Relative toxicity of benzodiazepines and hypnotics commonly used for self-poisoning: An epidemiological study of fatal toxicity and case fatality

Fatal Intoxications with Zopiclone-A Cause for Concern?

INTRODUCTION

Zopiclone, a controlled substance prescribed for insomnia, has become a common toxicological finding in forensic autopsy cases. This study investigated the role and extent of zopiclone use in fatal intoxications in Sweden.

METHODS

All forensic autopsy cases positive for zopiclone in femoral blood during 2012-2020 were selected. Among these cases, fatalities caused by intoxication according to the cause of death certificates issued by the forensic pathologist were identified. Intoxications where zopiclone contributed to the cause of death were included in the study. The Swedish Prescribed Drug Register was utilized to examine whether the included cases were prescribed zopiclone or not.

RESULTS

In total 7320 fatal intoxications underwent a forensic autopsy during the study period, 573 of them were caused by zopiclone. Among the zopiclone fatalities, 87% (n = 494) had a prescription for zopiclone, and 8% (n = 43) were monointoxications. Most fatalities, 62% (n = 354) were suicides, and zopiclone was involved in about 17% (n = 354) of all intoxication suicides in Sweden. Women were significantly (p < 0.01) overrepresented in suicides with zopiclone, comprising 56% (n = 291) of fatalities. The median age was 55 years among zopiclone intoxications compared with 44 years amongst all fatal intoxications.

CONCLUSION

This study demonstrates that the toxicity of zopiclone can be lethal both in combination with other substances and on its own. Most individuals dying in fatal zopiclone intoxications were prescribed zopiclone, which potentially indicates that a more restrictive prescribing rate could prevent future intoxication deaths, especially when caring for patients with an increased suicide risk.

Substances Detected During Coroner Postmortem Toxicology Analyses in Poisoning- and Nonpoisoning-Related Suicides

Importance

Determining the association between drug use and suicide is complicated but can help to inform targeted suicide prevention strategies.

Objective

To examine the substances prevalent in poisoning- and nonpoisoning-related suicides in Australia.

Design, Setting, and Participants

This was a multiple-year, cross-sectional study of suicides from July 2013 to October 2019 in Australia with toxicology data available in a national coronial database. The cause of death was classified as poisoning related if any type of poisoning was determined by the coroner to contribute to the cause of death. Prevalence ratios (PRs) were calculated to compare substance detection in poisoning- vs nonpoisoning-related suicides. Data were analyzed from October 2021 to April 2023.

Exposures

All substances detected in decedents at the time of death according to toxicology reports were recorded.

Main Outcome(s) and Measure(s)

The most common individual substances and substance classes were identified. From these, blood concentrations of substances of interest were analyzed, and the most commonly occurring combinations of substance classes were listed.

Results

Toxicology was performed on 13 664 suicide decedents (median [IQR] age, 44 [31-57] years; 10 350 male [76%]). From these, 3397 (25%) were poisoning-related suicides (median [IQR] age, 50 [38-63] years; 2124 male [63%]). The remainder were classified as nonpoisoning-related suicides (median [IQR] age, 42 [29-55] years; 8226 male [80%]). PRs for common medicine classes being detected in poisoning-related suicides compared with nonpoisoning-related suicides were as follows: antidepressants (PR, 1.63; 95% CI, 1.54-1.73), benzodiazepines (PR, 2.01; 95% CI, 1.90-2.13), nonopioid analgesics/anti-inflammatory drugs (PR, 1.88; 95% CI, 1.78-2.00), and opioids (PR, 2.72; 95% CI, 2.58-2.87). Alcohol (as ethanol ≥0.03 g/100 mL) was almost equally prevalent in poisoning- and nonpoisoning-related deaths (PR, 1.07; 95% CI, 1.01-1.14), whereas amphetamines (PR, 0.68; 95% CI, 0.61-0.77) and cannabinoids (PR, 0.67; 95% CI, 0.60-0.74) were detected more often in nonpoisoning-related suicides. Combinations of multiple sedative agents in poisoning-related suicides were common.

Conclusions and Relevance

Both poisoning- and nonpoisoning-related suicide deaths featured a high prevalence of psychotropic medicines or potential intoxication, which suggests the association of suicide with poor mental health and substance misuse. Findings suggest that substances with a high involvement in poisoning-related suicides should be prescribed cautiously, including antidepressants that are toxic in overdose, sedatives, opioids, and potentially lethal combinations.

Knowledge, Attitudes and Practices Related to Medication, Antibiotics, and Vaccination among Public Service Population: National Survey Conducted in France

Medication, antibiotics, and immunization are three major and cost-effective medical interventions but their use is balanced. Knowledge, attitudes and practices (KAP) are a cornerstone. This retrospective study aims at analyzing KAP related to these concerns among the public service population in order to establish the basis for the implementation of selective preventive actions. From a cross-sectional anonymous online questionnaire-based survey among the insurees of a French mutual organization (Union Prévention Santé pour la Fonction publique, UROPS), 33 questions related to medication, antibiotics and vaccination were extracted to evaluate KAP. New variables were constituted: levels of knowledge, antibiotic misuse, proactive behavior and vaccinophobia. Multiple correspondence analysis was performed to identify respondents' homogenous groups. In addition, bivariate statistical comparisons were provided and logistic regressions were carried out to identify determinants of these new variables. Public service population (workers and retired) were highly exposed to polymedication (8.7% vs. 24.4%, p < 0.0001), hypnotics overtake (24.3% vs. 18.4%, p < 0.0001), and misuse antibiotics (33.2% vs. 22.6%, p < 0.0001) despite good levels of knowledge. Proportions of vaccinophobia was low (0.8% vs. 1.7%, p < 0.0001). However, workers have different KAP than retired, without shared determinants in the 3 health domains studied. Respondents were proactive (85.8% vs. 81.6%, p < 0.0001), used multiple sources of trustworthy information and seems to be ready for the delegation of health tasks. Thus, preventive actions related to antibiotics and polymedication should be a priority in vaccination education for mutual organizations such as UROPS. Studying their insurees longitudinally could be interesting to highlight the impact of selective prevention on behaviors, through trusted health professionals (general practitioners, pharmacists…).

Association between hospital-diagnosed sleep disorders and suicide: a nationwide cohort study

STUDY OBJECTIVES

Sleep disorders are related to mental disorders. Yet few studies have examined their association with suicide. We examined whether males and females diagnosed with sleep disorders had higher rates of suicide than individuals not diagnosed with sleep disorders.

METHODS

In a cohort study, nationwide data on all males and females aged over 15 years living in Denmark during 1980-2016 were analyzed. Sleep disorders were identified through diagnoses recorded during contacts to somatic hospitals. Incidence rate ratios (IRR) were estimated using Poisson regression models and adjusted for covariates.

RESULTS

In all, 3 674 563 males and 3 688 164 females were included, of whom 82 223 (2.2%, mean age: 50.2 years, SD: 17.5) males and 40 003 (1.1%, mean age: 50.6 years, SD: 19.9) females had sleep disorder diagnoses. Compared with those with no sleep disorders, the adjusted IRR for suicide were 1.6 (95% CI, 1.4 to 1.7) and 2.2 (95% CI, 1.8 to 2.6) for males and females with sleep disorders, respectively. Excess rates for narcolepsy were found for males (IRR: 1.2, 95% CI, 1.0 to 1.5) and females (IRR: 3.3, 95% CI, 3.0 to 4.1), and for sleep apnea in males (IRR: 1.8, 95% CI, 1.5 to 2.2). A difference with respect to age and sex was observed (p < 0.001) between males and females. Males and females had IRR of 4.1 (95% CI, 3.1 to 5.5) and 7.0 (95% CI, 4.8 to 10.1), during the first 6 months after being diagnosed with a sleep disorder.

CONCLUSIONS

Sleep disorders were associated with higher suicide rates even after adjusting for preexisting mental disorders. Our findings suggest attention toward suicidality in patients with sleep disorders is warranted.

Characterizing stimulant overdose: A qualitative study on perceptions and experiences of "overamping"

BACKGROUND

The dominant focus of North America's current overdose crisis has been opioids, resulting in considerable research and harm reduction efforts to address opioid-related overdose risks. Less attention has been paid to people who use stimulants (PWUS) despite recent increases in stimulant use and stimulant-involved overdoses (i.e., "overamping"). Stimulant users' definitions, risk factors and experiences of, and responses to, overamping are poorly understood, thereby putting PWUS at heightened risk of adverse health outcomes. This study explores how PWUS understand, experience, and respond to overamping.

METHODS

In-depth qualitative interviews were conducted with 61 PWUS in Vancouver, Canada's Downtown Eastside neighbourhood. Thematic analysis of interviews focused on contextualizing stimulant overdoses, including how PWUS understand, define, experience, and respond to overamping.

RESULTS

Participants associated overamping experiences with commonly identified signs and symptoms, such as rapid onset, elevated heart rate, incontinence, and audiovisua hallucinations, but also reported more serious indicators of overamping, such as unconsciousness, cardiac arrests and seizures. Our findings demonstrate that, among PWUS, there was no unified understanding of overamping such as with opioid overdose and individual experiences had substantial variation in severity and presentation. This impacted the ability to adequately respond to stimulant overdoses, which were primarily self-managed through methods including stabilizing breathing, polysubstance use, and cold showers.

CONCLUSION

Given the growing role of stimulants in North America's overdose crisis, there is an urgent need to improve the identification of stimulant overdoses in real world settings. Our findings identify a gap in current understandings of stimulant overdose, and demonstrate the need for public health and harm reduction interventions to better address overamp risk among PWUS, including harm reduction campaigns to disseminate information regarding identifying signs of, and proper responses to, overamping.

[Toxicology of suicide cases in the state of Rio Grande do Sul, Brazil, 2017 to 2019Perfil toxicológico de los casos de suicidio en Rio Grande do Sul (Brasil), 2017-2019]

Objetivo.

Descrever o perfil toxicológico de todas as vítimas de suicídio no Rio Grande do Sul, Brasil, de 2017 a 2019.

Métodos.

Neste estudo descritivo e transversal, foram consultados todos os laudos periciais e as ocorrências policiais relacionados aos óbitos por suicídio no estado. Foram realizadas análises de correspondência múltipla e construídos modelos independentes de regressão logística, tendo como variáveis dependentes o etanol, os ansiolíticos, os antidepressivos, as substâncias ilícitas e os agentes tóxicos não medicamentosos.

Resultados.

Foram realizados 2 978 exames de alcoolemia, com resultado positivo em 28,5%. A chance de resultados positivos para alcoolemia foi 0,5 (IC95%: 1,1 a 2,2) vez maior para suicídio durante a noite, 1,0 (IC95%: 1,4 a 2,9) vez maior para suicídio aos finais de semana e 0,9 (IC95%: 1,3 a 2,7) vez maior na presença de antecedentes criminais. A pesquisa de psicotrópicos (2 900 amostras) detectou algum medicamento em 30,4%. Os ansiolíticos foram a classe mais frequente, com chance 1,5 (IC95%: 1,6 a 4,1) vez maior em mulheres e 0,8 (IC95%: 1,2 a 2,7) vez maior para suicídios ocorridos no outono-inverno. As substâncias ilícitas (n = 338) tiveram chance 4,1 (IC95%: 1,9 a 14,4) vezes maior de detecção na macrorregião de Pelotas em relação à de Passo Fundo e 1,2 (IC95%: 1,3 a 3,6) vez maior em pessoas com resultados positivos para etanol. Não houve diferença significativa entre adolescentes e adultos.

Conclusões.

Embora sem evidência de causalidade, os resultados mostram um vínculo entre o suicídio e diversos psicoativos. Os médicos legistas devem ser orientados quanto à necessidade de realização de exames toxicológicos em todos os casos de suicídio.

Nonopioid Overdose Death Rates Rose Almost As Fast As Those Involving Opioids, 1999-2016

The number of Americans dying from drug overdoses has risen rapidly, but the contribution of nonopioid drugs to this growth is not well understood. Using vital statistics data from the universe of deaths among US residents in the period 1999-2016, I calculated levels of and increases in overall nonopioid fatal overdose rates and those for subgroups stratified by manner of death, sex, race/ethnicity, and age. Mortality rates were also calculated separately for sedatives, stimulants, antidepressants, and cocaine. Recently developed methods were used to correct for the incomplete reporting of drug involvement on death certificates. From 1999 to 2016 the number of nonopioid drug deaths rose 274 percent, and deaths per 100,000 population rose by 223 percent. Over the same period, opioid-involved fatality counts and rates grew by 371 percent and 307 percent, respectively. Fatal overdose rates involving stimulants increased more than tenfold, with slower growth but higher rates for deaths involving sedatives and cocaine. Midlife non-Hispanic whites generally experienced the highest levels and rise in nonopioid death rates, but cocaine fatality rates were particularly common among nonwhite or Hispanic males ages 40-59. Policies designed to curb the opioid epidemic are probably helpful in reducing nonopioid deaths, but targeted interventions may also be needed.

[Synthesis of evidence: Guidance for the diagnosis and treatment of Chagas diseaseSíntese de evidências: Guia de diagnóstico e tratamento da doença de Chagas]

Introducción.

La enfermedad de Chagas o tripanosomiasis americana es causada por el protozoo flagelado Trypanosoma cruzi, transmitido principalmente por insectos vectores (denominados popularmente en las diferentes zonas de la Región de las Américas “vinchucas”, “pitos”, “chinches”, “chirimachas” o “kissing bugs”). El parásito es transmitido por vía transplacentaria, transfusiones y, menos frecuentemente, por vía oral o trasplante de órganos. La implementación de políticas públicas y el manejo de la condición clínica requiere ser fortalecido debido a las dificultades diagnósticas y terapéuticas que presenta esta parasitosis sistémica. Para contribuir con ello, la Organización Panamericana de la Salud (OPS) desarrolló una guía para el manejo de la tripanosomiasis americana.

Objetivos.

Sintetizar las recomendaciones incluidas en la Guía para el diagnóstico y el tratamiento de la enfermedad de Chagas, publicada por la Organización Panamericana de la Salud en 2018, con el fin de presentar el adecuado diagnóstico y tratamiento de la enfermedad de Chagas y abordar aspectos sobre su implementación.

Métodos.

Se llevó a cabo una síntesis de la guía y sus recomendaciones. Adicionalmente, se realizó una búsqueda sistemática en PubMed, Lilacs, Health Systems Evidence, Epistemonikos y literatura gris de estudios desarrollados en las Américas con el fin de identificar barreras, facilitadores y estrategias de implementación.

Resultados.

Se presentan 10 recomendaciones aplicables a pacientes adultos y pediátricos con sospecha de enfermedad de Chagas, exposición a T. cruzi y diagnóstico confirmado de enfermedad de Chagas aguda, crónica y congénita. Se identificaron reportes que abordaron aspectos de implementación.

Conclusiones.

Las recomendaciones buscan proveer estrategias para el diagnóstico y tratamiento oportunos de la enfermedad de Chagas, así como consideraciones para su implementación.

A comprehensive analysis of attempted and fatal suicide cases involving frequently used psychotropic medications

OBJECTIVES

Self-poisoning is the most common suicide method in non-lethal suicide attempts and the third most frequent in fatal suicides. Psychoactive drugs are often used for intentional self-poisoning. While poisons centre data typically focus on survived suicide attempts and underrepresent fatal self-poisoning, medical examiner reports give insight into suicide deaths. To close this gap, we combined and compared data sets from both sources, assessing the mortality of psychotropic drugs used for self-poisoning.

METHODS

Anonymized cases of self-poisoning with suicidal intention from 2000 to 2010 were extracted from the national poisons centre case database and compared with cases of suicide documented in the project "Suicides, a national survey". All cases with single substance exposure to a psychoactive drug (antidepressants, mood stabilizers, antipsychotics, sedatives) were included in the analyses. Opioids, over-the-counter- and illicit- drugs were excluded from the analysis. A mortality index was calculated by the ratio of the number of suicides and the sum of all (lethal and non-lethal) suicide attempts.

RESULTS

Tricyclics had a higher mortality rate than other antidepressants. Among the sedatives, zolpidem was found to have a higher mortality index compared to benzodiazepines. Clozapine and levomepromazine were found to be the most lethal antipsychotics. Non-lethal suicide cases with single substance exposure (n = 4697) diminished as age increased, while the rate of suicide cases (n = 165) was higher in elderly subjects (>65 years of age, p < 0.001).

CONCLUSION

In summary, our findings confirm previous study results on the relative toxicity of distinct classes of psychotropic drugs. In this comprehensive analysis of a national cohort lorazepam had a lower mortality rate compared to other sedatives.

A national case fatality study of drugs taken in intentional overdose

BACKGROUND

Intentional drug overdose (IDO) has been linked with marked increases in premature mortality risk due to suicide, accidents and other causes, yet little is known about how case fatality risk varies according to the type of drug/s taken. This study aimed to examine the incidence of IDO, to identify the predictors of fatal IDO and to establish which drugs are linked with greater risk of a fatal outcome.

METHODS

Data from the National Self-Harm Registry, and the National Drug-Related Deaths Index, 2007-2014, were used to calculate incidence, examine overdose characteristics and estimate case fatality risk ratios.

RESULTS

We examined 63,831 non-fatal and 364 fatal IDOs (incidence: 148.8 and 1.01 per 100,000 respectively). Compared to non-fatal IDOs, fatal cases were more often male (55.2% vs. 42.0%), older in age (median 44 vs. 35 years), and more frequently involved multiple drugs (78.3% vs. 48.5%). Tricyclic antidepressants were associated with a 15-fold increased risk of death and opioids a 12-fold increased risk, relative to the reference category (non-opioid analgesics). While the risk of fatal outcome was higher for males than females, the elevation in risk was greater in females when tricyclic antidepressants or opioids were taken.

CONCLUSION

Male gender, increasing age and multiple drug use were associated with fatal IDO outcome. Tricyclic antidepressants and opioids were associated with a significantly increased risk of death following intentional overdose. Clinicians need to consider the case fatality risk of drugs when determining treatment for patients at risk of or those who have previously harmed themselves.

The relative lethal toxicity of pharmaceutical and illicit substances: A 16-year study of the Greater Newcastle Hunter Area, Australia

AIMS

We aim to calculate 2 metrics of relative lethal toxicity; the fatal toxicity index (FTI; number of deaths per year of a daily dose) and the case fatality (CF; number of deaths per overdose) with a focus on opioids, antidepressants, antipsychotics, benzodiazepines and illicit drugs.

METHODS

This descriptive cohort study used the Australian National Coronial Information System (NCIS) to identify a population of individuals with drug-associated deaths in the Greater Newcastle Hunter Area between January 2002 and December 2016. This was combined with Australian medicine dispensing data and corresponding data from the Hunter Area Toxicology Service to calculate FTI and CF.

RESULTS

There were 444 drug-related deaths and 21,296 overdoses during the study period. FTI and CF were well correlated (Spearman's rho 0.64, P < .001). Of the classes of interest, opioids had the highest FTI (40.3 95% confidence interval [CI] 35.2-45.4 deaths per 100 years of use at the defined daily dose or deaths/DDD/100 years) and CF (12.4% 95%CI 11.0-13.9). Fentanyl, methadone and morphine had the highest relative fatal toxicity within this class. Tricyclic antidepressants had the highest relative fatal toxicity of all antidepressants (FTI 14.5 95%CI 9.7-19.3 deaths/DDD/100 years and CF 7.1% [95%CI 4.8-9.3]) and benzodiazepines appeared to be more associated with multiple agent deaths than single. Of the illicit drugs, heroin had the highest CF (26.4%, 95%CI 19.1-33.7).

CONCLUSION

Knowledge of relative lethal toxicity is useful to prescribers and medicines and public health policy makers in restricting access to more toxic drugs and may also assist coroners in determining cause of death.

Infections, Anti-infective Agents, and Risk of Deliberate Self-harm and Suicide in a Young Cohort: A Nationwide Study

BACKGROUND

Evidence links infections to mental disorders and suicidal behavior. However, knowledge is sparse regarding less severe infections, anti-infective treatment, and deliberate self-harm. Using nationwide Danish longitudinal registers, we estimated associations between infections treated with anti-infective agents and infections requiring hospitalization with the risk of deliberate self-harm.

METHODS

A total of 1.3 million people born between 1977 and 2002 were followed during the period from 1995 to 2013. In total, 15,042 individuals were recorded with deliberate self-harm (92% had been treated with anti-infective agents and 19% had been hospitalized for infections) and 114 died by suicide (64% had been treated with anti-infective agents and 13% had been hospitalized for infections). Hazard rate ratios were obtained while adjusting for age, gender, calendar period, education, hospitalizations with infections, prescribed anti-infective agents during childhood, parental mental disorders, and parental deliberate self-harm.

RESULTS

Individuals with infections treated with anti-infective agents had an increased risk of deliberate self-harm with a hazard rate ratio of 1.80 (95% confidence interval = 1.68-1.91). The associations fitted a dose-response relationship (p < .001) and remained significant up to 5 years after last infection. An additive effect was found for individuals with an additional hospitalization for infections with an increased hazard rate ratio of 3.20 (95% confidence interval = 2.96-3.45) for deliberate self-harm.

CONCLUSIONS

An increased risk of deliberate self-harm was found among individuals with infections treated with anti-infective agents in temporal and dose-response associations. These results add to the growing literature on a possible link between infections and the pathophysiological mechanisms of suicidal behavior.

Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning

BACKGROUND

Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour.

METHOD

Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012.

RESULTS

There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47).

CONCLUSIONS

There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.