Sleeping Pills, Placebos And Insomnia: The Surprising Science Behind Pills (& Sleep Supplements)

Quick Summary

• A major meta-analysis shows that placebo pills create small to moderate, but significant, improvements in sleep for people with primary insomnia.

• These improvements are not just based on how people feel they slept; they are confirmed by objective, physiological measurements from clinical sleep studies.

• On average, the placebo effect accounts for nearly two-thirds (about 64%) of the total benefit seen from actual sleep medication.

• This comprehensive analysis was based on a broad, global search of clinical trials, not just those submitted to the FDA, strengthening the reliability of its conclusions.

Primary insomnia is a common health issue defined by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep with daytime consequences. For the many who seek medical help, medication is often the first line of defence. While sleeping pills can be effective, their benefit is often moderate and comes with a risk of side effects (Winkler & Rief, 2015).

This has led researchers to ask a critical question: How much of a sleeping pill's benefit comes from the active ingredients, and how much comes from the simple belief that it will work?

What Exactly Is the Placebo Effect in Insomnia Medication Treatment?

The placebo effect in insomnia treatment refers to the real, measurable improvements in sleep that occur when a person takes an inactive substance, like a sugar pill, believing it is a real medication. This isn't just a trick of the mind; it is a genuine mind-body effect where a person's expectations and beliefs about a treatment can trigger actual physiological changes.

So is this placebo effect actually a thing in medicine?

Is the Placebo Effect Strong in Other Areas of Medicine?

Yes, the placebo effect is a well-documented phenomenon across many areas of medicine, and its strength can be surprisingly high.

For instance, the placebo response is particularly strong in antidepressant trials, where it can account for as much as 75% of the total treatment effect (Winkler & Rief, 2015). In studies on pain or generalized anxiety disorder, the placebo effect is also substantial, contributing up to 50% of the therapeutic outcome (Winkler & Rief, 2015).

This history of powerful placebo responses in other areas of medicine set the stage for the researchers to ask more detailed questions about its role in sleep.

But first, what did we already know before this major analysis?

What Did Previous Research Find About Sleeping Pills, Placebo Effects And Insomnia?

Previous research consistently showed that placebos had a significant effect on subjective sleep measures. In other words, when people in clinical trials designed to test sleep medications took a placebo pill, they consistently reported that their sleep had improved. Two key meta-analyses had established that people taking placebos felt they fell asleep faster and slept longer (McCall & D’Agostino, 2003; Belanger et al., 2007).

However, the major point of uncertainty was whether this effect was real or just a matter of perception. The evidence for this was unclear, with studies showing mixed and inconclusive results when it came to objective, physiological changes in sleep (Winkler & Rief, 2015). For example, one analysis found a significant objective effect (Huedo-Medina et al., 2012), while two others did not find significant changes in lab-based sleep data (McCall & D’Agostino, 2003; Belanger et al., 2007).

This uncertainty was likely because earlier reviews had a limited number of studies that included objective data. This left a critical question unanswered: can a sugar pill genuinely change the way your brain and body experience sleep?

How Was This Meta-Analysis Able to Answer Questions About Placebos And Sleep Medications?

Winkler and Rief’s (2015) comprehensive meta-analysis published in the journal SLEEP was able to provide a definitive answer by taking a broader, more thorough approach.

The researchers cast a much wider net than some previous analyses. Instead of limiting their review to studies submitted to a single regulatory body like the U.S. Food and Drug Administration (FDA), they conducted a comprehensive global search. Their process included multiple international scientific databases, such as PubMed, PsycINFO, and the World Health Organization's International Clinical Trials Registry Platform. Ultimately, the researchers included in their study:

• 32 separate randomized controlled trials

• The trials had a total of 3,969 participants

This larger and more reliable set of data allowed the researchers to draw more reliable conclusions.

So, with this more powerful dataset, what did they find?

Can a Placebo Genuinely Change How You Sleep?

Yes, the meta-analysis by Winkler and Rief (2015) found that placebos lead to significant improvements in objectively measured sleep, not just in subjective reports. The results showed that people in the control group who took a placebo pill experienced genuine, statistically significant enhancements in their sleep, as recorded by polysomnography, a comprehensive test used to diagnose sleep disorders by monitoring brain waves, heart rate, and other physiological signals (Winkler & Rief, 2015).

How Big Is the Placebo Effect On Key Sleep Metrics?

The study by Winkler and Rief (2015) measured the improvements in sleep using a statistical tool called Hedges g, which is a standard way to see how big an effect is. The results showed a consistent small-to-moderate impact across several key sleep metrics:

• Falling Asleep Faster (Sleep Onset Latency): The effect size was -0.35, representing a significant reduction in the time it took to fall asleep.

• Sleeping Longer (Total Sleep Time): The effect size was 0.42, showing a clear increase in the total amount of sleep participants got.

• Waking Up Less (Wake After Sleep Onset): The effect size was -0.29, indicating a reduction in time spent awake after initially falling asleep.

• More Efficient Sleep (Sleep Efficiency): The effect size was 0.31, representing an increase in the percentage of time in bed that was actually spent sleeping.

Importantly, the study found no significant difference between the size of the effect on these objective, lab-based measurements and the subjective improvements people reported in their sleep diaries.

This confirms that the placebo response in insomnia is a real phenomenon that produces physiological changes.

This is a compelling finding, but how does the placebo's effect stack up against an actual sleep medication?

How Much of a Sleeping Pill's Effect Is Just the Placebo Effect?

The 2015 meta-analysis revealed that, on average, 63.56% of the improvement seen from sleep medication is also achieved in the placebo group (Winkler & Rief, 2015). This means that nearly two-thirds of the benefit people get from a sleeping pill may be attributed to the placebo response rather than the pharmacological action of the drug itself.

To put this in perspective, think of it this way: if a new sleep medication helps a person get an extra 60 minutes of sleep per night compared to no treatment, this research suggests that about 38 of those minutes could be achieved simply by taking a placebo.

The power of the placebo was so pronounced that for one outcome measure—subjective Wake After Sleep Onset—the placebo was actually more effective than the active medications studied!

So if the placebo effect is this powerful, what does it mean for how we should approach insomnia treatment?

What Are the Practical Takeaways From This Research?

The main takeaway is that psychological and expectation-based factors are powerful tools in managing insomnia especially with sleeping pills, and should be thoughtfully incorporated into clinical practice.

The strength of the placebo response is not a reason to dismiss treatment; rather, it highlights the potent connection between the mind and body in regulating sleep. It also highlights why the most effective insomnia treatment is CBT for insomnia, a psychology-based treatment that targets both physical sleep-wake system factors and mind/emotion factors that perpetuate insomnia.

Here are a few other practical considerations based on these findings:

• The Power of Ritual: The simple act of taking a pill is a powerful behavioral ritual. It signals to the brain that sleep is expected, which can help reduce the anxiety and hyperarousal often associated with insomnia. This shouldn’t be underestimated when reducing sleeping pill usage. Furthermore, this same principle can be applied positively to non-medication bedtime routines, reinforcing the brain's association between certain actions and the onset of sleep.

• The Role of Positive (& Negative) Expectation: This research underscores that a patient's beliefs are powerful. Powerful enough to produce real-world benefits and most likely, maintain real-world problems. Addressing beliefs is a foundational element of Cognitive Behavioral Therapy for Insomnia (CBT-I), which works to restructure unhelpful thoughts and beliefs about sleep into more helpful and realistic ones, thereby reducing anxiety and improving sleep outcomes.

• The Therapeutic Relationship: A strong, trusting relationship between a patient and a healthcare provider can significantly shape treatment expectations. As other researchers have noted, managing patient expectations and fostering a positive therapeutic alliance are effective strategies for optimizing treatment outcomes, partly by leveraging these placebo mechanisms (Enck et al., 2013).

• Re-evaluating the Benefit-Risk Ratio: Given the potential for side effects from sleep medications, such as daytime fatigue, tolerance, and dependency, and understanding that a large portion of the benefit is from the placebo effect suggests a more cautious and considered approach to prescribing. It reinforces why CBT-I, which can provide similar benefits without the associated risks, is the first line recommended treatment for insomnia and non-pharmacological treatments should be recommended alongside any medication.

Overall, the belief that a treatment will work is not just wishful thinking; it is a potent therapeutic agent in itself.

The research by Winkler and Rief (2015) provides strong evidence that the placebo response accounts for the majority of the benefits seen in pharmacological trials for insomnia. This knowledge opens the door for intelligent clinicians to better harness the power of expectation and belief to help people achieve better sleep, with or without medication.

Looking to talk to a NZ sleep clinic for sleep help? Whether it’s an Auckland sleep clinic, Wellington sleep clinic, Christchurch sleep clinic, Hamilton sleep clinic or anywhere in NZ, we can help. Request a free chat below or book an assessment and get started addressing your sleep problems today.

Frequently Asked Questions About Sleeping Pills, Placebos And Insomnia

Q1: Can a placebo or sugar pill actually improve my sleep?

A1: Yes. A major meta-analysis confirmed that taking a placebo can lead to small-to-moderate, but statistically significant, improvements in sleep for people with insomnia. The study found that people taking a placebo fell asleep faster, slept longer, and woke up less during the night (Winkler & Rief, 2015).

Q2: Does a placebo just make you feel like you slept better, or is the effect real?

A2: The effect is real and physically measurable. It is not just a feeling or a trick of the mind. The research showed that placebos improved objective sleep metrics that were recorded by scientific equipment in a sleep lab, a method known as polysomnography. This confirms the improvements are genuine physiological changes (Winkler & Rief, 2015).

Q3: How much of a sleeping pill's effect is just the placebo?

A3: On average, nearly two-thirds (about 64%) of the benefit seen from taking sleep medication can be attributed to the placebo effect. This suggests that a person's belief and expectation in a treatment play a massive role in its overall effectiveness (Winkler & Rief, 2015).

Q4: How does the placebo effect for insomnia actually work?

A4: Researchers suggest it works through powerful psychological factors. The simple ritual of taking a pill, combined with a positive expectation that it will help, can reduce the anxiety and mental hyperarousal that often interfere with sleep. This process helps signal to your brain that it is safe to relax and fall asleep (Winkler & Rief, 2015).

Q5: Does this mean I shouldn't take sleep medication?

A5: This research on placebo effects and sleeping pills does not suggest you should stop taking medication prescribed by your doctor. The key takeaway from the study is that your mindset and expectations are powerful tools in managing insomnia. It reinforces the importance of discussing all treatment options with your healthcare provider, including non-medication approaches like Cognitive Behavioral Therapy for Insomnia (CBT-I), which also works to change your beliefs and thoughts about sleep (Winkler & Rief, 2015).

References

Belanger, L., Vallieres, A., Ivers, H., Moreau, V., Lavigne, G., & Morin, C. M. (2007). Meta-analysis of sleep changes in control groups of insomnia treatment trials. Journal of Sleep Research, 16(1), 77–84.

Enck, P., Bingel, U., Schedlowski, M., & Rief, W. (2013). The placebo response in medicine: minimize, maximize or personalize? Nature Reviews Drug Discovery, 12(3), 191–204.

Huedo-Medina, T. B., Kirsch, I., Middlemass, J., Klonizakis, M., & Siriwardena, A. N. (2012). Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. BMJ, 345, e8343.

McCall, W. V., & D’Agostino, R., Jr. (2003). A meta-analysis of sleep changes associated with placebo in hypnotic clinical trials. Sleep Medicine, 4(1), 57–62.

Winkler, A., & Rief, W. (2015). Effect of placebo conditions on polysomnographic parameters in primary insomnia: a meta-analysis. SLEEP, 38(6), 925–931.

Written By The Better Sleep Clinic

Reviewed By Dan Ford, Sleep Psychologist