‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.

1. Review other medication, possible underlying causes, substance misuse, expectations of sleep and sleep hygiene before considering a hypnotic.

2. Hypnotics should not be prescribed indiscriminately, or routinely. Use hypnotics intermittently where possible. Before prescribing, inform patients that all hypnotics are licensed for short-term use only, and may cause rebound insomnia.

3. Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress.

4. All hypnotics can affect judgement, concentration and driving the next day; all can potentially cause dependence.

5. Benzodiazepines should be withdrawn gradually in patients who may be dependent. See BNF section 4.1 for details about the benzodiazepine withdrawal syndrome, and a method of stepped withdrawal.

6. Temazepam is a Schedule 3 CD. A maximum of 30 days supply for all controlled drugs is the good practice advice from the Department of Health.

7. If drug therapy is used, the guidelines of the Royal College of Psychiatrists should be followed.

 Use the lowest effective dose.

 Use intermittent dosing (alternate nights or less) where possible.

 Prescribe for no more than 4 weeks in the majority of cases.

 Discontinue slowly.

 Be alert for rebound insomnia and withdrawal symptoms.

 Advise patients of additive effects with alcohol and other sedating drugs.

 Avoid use altogether in patients with respiratory disease, severe hepatic impairment and in addiction prone individuals.

8. Patients with insomnia may benefit from the occasional use of a sedating antihistamine.

9. Chloral hydrate and its derivatives are considered less suitable for prescribing. Drug Safety Update June 2009 highlights that Chloral hydrate (Welldorm) and Triclofos are not first-line options for insomnia. They are indicated only for the short-term treatment of severe insomnia which is interfering with normal daily life and where other therapies have failed, as an adjunct to non-pharmacological therapies. The use of hypnotics in children and adolescents is not generally recommended, and if used should be under the supervision of a specialist, noting that Welldorm elixir can be used in children aged two years or older as an adjunct to behavioural therapy and sleep hygiene management, usually for less than two weeks.

10. NICE Guidance on Zaleplon, zolpidem and zopiclone for short-term management of insomnia (April 2004)

 - If, after due consideration of nonpharmacological measures, hypnotic drug therapy is considered it should only be prescribed for short periods, in strict accordance with licensed indications.

 - Because of the lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics, the drug with the lowest purchase cost should be prescribed.

 - Switching should only occur if the patient experiences adverse effects directly related to a specific agent. This is the only circumstance where a drug with higher cost would be recommended.

 - Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.