Editing Insomnia (section)

==== Benzodiazepines ====
[[File:Normison.jpg|thumb|Normison ([[temazepam]]) is a [[benzodiazepine]] commonly prescribed for insomnia and other [[sleep disorders]].<ref>{{cite web | url = http://www.websters-online-dictionary.org/definitions/Temazepam | title = Temazepam | archive-url = https://web.archive.org/web/20130530212815/http://www.websters-online-dictionary.org/definitions/Temazepam | archive-date=30 May 2013 | work = Websters-online-dictionary.org. | access-date = 20 November 2011 }}</ref>]]

The most commonly used class of hypnotics for insomnia are the [[benzodiazepine]]s.<ref name=Psych4th>{{cite book | vauthors = Geddes J, Price J, McKnight R, Gelder M, Mayou R |title=Psychiatry |date=2012 |publisher=Oxford University Press |location=Oxford |isbn=978-0-19-923396-0 |edition=4th}}</ref>{{rp|363}} Benzodiazepines are [[statistical significance|not significantly]] better for insomnia than [[antidepressant]]s.<ref name="pmid17619935">{{cite journal | vauthors = Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M | title = The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs | journal = Journal of General Internal Medicine | volume = 22 | issue = 9 | pages = 1335–50 | date = September 2007 | pmid = 17619935 | pmc = 2219774 | doi = 10.1007/s11606-007-0251-z }}</ref> Chronic users of [[hypnotic]] medications for insomnia do not have better sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic medications have more regular night-time awakenings than insomniacs not taking hypnotic medications.<ref>{{cite journal | vauthors = Ohayon MM, Caulet M | s2cid = 20655328 | title = Insomnia and psychotropic drug consumption | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 19 | issue = 3 | pages = 421–31 | date = May 1995 | pmid = 7624493 | doi = 10.1016/0278-5846(94)00023-B }}</ref> Many have concluded that these drugs cause an unjustifiable risk to the individual and to [[public health]] and lack evidence of long-term effectiveness. It is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly.<ref>{{cite journal | s2cid = 40188442 | title = What's wrong with prescribing hypnotics? | journal = Drug and Therapeutics Bulletin | volume = 42 | issue = 12 | pages = 89–93 | date = December 2004 | pmid = 15587763 | doi = 10.1136/dtb.2004.421289 }}</ref> Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of [[nonbenzodiazepine]]s.<ref name="Kaufmann">{{cite journal | vauthors = Kaufmann CN, Spira AP, Alexander GC, Rutkow L, Mojtabai R | title = Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010 | journal = Pharmacoepidemiology and Drug Safety | volume = 25 | issue = 6 | pages = 637–45 | date = June 2016 | pmid = 26711081 | pmc = 4889508 | doi = 10.1002/pds.3951 }}</ref>

The [[benzodiazepine]] and [[nonbenzodiazepine]] [[hypnotic]] medications also have several side effects, such as daytime fatigue, motor vehicle crashes and other accidents, cognitive impairments, and falls and fractures. Elderly people are more sensitive to these side effects.<ref>{{cite journal | vauthors = Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE | title = Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits | journal = BMJ | volume = 331 | issue = 7526 | pages = 1169 | date = November 2005 | pmid = 16284208 | pmc = 1285093 | doi = 10.1136/bmj.38623.768588.47 }}</ref> Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer term benzodiazepines can lead to [[drug tolerance|tolerance]], [[physical dependence]], [[benzodiazepine withdrawal syndrome]] upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as – like alcohol – they promote light sleep while decreasing time spent in deep sleep.<ref>{{cite journal | vauthors = Tsoi WF | title = Insomnia: drug treatment | journal = Annals of the Academy of Medicine, Singapore | volume = 20 | issue = 2 | pages = 269–72 | date = March 1991 | pmid = 1679317 }}</ref> A further problem is, with regular use of short-acting sleep aids for insomnia, daytime [[rebound anxiety]] can emerge.<ref>{{cite journal | vauthors = Montplaisir J | title = Treatment of primary insomnia | journal = CMAJ | volume = 163 | issue = 4 | pages = 389–91 | date = August 2000 | pmid = 10976252 | pmc = 80369 }}</ref> Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase.<ref name="handbook_of_integrative">{{Cite book |vauthors=Carlstedt RA |title=Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine: Perspectives, Practices, and Research |date=2009 |publisher=Springer |url=https://books.google.com/books?id=4Tkdm1vRFbUC |isbn=978-0-8261-1094-7 |pages=128–30 |access-date=2020-05-12 |archive-date=2020-06-04 |archive-url=https://web.archive.org/web/20200604135538/https://books.google.com/books?id=4Tkdm1vRFbUC%2F |url-status=live }}</ref> This is likely due to their addictive nature, both due to misuse and because – through their rapid action, tolerance and withdrawal they can "trick" insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the [[long-term use of benzodiazepines]] and is recommended whenever possible.<ref>{{cite book | vauthors =  Lader M, Cardinali DP, Pandi-Perumal SR |title=Sleep and sleep disorders: a neuropsychopharmacological approach |date=2006 |publisher=Landes Bioscience/Eurekah.com |location=Georgetown, Tex. |isbn=978-0-387-27681-6 |page=127 }}</ref><ref name="Authier-">{{cite journal | vauthors = Authier N, Boucher A, Lamaison D, Llorca PM, Descotes J, Eschalier A | title = Second meeting of the French CEIP (Centres d'Evaluation et d'Information sur la Pharmacodépendance). Part II: benzodiazepine withdrawal | journal = Therapie | volume = 64 | issue = 6 | pages = 365–70 | year = 2009 | pmid = 20025839 | doi = 10.2515/therapie/2009051 }}</ref>

Benzodiazepines all bind unselectively to the [[GABAA receptor|GABA<sub>A</sub> receptor]].<ref name="pmid17619935" /> Some theorize that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α<sub>1</sub> subunit of the GABA<sub>A</sub> receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α<sub>1</sub> subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics&nbsp;– alprazolam and diazepam, in turn, have higher activity at the α<sub>2</sub> subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α<sub>1</sub> subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α<sub>2</sub> subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.<ref name="Insomnia"/>