Hypnotic medication in the treatment of chronic insomnia: non nocere! Doesn't anyone care?

Chronic primary insomnia is a recurrent condition that negatively effects the daily functioning of patients, diminishing the quality of their lives. It is associated with, and in some situations, is a risk factor in both psychiatric (depression) and physical (cardiovascular) illness. Treatment effectiveness has been shown in the shout term for both drug (benzodiazepine and benzodiazepine agonists) and behavioral treatment. Expert opinion has strongly advised against long term drug treatment because of concerns about residual sedative effects, memory impairment, falls, respiratory depression, rebound insomnia, medication abuse, dose escalation, dependency and withdrawal difficulties, and an increased risk of death possibly associated with the current hypnotic medications. Many of these concerns could be made against using these agents at all. Worries about these potential problems are challenged by the widespread clinical practice of using hypnotic drugs long-term without any of these difficulties developing and with patients who feel their sleep and daily function function is improved with the nightly use of their sleeping pill. The ability to mount a randomized, placebo-controlled, parallel group, double-blind trial of hypnotic medication in primary insomnia may not be possible. We may have to develop large systematic clinical databases, a number of case series in effect, to monitor both emergent symptoms and possible clinical effectiveness. There is the additional concern that there is a reluctance to examine the long-term drug treatment of insomnia. This reluctance may reflect a negative moral judgement about treating primary insomnia with drugs, a sort of "pharmacological Calvinism", rather than just a data based judiciousness. (C) 2000 Harcourt Publishers Ltd.