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Healthcare costs of outpatient adverse effects likewise need evaluation. Excessive mortality may be the most expensive harm caused by hypnotics. The main thrust of this article is, assuming that hypnotic use causes harmful health outcomes, what would be the economic costs of this harm? The controlled hospital trials were not designed to assess the costs of hypnotic harms.

A best estimate is that U. More research is needed to more accurately assess unnecessary and excessive hypnotics costs to providers and insurers, as well as financial and health damages to the patients themselves. My only suggestion is for the author not to slip into the use of terminology that the causal connection is proven. Moloney et al. For example, in the long run, CBT-treated patients tapered off zolpidem slept better over time than a contrast group randomly provided with continuing zolpidem Consequences of insomnia such as absenteeism, automobile crashes, and increased medical costs were estimated to be costing the U.

Some insomnia cost studies were sponsored by hypnotic manufacturers or others with interests in attributing the costs to insomnia. A few relatively minor concerns The term proven is used quite a bit. Insufficient evidence of any benefit was found for the other benzodiazepine agonists 3. Should a 70 year old with a severe chest infection be hospitalized? Harms inferred from epidemiological association might or might not be caused in part by hypnotics, since even in studies controlling as much as possible for possible confounding by comorbidities and other factors, it is impossible to exclude all potential confounding factors of associations.

The treated subset was more likely to have a mental health diagnosis and anti-depressant medications. Several of the references also discussed the counterbalancing dangers that epidemiological association may underestimate the harms that hypnotics cause. Just saying that there are no benefits may be a bit oversold.

The author, himself, admits that this may not be resolved without randomized control trials with some diagnosed insomniacs not receiving hypnotics or receiving non-drug therapies instead. The difficulty with drawing causal conclusions from epidemiological studies is nicely illustrated by one of the cited references with some of the most compelling evidence, the study by Anderson, et al 1. The greater increase in health morbidity and mortality in those prescribed hypnotics may arise from the possibility that hypnotics are more likely to be prescribed by health professionals in cases with greater and more serious co-morbidity and those likely to have increased mortality risk.

Daniel F. Competing interests: The author has no financial interests or conflicts to declare. There is often causal language that may be more strong than the evidence warrants. It will thus be more effectively taken up than if the author takes the one step too far to insist upon the causal link. We simply cannot be certain until randomized controlled trials are conducted.

The only lingering doubt, however, is not knowing the outcome had they not been medicated. This is strong circumstantial evidence that the hypnotic medications were causing an increase in medical costs. Perhaps this section could be better labeled.

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