to treat non-restorative sleep and associated symptoms in conditions like fibromyalgia as well.
This group of drugs is related to . Whereas the term sedative describes drugs that serve to calm or Anxiolytic, the term hypnotic generally describes drugs whose main purpose is to initiate, sustain, or lengthen sleep. Because these two functions frequently overlap, and because drugs in this class generally produce dose-dependent effects (ranging from anxiolysis to loss of consciousness), they are often referred to collectively as sedative–hypnotic drugs. (2025). 9780071468046, The McGraw-Hill Companies, Inc.. ISBN 9780071468046
Hypnotic drugs are regularly prescribed for insomnia and other sleep disorders, with over 95% of insomnia patients being prescribed hypnotics in some countries. Many hypnotic drugs are habit-forming and—due to many factors known to disturb the human sleep pattern—a physician may instead recommend changes in the environment before and during sleep, better sleep hygiene, the avoidance of caffeine and alcohol or other stimulating substances, or behavioral interventions such as cognitive behavioral therapy for insomnia (CBT-I), before prescribing medication for sleep. When prescribed, hypnotic medication should be used for the shortest period of time necessary.
Among individuals with sleep disorders, 13.7% are taking or prescribed nonbenzodiazepines (Z-drugs), while 10.8% are taking , as of 2010, in the USA. Early classes of drugs, such as , have fallen out of use in most practices but are still prescribed for some patients. In children, prescribing hypnotics is not currently acceptable—unless used to treat or sleepwalking. Elderly people are more sensitive to potential side effects of daytime fatigue and cognitive impairment, and a meta-analysis found that the risks generally outweigh any marginal benefits of hypnotics in the elderly. A review of the literature regarding benzodiazepine hypnotics and Z-drugs concluded that these drugs have adverse effects, such as dependence and accidents, and that optimal treatment uses the lowest effective dose for the shortest therapeutic time, with gradual discontinuation to improve health without worsening of sleep.
Falling outside the above-mentioned categories, the neurohormone melatonin and its analogues (e.g., ramelteon) serve a hypnotic function.
Other drawbacks of hypnotics, including benzodiazepines, are possible Drug tolerance to their effects, rebound insomnia, and reduced slow-wave sleep and a withdrawal period typified by rebound insomnia and a prolonged period of anxiety and agitation. The list of benzodiazepines approved for the treatment of insomnia is similar among most countries, but which benzodiazepines are officially designated as first-line hypnotics prescribed for the treatment of insomnia can vary distinctly between countries. Longer-acting benzodiazepines, such as nitrazepam and diazepam, have residual effects that may persist into the next day and are, in general, not recommended.
It is not clear whether the newer nonbenzodiazepine (Z-drug) hypnotics are better than the short-acting benzodiazepines. The efficacy of these two groups of medications is similar. According to the US Agency for Healthcare Research and Quality, indirect comparison indicates that side effects from benzodiazepines may be about twice as frequent as from nonbenzodiazepines. Some experts suggest using nonbenzodiazepines preferentially as a first-line long-term treatment of insomnia. However, the UK National Institute for Health and Clinical Excellence (NICE) did not find any convincing evidence in favor of Z-drugs. A NICE review pointed out that short-acting Z-drugs were inappropriately compared in clinical trials with long-acting benzodiazepines. There have been no trials comparing short-acting Z-drugs with appropriate doses of short-acting benzodiazepines. Based on this, NICE recommended choosing the hypnotic based on cost and the patient's preference.
Older adults should not use benzodiazepines to treat insomnia unless other treatments have failed to be effective., which cites
When benzodiazepines are used, patients, their caretakers, and their physician should discuss the increased risk of harms, including evidence which shows twice the incidence of traffic collisions among driving patients, as well as falls and hip fracture for all older patients.
Their mechanism of action is primarily at GABAA receptor. (2025). 9780120883974, Elsevier. ISBN 9780120883974
Examples include zopiclone (Imovane), eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien). Since the generic names of all drugs of this type start with Z, they are often referred to as Z-drugs.
Research on nonbenzodiazepines is new and conflicting. A review by a team of researchers suggests the use of these drugs for people who have trouble falling asleep (but not staying asleep),Because the drugs have a shorter elimination half life they are metabolized more quickly: nonbenzodiazepines zaleplon and zolpidem have a half-life of 1 and 2 hours (respectively); for comparison, the benzodiazepine clonazepam has a half-life of about 30 hours. This makes the drug suitable for sleep-onset difficulty, but the team noted sustained sleep efficacy was unclear. as next-day impairments were minimal. The team noted that the safety of these drugs had been established, but called for more research into their long-term effectiveness in treating insomnia. Other evidence suggests that drug tolerance to nonbenzodiazepines may be slower to develop than with benzodiazepines. A different team was more skeptical, finding little benefit over benzodiazepines.
The development of gaboxadol was discontinued in 2007. This was due to high rates of psychiatric and effects in drug abuse at supratherapeutic doses, failure of a 3-month efficacy trial, and other cited reasons.
Muscimol, the compound from which gaboxadol was derived, is a natural product constituent of Amanita mushrooms such as Amanita muscaria (fly agaric) and is a potent GABAA receptor agonist similarly. However, muscimol is less selective, more toxicity, and far less-researched than gaboxadol. Muscimol is reported to induce sleep in humans in addition to its well-known hallucinogenic effects that occur at sufficiently high doses. The drug shows similar effects on sleep in rodents as gaboxadol. By the mid-2020s, microdosing of muscimol and Amanita mushrooms for claimed therapeutic benefits, the most prominently cited of which is improved sleep, has become increasingly prominent.
Sodium oxybate also completed formal clinical development for fibromyalgia. This condition has very high rates of non-restorative sleep (unrefreshing sleep) that may be directly involved in its symptoms. Sodium oxybate improved sleep in fibromyalgia and showed moderate effectiveness in treating multiple symptoms across the condition including pain and fatigue. However, despite its effectiveness, sodium oxybate was ultimately not approved for treatment of fibromyalgia owing mostly to concerns about possible drug misuse. Sodium oxybate has also been investigated and been of interest to improve sleep and associated symptoms in other conditions with sleep disruption, such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and long COVID, which also have high rates of non-restorative sleep. In addition, sodium oxybate was limitedly studied to improve insomnia in people with depression or bipolar disorder. However, it was reported to paradoxically disrupt sleep and induce narcolepsy-like changes in these individuals. Moreover, concerns about misuse have limited use of sodium oxybate for other medical conditions. GHB has also garnered a reputation as a date rape drug, although the actual prevalence of this appears to be much lower than popular perception.
The GABAB receptor agonist baclofen has also been more limitedly investigated for improvement of sleep and has been found to be effective in enhancing sleep similarly to sodium oxybate. However, in people with narcolepsy, baclofen and sodium oxybate both improved sleep but only sodium oxybate reduced daytime sleepiness. In any case, research in this area is limited, and there remains significant interest in baclofen in the potential treatment of sleeping problems. Unlike sodium oxybate, baclofen is not a controlled substance and has much less or no misuse potential. Baclofen and sodium oxybate have been found to activate the GABAB receptor differently, which is thought to underlie the differences in their effects. Another difference between baclofen and sodium oxybate is that baclofen has a much longer elimination half-life and duration of action in comparison (half-life 3–4hours versus 0.5–1.0hours, respectively).
Research about using medications to treat insomnia evolved throughout the last half of the 20th century. Treatment for insomnia in psychiatry dates back to 1869, when chloral hydrate was first used as a soporific.
During the 1970s, and were introduced as safer alternatives to replace barbiturates; by the late 1970s, benzodiazepines emerged as the safer drug.
Benzodiazepines are not without their drawbacks; substance dependence is possible, and deaths from overdoses sometimes occur, especially in combination with alcohol or other . Questions have been raised as to whether they disturb sleep architecture.
Nonbenzodiazepines or Z-drugs like zolpidem were introduced in the 1990s and 2000s. Although it is clear that they are less toxic than barbiturates, their predecessors, comparative efficacy over benzodiazepines has not been established. Such efficacy is hard to determine without longitudinal studies. However, some psychiatrists recommend these drugs, citing research suggesting they are equally potent with less potential for abuse.
Orexin receptor antagonists like suvorexant were introduced in the 2010s and 2020s.
/ref> Moreover, there was tension concerning hypnotics in the pharmaceutical industry at the time owing to bizarre reports of zolpidem (Ambien)-induced delirium that emerged in the media in 2006, which may have made the developer of gaboxadol more concerned about potential liability issues. According to journalist Hamilton Morris, the discontinuation of gaboxadol's late-stage development may have deprived people with insomnia access to an effective, safe, and non-addictive treatment. There has been some further study of gaboxadol as a hypnotic by David Nutt and colleagues following the discontinuation of its development.
GABAB receptor agonists
The GABAB receptor agonist sodium oxybate (SXB; Xyrem), also known as γ-hydroxybutyrate (GHB), has hypnotic and sleep-improving effects. It robustly increases slow wave sleep (deep sleep), decreases sleep fragmentation, and improves rapid eye movement (REM) sleep consolidation, all whilst preserving physiological sleep architecture. The drug is approved and clinically used in the treatment of narcolepsy and excessive daytime sleepiness (EDS). Narcolepsy is associated with poor sleep, and sodium oxybate improves sleep quality and stability in the condition, in turn reducing symptoms like daytime sleepiness and cataplexy. The robust enhancement of slow wave sleep by sodium oxybate is unusual and potentially advantageous relative to other hypnotics. In addition, unlike the case of many other hypnotics, drug tolerance does not appear to develop to the hypnotic effects of sodium oxybate.
GABA reuptake inhibitors
The GABA transporter 1 (GAT-1) and GABA reuptake inhibitor tiagabine (Gabitril) is approved and clinically used as an anticonvulsant. It has also been used off-label use in the treatment of and other conditions. The drug increases γ-aminobutyric acid (GABA) levels in the brain and has been found to improve sleep, including by increasing slow wave sleep (deep sleep). In addition, tiagabine has been reported to make sleep feel more restorative and to improve several cognitive outcomes. The drug has an elimination half-life of 5 to 8hours.
Melatonin receptor agonists
Melatonin, the hormone produced in the pineal gland in the brain and secreted in dim light and darkness, among its other functions, promotes sleep in Diurnality mammals. It activates the melatonin MT1 and MT2 receptors to produce beneficial effects on sleep, therefore being used exogenously for mild insomnia. A small improvement in sleep onset and total sleep time by using melatonin has been shown in recent systematic reviews. Synthetic analogues of melatonin, or melatonin receptor agonists, have also been made. Among these, ramelteon and tasimelteon are used for sleep disorders. Agomelatine is an antidepressant of this class, with some studies also reporting an effect on sleep.
Histamine H1 receptor antagonists
, also known as histamine H1 receptor antagonists, are a class of drugs that inhibit action at histamine H1 receptors. They are clinically used to alleviate allergic reactions including allergic rhinitis, allergic conjunctivitis, and urticaria, which are mediated by histamine. First-generation antihistamines, such as doxylamine (Unisom) and diphenhydramine (Benadryl), often cause sedation as a side effect, which can be utilized to treat insomnia. Some antihistamines, such as doxylamine, are available for purchase over-the-counter (OTC) in some countries and can be used for the occasional relief of insomnia. Many sedating antihistamines also have anticholinergic activity that can produce like cognitive impairment. Low-dose doxepin (Silenor) is approved by the FDA for the treatment of insomnia. Non-selective hypnotics that possess histamine H1 receptor antagonism include the amitriptyline, high-dose doxepin, trazodone, and trimipramine; the olanzapine and quetiapine; and the antihistamines hydroxyzine, promethazine, and cyproheptadine, among others. Second-generation antihistamines such as cetirizine and loratadine produce much less if any sedation due to a greatly reduced capacity to cross the blood–brain barrier.
Orexin receptor antagonists
Orexin receptor antagonists are drugs that block the orexin OX1 and/or OX2 receptors, hence reducing the wakefulness-promoting effects of the orexin system and inducing sleep. Non-selective orexin receptor antagonists including suvorexant, lemborexant, and daridorexant and selective orexin OX2 receptor antagonists like seltorexant have been shown in clinical study to improve sleep onset, sleep duration, and sleep quality.
Serotonin 5-HT2A receptor antagonists
Serotonin 5-HT2A receptor antagonists such as ritanserin, ketanserin, eplivanserin, volinanserin, nelotanserin, and pimavanserin have been studied and developed to improve sleep. They do not improve sleep onset, but have been found to increase slow wave sleep (deep sleep) and reduce nighttime awakenings. Conversely, improvement in subjective sleep ratings have been more mixed. Ultimately no selective serotonin 5-HT2A receptor antagonists have been approved for treatment of insomnia. The only selective serotonin 5-HT2A receptor antagonist to be approved for any indication is pimavanserin for treatment of Parkinson's disease psychosis. Besides selective serotonin 5-HT2A receptor antagonists however, many non-selective agents used as hypnotics show serotonin 5-HT2A receptor antagonism, for instance like trazodone, mirtazapine, and amitriptyline, like quetiapine and olanzapine, and like hydroxyzine and cyproheptadine.
Gabapentinoids
, also known as α2δ subunit-containing voltage-gated calcium channel ligands, include drugs like gabapentin, pregabalin, and gabapentin enacarbil. They have been found to increase slow wave sleep (deep sleep) in people with insomnia and healthy individuals. However, they do not appear to improve sleep onset. The gabapentinoid atagabalin (PD-0200390) was under formal development for treatment of insomnia, but development was discontinued following unsatisfactory clinical trial results. PD-0299685 is another gabapentinoid that was under development for the treatment of insomnia, specifically that related to menopausal symptoms, but its development was discontinued similarly.
Cannabinoids
, or cannabinoid receptor , such as the δ9-tetrahydrocannabinol (THC) found in cannabis, have been found to be effective in improving sleep in healthy people and in people with insomnia. They have been found to improve sleep onset, sleep duration, and sleep quality. Cannabidiol (CBD), which acts differently than other cannabinoids like THC, is not effective in improving sleep on the other hand. Zenivol is a cannabis extract which is approved for the treatment of insomnia in Germany.
α1- and β-adrenergic receptor antagonists
The α1-adrenergic receptor antagonist prazosin is used off-label use to treat insomnia, , and poor sleep quality in people with post-traumatic stress disorder (PTSD). It is clinically effective for this purpose. However, the drug is also an antihypertensive agent and can lower blood pressure, thereby producing like dizziness and orthostatic hypotension. Certain non-selective hypnotics such as trazodone and tricyclic antidepressants (TCAs) like amitriptyline and trimipramine are also α1-adrenergic receptor antagonists. The combination of prazosin and the centrally-penetrant beta blocker (β-adrenergic receptor antagonist) timolol has been found to be synergistic in producing sedative and hypnotic effects in animals. Conversely, timolol alone produced no such effects. Centrally active beta blockers like propranolol and metoprolol on their own are not effective or clinically used as hypnotics and have actually been associated with insomnia as a side effect. Certain beta blockers like labetalol and carvedilol also block the α1-adrenergic receptor to varying extents and have been associated with somnolence as a side effect. However, these two beta blockers have also been associated with insomnia similarly to selective beta blockers.
α2-Adrenergic receptor agonists
α2-Adrenergic receptor like clonidine can improve sleep and may be useful in the treatment of insomnia. An example of this is in the treatment of insomnia in children and adolescents with attention deficit hyperactivity disorder (ADHD), for instance due psychostimulant therapy. Similarly to clonidine, the α2-adrenergic receptor agonist dexmedetomidine has sedative and hypnotic effects and is used to produce sedation in hospital settings. The sleep induced by dexmedetomidine is said to closely resemble natural sleep. The selective α2A-adrenergic receptor agonist tasipimidine (ODM-105) is under development for the treatment of insomnia and is in phase 2 for this indication as of October 2024. α2-Adrenergic receptor agonists can produce hypotension and bradycardia as , which has limited their use. Activation of the α2A-adrenergic receptor is thought to be responsible for most of the physiological effects of the α2-adrenergic receptors, including hypotension. On the other hand, the preferential α2A-adrenergic receptor agonist guanfacine appears to show less sedation and hypotension than clonidine.
Serotonin precursors
The serotonin precursors tryptophan and 5-hydroxytryptophan (5-HTP; oxitriptan) are available as over-the-counter supplements. They are often used to produce sleepiness and treat insomnia. However, little to no clinical data exist to support their use or effectiveness.
Multiple mechanisms
Antidepressants
Some have hypnotic and/or sedative effects. These include the serotonin antagonist and reuptake inhibitor (SARI) trazodone, tricyclic antidepressants (TCAs) such as amitriptyline, doxepin, and trimipramine, and tetracyclic antidepressants (TeCAs) like mirtazapine and mianserin. These agents produce their hypnotic and sedative effects via multiple mechanisms of action that may include histamine H1 receptor antagonism, serotonin 5-HT2A receptor antagonism, and α1-adrenergic receptor antagonism. Some hypnotic antidepressants, such as trazodone and mirtazapine, have been shown to enhance slow wave sleep, which may be due to serotonin 5-HT2A receptor antagonism.
Antipsychotics
Certain typical antipsychotics (first-generation) like chlorpromazine and atypical antipsychotics (second-generation) including clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and zotepine may have sedative and/or hypnotic effects and have been used in the treatment of insomnia. However, the most commonly used agents for insomnia are quetiapine and olanzapine. They are thought to produce these effects via multiple mechanisms of action, including histamine H1 receptor antagonism, serotonin 5-HT2A receptor antagonism, α1-adrenergic receptor antagonism, and/or dopamine D2 receptor antagonism. While some of these drugs are frequently prescribed for insomnia, such use is not recommended unless the insomnia is due to an underlying mental health condition treatable by as the risks frequently outweigh the benefits. Some of the more serious adverse effects have been observed to occur at the low doses used for this off-label prescribing, such as dyslipidemia and neutropenia, and a recent network meta-analysis of 154 double-blind, randomized controlled trials of drug therapies vs. placebo for insomnia in adults found that quetiapine had not demonstrated any short-term benefits in sleep quality.
Herbal supplements
Some supplements, including valerian, kava, chamomile, lavender, passion flower, and hops among others, are purported to have hypnotic effects and are used to treat sleeping problems, but little to no clinical data are available to support their use.
Other drugs
Various other types of drugs have also been found to produce hypnotic-type effects in scientific research. Examples include histamine H3 receptor like α-methylhistamine, BP 2.94, GT-2203 (VUF-5296), and SCH-50971, adenosine A1 and A2A receptor agonists like adenosine and YZG-331, and dopamine D1 receptor receptor antagonists like NNC 01-0687 (ADX-10061, CEE-03-310, NNC-687).
Comparative effectiveness
A major systematic review and network meta-analysis of medications for the treatment of insomnia was published in 2022. It found a widely varying range of (standardized mean difference or SMD) in terms of clinical effectiveness for insomnia. The assessed medications and their effect sizes included (e.g., temazepam, triazolam, many others) (SMDs 0.58 to 0.83), (eszopiclone, zaleplon, zolpidem, zopiclone) (SMDs 0.03 to 0.63), sedative and (doxepin, doxylamine, trazodone, trimipramine) (SMDs 0.30 to 0.55), the antipsychotic quetiapine (SMD 0.07), orexin receptor antagonists (daridorexant, lemborexant, seltorexant, suvorexant) (SMDs 0.23 to 0.44), and melatonin receptor agonists (melatonin, ramelteon) (SMDs 0.00 to 0.13). The certainty of evidence varied and ranged from high to very low depending on the medication. Certain medications often used as hypnotics, including the antihistamines diphenhydramine, hydroxyzine, and promethazine and the antidepressants amitriptyline and mirtazapine among others, were not included in analyses due to insufficient data.
Risks
The use of sedative medications in older people generally should be avoided. These medications are associated with poorer health outcomes, including cognitive decline, fall, and . Sedatives and hypnotics should also be avoided in people with dementia, according to the clinical guidelines known as the Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D).Citation error. See the inline comment on how to fix it. The use of these medications can further impede cognitive function for people with dementia, who are also more sensitive to side effects of medications. Some hypnotics, such as low-dose doxepin, melatonin receptor agonists, and orexin receptor antagonists, may be safer and more appropriate in older adults however.
History
Hypnotica was a class of somniferous drugs and substances tested in medicine of the 1890s and later. These include Ethyl carbamate, acetal, methylal, sulfonal, paraldehyde, amylenhydrate, Acetophenone, chloralurethan, ohloralamid, or chloralimid.Pacific Record of Medicine and Surgery - Volume 5 - Page 36 1890
(2025). 9780195176681, Oxford University Press. ISBN 9780195176681 emerged as the first class of drugs in the early 1900s, after which chemical substitution allowed derivative compounds. Although they were the best drug family at the time (with less toxicity and fewer side effects), they were dangerous in drug overdose and tended to cause physical and psychological dependence.
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