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Archived Comments for: Insomnia - treatment pathways, costs and quality of life

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  1. Adverse effects of hypnotic treatments

    Daniel Kripke, UCSD

    11 July 2011

    As a humble scientist with only 49 years experience in sleep research, I find myself confused by the sophisticated economic analyses of Scott et al. on the cost-effectiveness of treating insomnia. Could it be that the economic models estimate the cost-benefits of successful insomnia treatment versus non-treatment but do not estimate the costs of adverse effects of treatment? For an old guy, reading gets a little blurry. I simply couldn┬┐t see in Figure 3 where those clever pathways allowed for the possibility of adverse effects.

    For example, the authors┬┐ analysis utilized the fact that people reporting insomnia have more automobile accidents than people not reporting insomnia. Did the analysis include the fact that people treated for insomnia with hypnotic drugs have worse driving than people not treated with hypnotic drugs [1]? Did the analysis include controlled trial evidence that patients randomly treated with hypnotics have more depression, more infection, and more cancer than those randomized to placebo [2-4]? Mallon, Broman, and Hetta found that use of hypnotics was associated with mortality ratios of 4.54 in men and 2.03 in women [5]. There are 18 published studies showing that use of hypnotics is associated with excess mortality. Would mortality perhaps influence QALYs or health costs?

    It might be that treating insomnia with cognitive-behavioral methods would save money (I do not really know), but that probably has a rather different cost-benefit ratio than treating with hypnotic drugs. Different treatments will have different cost/benefit ratios. Whatever the treatment, we cannot assume that all the impairment associated with insomnia is causal, nor that all the benefit associated with treatment is causal (since those treated with placebo usually improve in controlled trials). Unfortunately, the current literature does not include large enough randomized controlled trials to really estimate cost-benefits of any insomnia treatment, and the largest trials have all been sponsored by hypnotics manufacturers who might have a financial interest in the reports.

    Reference List

    1. Gustavsen I, Bramness JG, Skurtveit S, Engeland A, Neutel I, Morland J: Road traffic accident risk related to prescriptions of the hypnotics zopiclone, zolpidem, flunitrazepam and nitrazepam. Sleep Med 2008.
    2. Kripke DF: Greater incidence of depression with hypnotics than with placebo. BMC Psychiatry 2007, 7:42.
    3. Joya FL, Kripke DF, Loving RT, Dawson A, Kline LE: Meta-Analyses of Hypnotics and Infections: Eszopiclone, Ramelteon, Zaleplon, and Zolpidem. J Clin Sleep Med 2009, 5:377-383.
    4. Kripke DF: Possibility that certain hypnotics might cause cancer in skin. J Sleep Res 2008, 7:245-250.
    5. Mallon L, Broman JE, Hetta J: Is usage of hypnotics associated with mortality? Sleep Med 2009, 10:279-286.

    Competing interests

    Dr. Kripke has no financial interests in hypnotic drugs and has recently retired from his clinical practice in treating insomnia. He is a long-time critic of hypnotics in his web site