What Is Rebound Insomnia? Is Bad Sleep After Stopping A Sleeping Pill Rebound Or Relapse?

Quick Summary

• A temporary drop in sleep quality: Rebound insomnia is a brief, sharp decline in sleep after stopping a sleeping pill, where your sleep actually becomes worse than it was before you ever started the medication.

• A predictable withdrawal effect: Rebound insomnia is a withdrawal response to the drug leaving your system, not a sign that your original insomnia has permanently returned. Even healthy sleepers experience it.

• Medication type matters: Sleeping pills that leave the body very quickly, as well as medications taken at higher doses, carry the highest risk of triggering these difficult nights.

• Tapering reduces the impact: Gradually reducing your dose under the guidance of a prescriber can noticeably soften the rebound compared to stopping the medication abruptly.

What Is Rebound Insomnia?

You have been taking a prescribed sleeping pill for weeks, perhaps even months or years, and you finally decide that you are ready to stop. You skip your dose, get into bed, and wait for sleep to arrive. Instead, the first night without the pill goes badly. You lie awake for much longer than you did before you ever started the medication, and you wake up far more often throughout the night. By the time morning arrives, you feel exhausted. And the conclusion feels obvious: the pill was the only thing holding your sleep together. Defeated, you go back to taking the medication the very next night.

The conclusion, “I can’t sleep without a sleeping pill” is very common, and it comes at a high cost to patients.

In a study of people seen by family doctors, researchers found that 75% of those on a prescribed sleeping pill (almost all of them taking benzodiazepines, an older class of sedative medications) had been taking the drug for more than six months (Hohagen et al., 1993). The actual payoff for all those months of medication use was surprisingly modest. Only 20% of the patients said their sleep had distinctly improved, and another 30% reported only a slight improvement. Yet the most striking finding was that every single long-term user in the study had tried to stop taking their medication at least once, and every one had failed.

So, why is a pill that offers only modest benefits so hard to put down? Later researchers have offered a blunt suggestion about this cycle: many people keep taking sleeping pills not because the medications work particularly well, but simply to avoid the bad nights of sleep that immediately follow stopping them (Voderholzer et al., 2001).

It turns out those bad nights have a specific medical name: rebound insomnia.

So, what exactly is rebound insomnia? And is it different from an insomnia relapse?

What Exactly Is Rebound Insomnia?

Rebound insomnia is defined a short-lived worsening of sleep that occurs immediately after stopping a sleeping medication, where your sleep quality drops to a level that is actually worse than before the medication began (Gillin et al., 1989).

The key phrase to remember here is “worse than before.” For a night or two, your ability to sleep drops below your old, pre-medication baseline. When researchers observe this in a sleep laboratory, the rebound effect shows up as a longer time needed to fall asleep, more time spent awake in the middle of the night, and less total sleep overall.

What Causes Rebound Insomnia?

The cause of rebound insomnia is a withdrawal effect of the drug leaving your system, not your original insomnia returning to haunt you (Voderholzer et al., 2001). This is a key piece of information that should change how you view that first bad night without your medication.

How do we know rebound insomnia is due to medication withdrawal?

The clearest evidence comes from studying people who never had insomnia in the first place. Healthy volunteers with no sleep complaints slept measurably worse after stopping the medication triazolam than they did before they ever started taking it (Roehrs et al., 1986; Voderholzer et al., 2001).

Logically, a person with no underlying sleep problem cannot relapse into a sleep problem they never had. In those volunteers, the disruption can only come from withdrawal of the drug (Roehrs et al., 1986; Voderholzer et al., 2001).

Does the mind contribute to rebound insomnia?

However, the drug is not the only factor at play; the mind plays a part too. In one revealing study, outpatients diagnosed with insomnia reported a rebound-like worsening of their sleep even after they stopped taking placebos, inactive dummy pills used in research (Hajak et al., 1998).

In this case, there was no active drug being withdrawn from their bodies, and still the patients reported sleeping worse (Hajak et al., 1998). Rebound insomnia, then, is a combination of two forces: the physical effect of the drug leaving the body, and the worry about whether you will be able to sleep without the pill.

If this is a well-documented withdrawal effect, where did the medical community first get the idea that sleeping pills could cause this specific type of rebound?

Where Did the Concept of Rebound Insomnia Originate?

The concept of rebound insomnia was first identified in 1978 by researchers studying patients who stopped taking short-acting benzodiazepines, a class of medications that leave the body very quickly (Kales et al., 1978).

Anthony Kales and his colleagues gathered data from six different sleep laboratory studies. In every one of those studies, the patients’ sleep got measurably worse than their original baseline once the drug was withdrawn, sometimes after they had only been taking the medication for a week or two.

The numbers from these early studies paint a clear picture of the struggle. In the triazolam study, seven people with insomnia averaged about 94 minutes awake per night before any treatment began. Across the first three nights after they stopped taking the medication, their time awake climbed to about 150 minutes per night (Kales et al., 1978). That is close to an entire extra hour of lying awake in the dark each night, experienced by people who had originally taken the pill specifically to sleep better.

Two decades later, after much scientific debate over the best ways to measure and define rebound insomnia, a large meta-analysis (a study that pools the results of many earlier studies to find broader trends) provided more clarity. This review found broad agreement that the risk of rebound insomnia is greatest with short-acting benzodiazepines (Soldatos et al., 1999).

Knowing that the first night can involve an extra hour of lying awake, how long does this frustrating period of rebound insomnia actually last?

How Long Does Rebound Insomnia Typically Last?

Rebound insomnia typically lasts for just one or two nights after stopping a medication, with the very first night usually the worst. After this, sleep returns to its previous baseline level (Gillin et al., 1989).

Across the studies of 0.5 mg triazolam that Gillin and colleagues reviewed, the rebound effect appeared in seven out of nine studies. Where rebound appeared, the first night was the hardest. Across six of those studies, total sleep time fell by an average of about 85 minutes, which is roughly a quarter below the patients’ baseline sleep. From the second night onward, however, sleep tended to stabilise, returning to baseline or sometimes even rising slightly above it.

The 1999 meta-analysis, which pooled data from 75 sleep laboratory studies, found a very similar pattern. On the first night after stopping triazolam, total sleep dropped by an estimated 70 minutes (Soldatos et al., 1999).

However, when averaged across the first three nights, that drop shrank to about 18 minutes (Soldatos et al., 1999). So the data show that one bad night does most of the damage. If you are going to experience rebound insomnia at all, brace yourself primarily for that first night.

Is rebound insomnia a measurable physical event, or is it just a subjective feeling?

Rebound insomnia is a real, objectively measurable event – it’s not all in your head. A double-blind study (neither the volunteers nor the researchers knew who was taking the active drug or the placebo) answered that question using polysomnography, an overnight test that records brain waves, eye movements and muscle activity. In this study, healthy young men took triazolam 0.25 mg, zopiclone, zolpidem, or a placebo every night for four weeks (Voderholzer et al., 2001).

The objective recordings were clear. On the first night after stopping triazolam, total sleep fell from 439 minutes to 405 minutes, representing about half an hour of lost sleep (Voderholzer et al., 2001). By the second night, total sleep was right back up at 442 minutes, almost as if nothing had happened. Two weeks later, not a single sleep measure differed from baseline in any of the groups.

Two caveats about the Voderholzer et al study: the participants were healthy volunteers rather than people with chronic insomnia, and only 10 people took triazolam. That means that while the study shows that rebound is a measurable and temporary physical event, the study cannot predict exactly how hard rebound will hit any individual person.

Okay. If the duration of rebound insomnia is relatively short but intense, do all sleeping pills carry the same risk of causing this first-night drop?

Which Sleeping Pills Are Most Likely to Cause Rebound Insomnia?

The sleeping pills most likely to trigger rebound insomnia are those that are eliminated from the body very quickly, particularly when they are taken at higher doses (Gillin et al., 1989; Roehrs et al., 1986).

To understand why fast-clearing drugs cause more trouble, think of taking your hand off a handrail while walking down a steep set of stairs. A slow-clearing drug is like slowly loosening your grip over several days; your body has time to adjust to the changing support. A fast-clearing drug, however, lets go of the railing all at once. For a night or two, the brain has nothing to hold on to, and sleep drops suddenly.

For example, Flurazepam, a medication whose active by-products linger in the body for days, showed no significant rebound effect in the first nights after patients stopped taking it (Gillin et al., 1989). Conversely, triazolam, which has a half-life (the time it takes for the body to clear half of a medication dose) of only about 2 to 5 hours, produced the strongest rebound.

Speed of clearance is not the entire story, though, and the rest of the data is good news if you currently take zolpidem (common in the USA) or zopiclone (common in NZ, Australia, UK and Europe). Both of these drugs clear the body quickly. Yet in the 2001 Voderholzer et al polysomnography study, both medications produced only small dips in sleep. In fact, the dips were small enough that chance could explain them (Voderholzer et al., 2001). The meta-analysis by Soldatos et al pointed in the same direction: after stopping zolpidem, first-night total sleep changed by only about 13 minutes, and falling asleep took only about 13 minutes longer (Soldatos et al., 1999). When placed next to triazolam’s 70-minute first-night drop, a 13-minute change is barely a blip on the radar.

Other sleep laboratory studies agree with these findings, noting no significant rebound after zolpidem in people with insomnia (Monti et al., 1994; Ware et al., 1997) or after zopiclone in healthy volunteers (Mann et al., 1996).

Before treating the question of medication type as settled, though, it is important to read the fine print of the research.

The groups in the 2001 study (Voderholzer et al., 2001) held only 7 to 11 people each. That number is too small, as the authors themselves noted, for the drug-to-drug comparisons to reach statistical significance. Furthermore, the Voderholzer et al (2001) study was funded by the manufacturers of zopiclone and zolpidem, and the meta-analysis (Soldatos et al., 1999) was partly supported by one of those same manufacturers. And neither paper can prove whether the drug’s specific chemistry, rather than the dose used, explains the difference in rebound.

Does Sleep Medication Dose Influence Rebound Insomnia?

Sleep medication dose does appear to influence the likelihood of rebound insomnia. Healthy sleepers taking triazolam for six nights showed significant rebound after taking a 0.5 mg dose, but not after taking a smaller 0.25 mg dose (Roehrs et al., 1986).

Yet a lower dose is not a guarantee of an easy transition: rebound still appeared after a 0.25 mg dose in the 2001 study (Voderholzer et al., 2001) and in a smaller study of people with insomnia (Kales et al., 1986).

With different medications and doses complicating the picture, how can you tell if a bad night after stopping is just temporary rebound or a true relapse of your original sleep problem?

How Can You Tell the Difference Between Rebound Insomnia and Relapse?

You can tell rebound insomnia from relapse by looking at severity and timing. Rebound is a temporary withdrawal effect that is worse than your original sleep problem and fades after a few days. On the other hand, relapse looks like your old insomnia and persists over time.

So a bad night in the first few days after stopping your medication is most likely rebound insomnia.

Two features help clinicians tell rebound and relapse apart:

·      Severity: Rebound insomnia is worse than your sleep was before you ever started treatment (Gillin et al., 1989). Relapse, on the other hand, looks like the insomnia you had before you took the pill.

·      Timing: Rebound insomnia arrives within the first days of stopping, hits hard, and then fades (Gillin et al., 1989). Relapse does not fade after those first few nights; it stays with you.

So, when you are lying awake, ask yourself a simple question: if this first night off the pill is worse than your worst nights before you ever sought treatment, is that night really your old insomnia returning? More likely, that first bad night is the physical and psychological effect of the drug leaving your system; it is not your natural ability to sleep failing you permanently.

Telling rebound from relapse in one specific person is ultimately a clinical judgement call. If your sleep is still poor once the first week or so has passed, raise it with your prescriber before deciding that the pill was the only thing holding your sleep together.

Knowing how to identify rebound insomnia is helpful, but what steps should you take before you even attempt to stop taking your medication?

What Should You Do Before Stopping a Sleeping Pill?

Before stopping a sleeping pill, talk to your prescriber about a gradual tapering plan rather than quitting the medication abruptly on your own.

Gradual withdrawal has research behind it. In one telling study, 30 people with insomnia stopped taking 0.5 mg triazolam abruptly, while 30 others stepped down through progressively lower doses first (Greenblatt et al., 1987). The group that stopped abruptly showed clear rebound insomnia on their self-reported sleep measures. The tapered group, however, showed only modest rebound. Both groups were taking the same drug, starting at the same dose, but the gradual reduction provided a much gentler exit.

Once you have a tapering plan, prepare for the first few nights after your final dose, as these will be the hardest ones. Simply knowing that rebound is a normal, temporary reaction that usually passes makes a bad night much easier to sit through without panicking and reaching for the pill bottle. It is also wise to agree with your prescriber in advance on exactly what you will do if your sleep has not settled after the first week.

If you have tried to stop in the past and found the process too difficult to manage alone, where do you go from here?

Where To From Here?

If you have tried to stop taking a sleeping pill in the past and ended up going back to it because your sleep fell apart, you are in very large company, and you likely did nothing wrong. Rebound insomnia is a well-documented effect of stopping sleep medications. A bad night after stopping is not a personal failure, or proof that your brain has forgotten how to sleep without chemical assistance. It is your body reacting the way research predicts when a sedative hypnotic medication is removed.

Creating a successful exit plan is much easier when you have expert support. A Behavioral Sleep Medicine specialist can work alongside your prescriber to help you come off medication. Rather than offering basic advice, a Behavioral Sleep Medicine specialist uses a structured, individualised programme that targets the specific behavioural and psychological reasons your sleep became difficult in the first place. The aim of this process is to rebuild your natural sleep drive so that your sleep can stand on its own once the medication is gone. By addressing the root causes of your insomnia, coming off the pill becomes a planned, confident step forward, rather than a frightening leap of faith in the dark.

Frequently Asked Questions About Rebound Insomnia

Q1: How long does rebound insomnia last?

A1: Rebound insomnia usually just a night or two. Research suggests rebound insomnia hits hardest on the very first night after stopping a sleeping pill. After that initial shock to the system, sleep generally returns to its previous baseline level (Gillin et al., 1989).

Q2: Does rebound insomnia mean my original insomnia is coming back?

A2: No. Rebound insomnia is a withdrawal effect of the drug leaving your body, not your original insomnia returning. Experimental studies show healthy volunteers who have never had insomnia show the same pattern of worsened sleep when they stop taking these medications (Roehrs et al., 1986; Voderholzer et al., 2001). A true relapse looks like your old insomnia and does not fade after the first few nights.

Q3: Which sleeping pills are most likely to cause rebound insomnia?

A3:  Medications that leave the body very quickly, as well as those taken at higher doses, carry the most risk of causing rebound insomnia (Gillin et al., 1989; Roehrs et al., 1986). In clinical studies, triazolam produced clear rebound, while zolpidem and zopiclone produced much smaller changes (Soldatos et al., 1999; Voderholzer et al., 2001). Because not every sleeping pill has been tested for this effect, ask your prescriber about the specific risks of your own medication.

Q4: Why is it so hard to stop taking a sleeping pill?

A4: Rebound insomnia is one of the most likely reasons. A bad first night without the medication can easily look like proof that your body cannot manage without the pill. In one study, every long-term sleeping pill user had tried and failed to stop at least once, even though only 20% of them reported that the medication provided a distinct improvement in their sleep (Hohagen et al., 1993). The fear of poor sleep after stopping a sleeping pill keeps people taking the drug (Voderholzer et al., 2001).

Q5: Should I stop taking my sleeping pill all at once to get it over with?

A5: No. Talk to your prescriber first to create a plan. In one study, people with insomnia who lowered their medication dose in gradual steps showed only modest rebound, while those who stopped abruptly showed rebound insomnia on their self-reported sleep measures (Greenblatt et al., 1987). A gradual taper is gentler on your system.

References

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Greenblatt, D. J., Harmatz, J. S., Zinny, M. A., & Shader, R. I. (1987). Effect of gradual withdrawal on the rebound sleep disorder after discontinuation of triazolam. New England Journal of Medicine, 317(12), 722–728.

Hajak, G., Clarenbach, P., Fischer, W., Rodenbeck, A., Bandelow, B., Broocks, A., & Rüther, E. (1998). Rebound insomnia after hypnotic withdrawal in insomniac outpatients. European Archives of Psychiatry and Clinical Neuroscience, 248(3), 148–156.

Hohagen, F., Rink, K., Käppler, C., Schramm, E., Riemann, D., Weyerer, S., & Berger, M. (1993). Prevalence and treatment of insomnia in general practice: A longitudinal study. European Archives of Psychiatry and Clinical Neuroscience, 242(6), 329–336.

Kales, A., Bixler, E. O., Vela-Bueno, A., Soldatos, C. R., Niklaus, D. E., & Manfredi, R. L. (1986). Comparison of short and long half-life benzodiazepine hypnotics: Triazolam and quazepam. Clinical Pharmacology & Therapeutics, 40(4), 378–386.

Kales, A., Scharf, M. B., & Kales, J. D. (1978). Rebound insomnia: A new clinical syndrome. Science, 201(4360), 1039–1041.

Mann, K., Bauer, H., Hiemke, C., Röschke, J., Wetzel, H., & Benkert, O. (1996). Acute, subchronic and discontinuation effects of zopiclone on sleep EEG and nocturnal melatonin secretion. European Neuropsychopharmacology, 6(3), 163–168.

Mitler, M. M., Seidel, W. F., van den Hoed, J., Greenblatt, D. J., & Dement, W. C. (1984). Comparative hypnotic effects of flurazepam, triazolam, and placebo: A long-term simultaneous nighttime and daytime study. Journal of Clinical Psychopharmacology, 4(1), 2–16.

Monti, J. M., Attali, P., Monti, D., Zipfel, A., de la Giclais, B., & Morselli, P. L. (1994). Zolpidem and rebound insomnia: A double-blind, controlled polysomnographic study in chronic insomniac patients. Pharmacopsychiatry, 27(4), 166–175.

Roehrs, T. A., Zorick, F. J., Wittig, R. M., & Roth, T. (1986). Dose determinants of rebound insomnia. British Journal of Clinical Pharmacology, 22(2), 143–147.

Soldatos, C. R., Dikeos, D. G., & Whitehead, A. (1999). Tolerance and rebound insomnia with rapidly eliminated hypnotics: A meta-analysis of sleep laboratory studies. International Clinical Psychopharmacology, 14(5), 287–303.

Voderholzer, U., Riemann, D., Hornyak, M., Backhaus, J., Feige, B., Berger, M., & Hohagen, F. (2001). A double-blind, randomized and placebo-controlled study on the polysomnographic withdrawal effects of zopiclone, zolpidem and triazolam in healthy subjects. European Archives of Psychiatry and Clinical Neuroscience, 251(3), 117–123.

Ware, J. C., Walsh, J. K., Scharf, M. B., Roehrs, T., Roth, T., & Vogel, G. W. (1997). Minimal rebound insomnia after treatment with 10-mg zolpidem. Clinical Neuropharmacology, 20(2), 116–125.

Written By Dan Ford, DBSM, Sleep Psychologist

Published By The Better Sleep Clinic