To the Editor: The literature review by Ripu D. Jindal, M.D., et al. (1) highlighted important and timely issues concerning the public health problem of insomnia and the lack of literature on the maintenance treatment of insomnia. Although the authors discussed the ongoing debate on the long-term use of benzodiazepines, they cited a range of clinical and biological studies suggesting that "the liability of abuse of benzodiazepines is generally low." We would also stress the need to consider data on sedative abuse from large-scale community surveys that were not included in the review. The lifetime prevalence of sedative abuse/dependence was 1.2% in the Epidemiologic Catchment Area study (2). Recently, data from the National Comorbidity Survey suggested a lifetime prevalence of sedative dependence at 0.5%, as well as 7.1% of the U.S. population reporting the nonprescription use of sedatives (3). Respondents with sedative misuse and dependence had high levels of psychopathology and an increased risk of suicidal ideation/attempts (3).

To further examine this issue, we conducted analysis of a large community sample (N=8,116, ages 15–64) in Ontario, Canada, that had the same methodology as the National Comorbidity Survey (4). In the Ontario sample, 4.3% of the respondents reported nonprescription use of sedative/hypnotic medications, and 0.3% of the sample met DSM-III-R criteria for sedative abuse or dependence. Lifetime sedative misuse had a significant association with past-year suicidal ideation (odds ratio=2.34, 95% confidence interval [CI]=1.15–4.73), lifetime DSM-III-R major depression (odds ratio=4.47, 95% CI=3.00–6.66), and any lifetime anxiety disorder diagnosis (social phobia, simple phobia, generalized anxiety disorder, panic disorder, agoraphobia) (odds ratio=3.00, 95% CI=2.11–4.30). All odds ratios presented are adjusted for age, gender, education, and low-income status.

In summary, data from community surveys in North American society suggest that misuse and abuse of sedative medications is prevalent in the community and is associated with significant psychiatric morbidity. Although the findings from the these community surveys are limited because of the cross-sectional design, we suggest that future longitudinal studies in clinical and community samples are required to delineate the risk factors associated with abuse of sedative medications. When treating individuals with insomnia, clinicians need to carefully weigh the risks and benefits of long-term sedative medications and to consider nonpharmacological treatments, such as cognitive behavior therapy (5).