Rebound Insomnia: A Critical Review

Rebound insomnia, a worsening of sleep compared to pretreatment levels, has been reported upon discontinuation of short half-life benzodiazepine hypnotics. This paper reviews the existing sleep laboratory studies for the presence or absence of rebound insomnia following treatment with triazolam, temazepam, and flurazepam in insomniac patients or poor sleepers, and, when possible, in normals. The results indicate that rebound insomnia is a distinct possibility after discontinuation of triazolam in both insomniacs and normal controls. Compared with baseline, disturbed sleep was reported in insomniacs or poor sleepers for the first one or two nights of withdrawal in seven of nine polygraphically recorded sleep studies following triazolam 0.5 milligrams and in one of two studies with an adequate number of subjects following triazolam 0.25 milligrams. In one study conducted in normal volunteers, rebound insomnia was observed following triazolam 0.5 milligrams but not triazolam 0.25 milligrams. In one study, which used subjective reports of sleep rather than polygraphic recordings, rebound insomnia was significantly attenuated after triazolam 0.5 milligrams by tapering the dose over four nights. The risk of rebound insomnia after temazepam 15 or 30 milligrams was low. In keeping with its long elimination half-life, flurazepam 30 milligrams continued to exert beneficial effects for the first two to three withdrawal nights, but the possibility of a mild rebound insomnia cannot be dismissed during the intermediate withdrawal period nights 4-10 following prolonged, consecutive, nightly administration more than 30 nights.