Summoning the Sandman: Mitigating the rebound effects of hypnotic therapy

Abstract

Insomnia significantly impairs quality of life, productivity, and mental health. Pharmacotherapy, such as benzodiazepines and Z-drugs, are often used, though notable risks include tolerance, dependence, withdrawal, and rebound insomnia, especially when used beyond short-term recommendations. This review summarises the pharmacological mechanisms and potential adverse effects, and further discusses the deprescribing strategies to reduce the occurrence of rebound and withdrawal effects. These include gradual dose tapering, substitution with longer-acting agents, adjunct use of melatonin, and integration of cognitive behavioural therapy for insomnia to support withdrawal and relapse prevention. Non-pharmacological approaches should be prioritised wherever feasible, and pharmacotherapy should be used judiciously, with patient education and interprofessional support. Ultimately, a balanced, individualised management plan that emphasises resolving the underlying reasons for insomnia, and incorporating judiscious use of non-pharmacological and pharmacotherapeutic options, should be aimed for.