The article “Hypnotics and driving: FDA action and clinical trials show need for precautions” (Current Psychiatry, April 2007) was superb in its thoroughness on sedative hypnotics’ risks. However, it lacked any comparative data and discussion about the risks associated with other commonly used sleep medications such as trazodone, ramelteon, or quetiapine. It also does not provide enough comparative information on driving impairment from diminished sleep. As for informed consent, a useful strategy is to find out if someone else shares the patient’s bed or bedroom, and to make sure he or she knows the risks of sedative hypnotics.
Finally, care should be taken when making a diagnostic assessment before using sedative hypnotics. Rule out other medical causes of poor sleep—such as sleep apnea—because I’ve observed that such patients use more sleep medication than necessary because the condition diminishes the drugs’ effectiveness. Of course, sleep hygiene techniques should be tried first.
H. Steven Moffic, MD
Professor of psychiatry and behavioral medicine
Medical College of Wisconsin
Milwaukee
Drs. Freeman and Buckland respond
We agree with Dr. Moffic that a more comprehensive comparison of hypnotics would be useful. Sleep problems are almost always multifactorial, and behavioral manipulation—not medication—often is the first and best intervention. We know that a driver’s reaction time decreases as fatigue and sleepiness increase,1 an important consideration when developing a treatment plan, especially when treating a patient who drives for a living. Physicians should investigate medical disorders such as sleep apnea and ensure that patients employ sleep hygiene principles before beginning any medication. Safety issues detailed in the article need to be part of the informed consent.
Enlisting the help of others close to the patient increases the detection of side effects and complications. This support can be applied to any medication or intervention used to treat our patients. The sedative hypnotics can be helpful to patients but also quite damaging. Any treatment plan must consider safety first.
Bradley Freeman, MD
Fourth-year resident
J. Jason Buckland, DO
Department of neuropsychiatry and
behavioral science
University of South Carolina School
of Medicine, Columbia