Abstract
Objective
Although cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for chronic insomnia, pharmacological treatment remains common in clinical practice. This study aimed to examine factors associated with favorable attitudes toward hypnotic use in patients with insomnia and to investigate whether suicidality mediates this relationship.
Methods
An online survey was conducted during June 18–25, 2025. We collected the demographic information of 548 individuals currently experiencing insomnia and their responses to questionnaires including sleep indices, the discrepancy between desired time in bed and desired total sleep time (DBST) index, attitude toward hypnotic use, the Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16), and Depressive Symptoms Inventory–Suicidality Scale (DSI-SS). Logistic regression and Pearson’s correlation were performed to explore the factors contributing to favorable attitudes toward hypnotic use. Mediation analysis was implemented.
Results
Logistic regression analysis adjusted for age and sex revealed that longer time in bed per day (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 0.001–0.12, p = 0.046) and higher scores on the DSI-SS (OR = 1.09, 95% CI = 0.01–0.16, p = 0.037) were significantly associated with favorable attitudes toward hypnotic use. Mediation analysis indicated that suicidality mediated the relationship between the insomnia severity and favorable attitudes toward hypnotics.
Conclusion
Suicidality mediates the association between insomnia severity and favorable attitudes toward hypnotic use, suggesting it may be a relevant psychological factor in this relationship.
Keywords: Insomnia, Suicidality, Hypnotics
Introduction
Insomnia is characterized by difficulties in sleep quantity, quality, or continuity. Population-based data indicate that approximately one-third of adults report insomnia symptoms; however, when applying Diagnostic and Statistical Manual of Mental Disorders or International Classification of Sleep Disorders diagnostic criteria, the average prevalence of insomnia disorder is around 10% [1]. Transient or acute insomnia is often precipitated by identifiable triggers and typically resolves within days to weeks. In contrast, chronic insomnia may develop when initial symptoms are maintained by perpetuating factors such as maladaptive sleep habits, hyperarousal, and cognitive distortions about insomnia.
According to the current guidelines [2–4], cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia. CBT-I targets these perpetuating factors and consists of five core components: sleep hygiene education, sleep restriction therapy, stimulus control therapy, relaxation techniques, and cognitive restructuring. Meta-analyses have shown that CBT-I leads to significant improvements in insomnia severity, sleep efficiency, sleep quality, wake after sleep onset, and sleep onset latency (SOL) [5, 6]. Compared to pharmacotherapy, CBT-I is equally or more effective, with superior long-term outcomes that are maintained for at least six months following treatment termination [7, 8]. When CBT-I is ineffective, unavailable, or not feasible, pharmacological treatments—such as benzodiazepine receptor agonists (BZRAs), orexin receptor antagonists (ORAs), sedating antidepressants, melatonin, and melatonin receptor agonists (MRAs)—may be considered as alternative treatment [9]. Hypnotic medications are often perceived as a convenient and rapidly effective option for alleviating insomnia symptoms. However, Z-class drugs and benzodiazepines, which are frequently prescribed as hypnotics, are associated with significant risks, including tolerance, abuse, dependence potential, and adverse effects such as anterograde amnesia, daytime sedation, and parasomnias including sleep walking or eating [10]. According to the clinical guidelines [2–4], long-term use of benzodiazepines (i.e., use beyond 4 weeks) is discouraged. These guidelines emphasize the importance of prescribing such medications on an intermittent, as-needed basis rather than daily use. Consequently, it is imperative that CBT-I be appropriately utilized as the primary approach before initiating pharmacotherapy for insomnia.
In clinical practice, hypnotics are frequently prescribed on a long-term basis. While retrospective cohort studies have identified several demographic and clinical predictors of long-term hypnotic use, including higher prescription rates in women, older adults, and non-Hispanic White individuals [11], as well as associations of antidepressant use, advanced age, and higher hypnotic doses with prolonged treatment duration [12], the factors driving sustained use remain insufficiently understood. Cognitive factors have been shown to influence the use of hypnotics in patients with insomnia. One recent short-term (3-month) prospective study based on the theory of planned behavior (TPB) [13] demonstrated that lower levels of perceived behavior control, defined as the belief that one can manage sleep problems without the aid of sleeping pills, were associated with stronger intentions to use hypnotics. Moreover, these behavioral intentions significantly predicted subsequent hypnotic use, particularly in individuals with high levels of hypnotic craving, suggesting that habitual use may override intention in certain cases. These findings indicate that cognitive and attitudinal variables can contribute to persistent hypnotic use.
Physicians’ prescribing attitudes may further reinforce or mitigate long-term hypnotic use. Among available pharmacological agents, the prescription rates of BZRAs have declined over recent years, whereas the use of ORAs has markedly increased since their market introduction in 2014 [14]. While efficacy was historically the primary consideration in prescribing BZRAs, the emergence of novel hypnotics such as ORAs and MRAs has prompted clinicians to increasingly emphasize safety alongside efficacy in their prescribing decisions [15]. Since prescribing attitudes are thought to play a significant role in the persistence of long-term hypnotic use, clinicians may be able to provide more personalized and prudent prescribing if they can identify patients at risk of long-term hypnotic use based on psychological and behavioral predictors.
While a favorable attitude toward hypnotics may help alleviate symptoms in patients with severe insomnia who do not respond to CBT-I, it can also promote indiscriminate use of hypnotics as a default strategy for managing insomnia. According to the Multimodal Optimized Treatment for Insomnia Framework (MOTIF), hypnotic medications should be considered only when the patient is unable to sleep without medication [16]. However, in real-world clinical practice, this approach is often not properly implemented, leading to suboptimal treatment decisions and prolonged hypnotic use.
Studies have shown that insomnia is an independent risk factor for suicidal ideation and behavior, even after accounting for depression or other psychiatric comorbidities [17]. Insomnia-related distress may increase emotional vulnerability and suicidal ideation, and individuals with higher suicidality may be more likely to seek rapid relief through hypnotic medications. This pathway provides a theoretical basis for considering suicidality as a mediator linking insomnia severity to attitudes toward hypnotic use. Furthermore, the use of sedative-hypnotic medications has been associated with an increased risk of suicidality, possibly due to disinhibition, cognitive side effects, or underlying psychological vulnerability [18, 19]. Favorable attitudes toward hypnotics have been shown to be associated with increased risk of long-term use and potential misuse in both general and psychiatric populations [20, 21]. These findings suggest that suicidality may play a mediating role in the relationship between insomnia and attitudes toward hypnotic use. Therefore, the present study aimed to examine the influence of insomnia on favorable attitudes to hypnotics and whether suicidality mediates this association. Identifying patients with such attitudes could help clinicians better understand patterns of hypnotic use and implement strategies for safer prescribing and monitoring.
Methods
Participants and procedure
From June 18–24, 2025, an anonymous online survey was conducted among the registered general population panels affiliated with EMBRAIN (Seoul, Korea), a professional survey company. The survey form was designed to gather demographic information, including participants’ age, sex, and marital status, alongside critical details regarding their past psychiatric history and responses to validated rating scales. To ensure the relevance of the data collected, specific eligibility criteria were established. Participants were required to affirmatively respond to the question, “Have you experienced difficulty falling asleep or maintaining sleep in the past three months?”, thereby focusing the study on individuals currently experiencing sleep disturbances. Furthermore, to exclude confounding factors such as circadian rhythm sleep–wake disorders, participants also needed to confirm, “Do you go to bed between 9 PM and 12 AM every day?”. Conversely, individuals whose work schedules might interfere with consistent sleep patterns were explicitly excluded by the question, “Are you working a shift?”. Prior to beginning the survey, all participants were presented with detailed information and were required to explicitly affirm their agreement for the participation.
The appropriate sample size was estimated at 600 participants, derived by allocating 50 samples to each of 12 predefined cells: sex (male, female) with six distinct age groups, based on the central limit theorem. For the recruitment phase, EMBRAIN disseminated 7,558 email invitations from its extensive database of 1.8 million registered panelists. This resulted in 1,882 individuals accessing the survey platform, with 640 completing the survey from. The top 5% of respondents within each quota were automatically excluded based on their response time. Additionally, responses were reviewed, and any submissions where the average time spent between questions was more than three times the overall average were excluded to address concerns about respondent diligence and comprehension. After these processes, the company delivered 600 de-identified responses to the researchers, ensuring anonymity and ethical handling of participant data. The study protocol was formally approved by the Institutional Review Board of the Asan Medical Center (2025 − 0607), obtaining written informed consent was waived, and participants can begin the survey when they select “yes” to the questions on agreement to participate.
Measures
Assessing sleep indices and the discrepancy between desired time in bed and desired total sleep time (DBST) index
Participants were asked to report their usual bedtime, sleep onset time, final wake time, and wake-up time, using the questions: “What is your usual bedtime?”, “What is your usual time to fall asleep?”, “What time do you finally awake?”, and “What is your usual time to finally get out of bed in the morning?”. From these responses, we derived sleep duration variables such as SOL and total time in bed (TIB). We also asked patients’ TIB even during the daytime using a question “What is the total number of hours you spend lying down within a 24-hour period, including sleeping time?“ [22].
The DBST index was calculated to quantify the gap between participants’ desired total sleep time (dTST) and the time they wished to spend in bed (dTIB) [23]. Specifically, we asked, “For how many hours do you wish to sleep a day?” for dTST and “From what time to what time do you wish to sleep?” for dTIB, then computed the DBST index as the difference between dTIB and dTST.
Assessing favorable attitudes toward taking hypnotics
To further characterize insomnia symptoms and hypnotic use, participants were asked to specify the type (difficulty initiating sleep, maintaining sleep, or both). Attitudes toward hypnotic use were assessed by asking, “What is your opinion on taking hypnotics for your own use?”, with response options including “1 = I absolutely never want to take hypnotics”, “2 = I do not want to take hypnotics”, “3 = I think it is okay for me to take hypnotics”, and “4 = I think I can sleep adequately just with hypnotics”. As a continuous variable, the response ranged from 1 to 4 for favorable attitudes toward taking hypnotics. As a categorical variable, participants who selected either “I think it is okay for me to take hypnotics” or “I think I can sleep adequately just with hypnotics” were classified as having a favorable attitude toward hypnotic use, while those choosing “I absolutely never want to take hypnotics” or “I do not want to take hypnotics” were considered to have an unfavorable attitude.
Insomnia severity
indexThe severity of insomnia was evaluated using the Insomnia Severity Index (ISI) [24]. This instrument consists of seven items, each rated on a five-point Likert scale, yielding a total possible score ranging from 0 to 28. Scores are interpreted as follows: 0–7 indicates no clinically significant insomnia, 8–14 reflects subthreshold insomnia, 15–21 corresponds to moderate clinical insomnia, and 22–28 indicates severe clinical insomnia. For this study, the validated Korean version of the ISI [25] was administered, and the internal consistency, as measured by Cronbach’s alpha, was 0.828 in our sample.
Patient health questionnaire-9
Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a widely used nine-item self-report scale [26]. Each item is scored from 0 (not at all) to 3 (nearly every day), resulting in a total score that ranges from 0 to 27. Severity classifications are as follows: 0–4 (none or minimal), 5–9 (mild), 10–14 (moderate), 15–19 (moderately severe), and 20–27 (severe depression). The Korean version of the PHQ-9, which has been previously validated, was used in this study, with a Cronbach’s alpha of 0.892.
Dysfunctional beliefs and attitudes about sleep-6
Dysfunctional beliefs about sleep were measured using the Dysfunctional Beliefs and Attitudes about Sleep-6 (DBAS-6) [27], a brief six-item scale derived from the original DBAS-16 [28] through machine-learning approaches. Each item is rated on an 11-point Likert scale ranging from 0 (strongly disagree) to 10 (strongly agree). The final score is calculated as the mean of all items, with higher scores indicating more dysfunctional sleep-related beliefs. The Korean version of the DBAS-6 was used, and the Cronbach’s alpha in this sample was 0.767.
Sleep-related behavior questionnaire-10
Sleep-related safety behaviors were assessed using the Sleep-Related Behavior Questionnaire (SRBQ-10) [29], a 10-item brief version of the original 32-item version SRBQ [30] derived using a machine-learning approach. Each item is rated on a five-point scale from 0 (almost never) to 4 (almost always), resulting in a total score between 0 and 40. Higher scores reflect a greater tendency to engage in sleep-related safety behaviors. The Korean version of the SRBQ-10 was used in this study, with a Cronbach’s alpha of 0.853 in our sample.
Depressive symptoms inventory–suicidality scale
Suicidality was measured using the Depressive Symptoms Inventory–Suicidality Scale (DSI-SS), a four-item self-report tool designed to assess suicidal thoughts and behaviors [31]. Each item is scored from 0 to 3, and a total score of 3 or above is considered indicative of clinically significant suicide risk. The Korean version of the DSI-SS was used in this study [32] with a Cronbach’s alpha of 0.935 in our sample.
Statistical analysis
Descriptive analyses were summarized as means and standard deviations for or continuous variables, such as age, and numbers and corresponding percentages for categorical variables, including sex, marital status, and other relevant demographic factors. Statistical significance for all analyses was defined at a p-value threshold of 0.05 for two-tailed tests. To explore the factors contributing to favorable attitudes toward hypnotics use, we conducted a logistic regression analysis using clinical and demographic variables. Pearson’s correlation coefficients were calculated among variables which were significant in the logistic regression analysis with the favorable attitudes towards taking hypnotics as a continuous variable. In addition, we performed mediation analyses to investigate the potential indirect effects of clinical variables and favorable attitudes towards taking hypnotics. It was conducted a regression-based single-mediator analysis in which the independent variable predicted the mediator, and both the independent variable and mediator predicted the outcome, based on Hayes’ PROCESS [33], which was also launched in the JASP. We considered the results of regression analysos for the covariates such as age, gender, and clinical characteristics, and rating scale, included in the logistic regression equations. Before conducting estimation, we checked standard regression assumptions, including linearity, homoscedasticity, and multicollinearity, and confirmed that no serious violations were present. All data analyses were carried out using JASP software, version 0.14.1.0 (JASP team, Amsterdam, The Netherlands).
Results
A total of 548 enrolled subjects who complained of insomnia were included in the statistical analysis. The mean age of the participants was 50.1 years (SD = 16.4), and 49.8% (n = 273) were male. When participants were grouped according to their attitude toward hypnotic use (Table 1), significant differences were found in age (p < 0.001), history of psychiatric disorders such as depression, anxiety, or insomnia (p < 0.001), and current use of sleeping pills (p = 0.005). No significant differences were observed between the groups regarding sex, marital status, or current insomnia symptoms including difficulty falling asleep, frequent waking, or both.
Table 1.
Baseline demographic and clinical characteristics of the participants (N = 548)
| Variable | Favorable (N = 300) Mean ± SD, N (%) |
Unfavorable (N = 248) Mean ± SD, N (%) |
P-value |
|---|---|---|---|
| Male, n (%) | 135 (45.0%) | 138 (55.6%) | 0.013 |
| Age (years) | 48.0 ± 15.2 | 52.6 ± 17.4 | < 0.001 |
| Marital status | |||
| Unmarried | 104 (34.7%) | 73 (29.4%) | 0.591 |
| Married, without kids | 16 (5.3%) | 16 (6.5%) | |
| Married, with kids | 168 (56.0%) | 147 (59.3%) | |
| Others | 12 (4.0%) | 12 (4.8%) | |
| Psychiatric history | |||
| Have you experienced or have you been treated for depression, anxiety, or insomnia? (yes) | 153 (51.0%) | 67 (27.0%) | < 0.001 |
| Are you currently experiencing insomnia? (yes) | 300 (100.0%) | 248 (100.0%) | |
| Difficulty falling asleep | 69 (23.0%) | 48 (19.4%) | 0.464 |
| Frequent waking | 137 (45.7%) | 125 (50.4%) | |
| Both | 94 (31.3%) | 75 (30.2%) | |
| Are you currently taking sleeping pills? (Yes) | 74 (24.7%) | 37 (14.9%) | 0.005 |
The participants’ baseline sleep indices and rating scale scores are presented in Table 2. Among the baseline sleep indices, significant group differences were observed in desired bedtime (22:43 ± 1:01 vs. 22:31 ± 1:10, p = 0.022), desired wake-up time (6:56 ± 1:04 vs. 6:43 ± 1:01, p = 0.22), final wake time (6:19 ± 1:49 vs. 5:59 ± 1:45, p = 0.033), and TIB during 24 h (TIB/d; 7.9 ± 2.8 vs. 7.3 ± 3.0, p = 0.014). Participants with a favorable attitude toward hypnotics reported significantly higher scores on both the ISI (16.3 ± 5.0 vs. 15.4 ± 4.8, p = 0.028) and the DSI-SS (2.0 ± 2.3 vs. 1.5 ± 2.3, p = 0.009). No significant differences were found between the groups in PHQ-9, DBAS-6, or SRBQ-10 scores.
Table 2.
Baseline sleep indices and rating scales scores of participants (N = 548)
| Variable | Favorable (N = 300) Mean ± SD, N (%) |
Unfavorable (N = 248) Mean ± SD, N (%) |
P-value |
|---|---|---|---|
| Sleep indices | |||
| Desired total sleep time, h | 7.3 ± 1.5 | 7.2 ± 1.2 | 0.588 |
| Desired bedtime | 10:43 ± 1:01 PM | 10:31 ± 1:10 PM | 0.022 |
| Desired wake-up time | 6:56 ± 1:04 AM | 6:43 ± 1:01 AM | 0.022 |
| Desired time in bed, h | 8.2 ± 1.1 | 8.2 ± 1.4 | 0.876 |
| Discrepancy between desired time in bed and desired total sleep time (DBST index) | 0.9 ± 1.7 | 1.0 ± 1.7 | 0.607 |
| Bedtime | 11:06 ± 1:09 PM | 11:02 ± 1:15 PM | 0.525 |
| Sleep onset time | 12:16 ± 1:28 AM | 12:10 ± 1:30 AM | 0.419 |
| Final wake time | 6:19 ± 1:49 AM | 5:59 ± 1:45 AM | 0.033 |
| Get out of bed time | 6:59 ± 1:39 AM | 6:45 ± 1:27 AM | 0.085 |
| Sleep onset latency, h | 1.2 ± 1.2 | 1.1 ± 1.6 | 0.521 |
| Time in bed, h | 7.9 ± 1.7 | 7.7 ± 1.5 | 0.153 |
| Time in bed during 24 h, h | 7.9 ± 2.8 | 7.3 ± 3.0 | 0.014 |
| Rating scale scores | |||
| Insomnia Severity Index | 16.3 ± 5.0 | 15.4 ± 4.8 | 0.028 |
| Patient Health Questionnaire-9 | 9.7 ± 5.8 | 9.0 ± 5.6 | 0.128 |
| Dysfunctional Beliefs and Attitudes about Sleep-6 | 5.5 ± 1.7 | 5.3 ± 1.6 | 0.112 |
| Sleep-Related Safety Behaviors-10 | 20.4 ± 7.3 | 20.2 ± 7.0 | 0.725 |
| Depressive Symptoms Inventory-Suicidality Scale | 2.0 ± 2.3 | 1.5 ± 2.3 | 0.009 |
To identify factors associated with favorable attitudes toward hypnotic use, logistic regression analyses were performed. In the model adjusted for age and sex, longer TIB/d (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 0.001–0.12, p = 0.046) and higher scores on the DSI-SS (OR = 1.09, 95% CI = 0.01–0.16, p = 0.037) were significantly associated with favorable attitudes. Full results of both unadjusted and adjusted models are presented in Table 3.
Table 3.
Logistic regression analysis exploring variables contribute to favorable attitudes toward taking hypnotics
| Unadjusted | Age, sex adjusted | |||
|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Female | 1.53 (0.09–0.77) | 0.013 | ||
| Age | 0.98 (−0.03 - −0.01) | < 0.01 | ||
| Sleep indices | ||||
| Desired total sleep time | 1.03 (−0.09–0.15) | 0.588 | 0.99 (−0.14–0.12) | 0.877 |
| Desired bedtime | 1.20 (0.03–0.34) | 0.023 | 1.15 (−0.03–0.30) | 0.099 |
| Desired wake-up time | 1.21 (0.03–0.36) | 0.023 | 1.09 (−0.09–0.26) | 0.327 |
| Desired time in bed | 0.99 (−0.15–0.13) | 0.876 | 0.95 (−0.19–0.09) | 0.452 |
| DBST index | 0.98 (−0.12–0.08) | 0.605 | 0.98 (−0.12–0.08) | 0.702 |
| Bedtime | 1.05 (−0.10–0.19) | 0.526 | 0.99 (−0.15–0.14) | 0.911 |
| Sleep onset time | 1.04 (−0.07–0.15) | 0.471 | 0.97 (−0.15–0.09) | 0.647 |
| Final wake time | 1.11 (0.01–0.20) | 0.034 | 1.05 (−0.06–0.15) | 0.372 |
| Get out of bed time | 1.10 (−0.01–0.21) | 0.086 | 1.03 (−0.09–0.14) | 0.639 |
| Sleep onset latency | 1.02 (−0.11–0.16) | 0.725 | 0.97 (−0.17–0.11) | 0.671 |
| Time in bed | 1.06 (−0.04–0.16) | 0.25 | 1.03 (−0.08–0.13) | 0.615 |
| Time in bed during 24 h | 1.08 (0.01–0.13) | 0.015 | 1.06 (0.001–0.12) | 0.046 |
| Rating scales scores | ||||
| ISI | 1.04 (0.004–0.07) | 0.029 | 1.03 (−0.01–0.07) | 0.096 |
| PHQ-9 | 1.02 (−0.01–0.05) | 0.129 | 1.02 (−0.02–0.05) | 0.339 |
| DBAS-6 | 1.09 (−0.02–0.18) | 0.112 | 1.07 (−0.04–0.17) | 0.198 |
| SRBQ-10 | 1.01 (−0.02–0.03) | 0.724 | 1.01 (−0.02–0.03) | 0.955 |
| DSI-SS | 1.11 (0.02–0.18) | 0.009 | 1.09 (0.01–0.16) | 0.037 |
DBST index discrepancy between desired time in bed and desired total sleep time, ISI InsomniaSeverity Index,PHQ-9 Patient Health Questionnaire-9, DBAS-6 Dysfunctional Beliefs andAttitudes about Sleep-6, SRBQ-10Sleep-related Safety Behaviors-10, DSI-SS DepressiveSymptoms Inventory-Suicidality Scale
Table 4 shows the results of Pearson’s correlation analysis. The favorable attitudes toward taking hypnotics significantly correlated with age (r = −0.10, p < 0.05), ISI (r = 0.10, p < 0.05), DSI-SS (r = 0.17, p < 0.01), and TIB/d (r = 0.11, p < 0.01).
Table 4.
Pearson correlation coefficients among variables which was significantly contributed to the favorable attitudes toward taking hypnotics
| Variables | Age | Favorable attitude to hypnotics | ISI | DSI-SS |
|---|---|---|---|---|
| Favorable attitude to hypnotics | −0.10* | |||
| ISI | −0.21** | 0.10* | ||
| DSI-SS | −0.20** | 0.17** | 0.32** | |
| TIB/d | −0.06 | 0.11** | 0.03 | 0.06 |
ISI Insomnia Severity Index, DSI-SS Depressive Symptom Inventory-Suicidality Scale, TIB/d timein bed during 24 h
*p < 0.05, ** p < 0.01
Mediation analysis showed that the total effect of insomnia on favorable attitudes toward hypnotics was marginally significant (β = 0.08, p = 0.055), while the direct effect was not significant (β = 0.04, p = 0.32). The indirect effect via suicidality was statistically significant (β = 0.04, z = 2.77, p = 0.006, 95% CI = 0.01 to 0.07). Among covariates, age was negatively associated with insomnia and suicidality (both p < 0.01), and TIB was positively associated with favorable attitude toward hypnotics (p = 0.018), independent of insomnia severity (Table 5; Fig. 1).
Table 5.
Results of direct, indirect, and total effects on mediation analysis
| Effect | Standardized Estimate |
Z-value | p | 95% CI |
|---|---|---|---|---|
| Direct effect: | ||||
| Insomnia → Favorable attitude to hypnotics | 0.04 | 0.98 | 0.320 | −0.4 to 0.13 |
| Indirect effect: | ||||
| Insomnia → Suicidality → Favorable attitude to hypnotics | 0.04 | 2.77 | 0.006 | 0.01 to 0.07 |
| Component | ||||
| Insomnia → Suicidality | 0.29 | 7.05 | < 0.001 | 0.21 to 0.37 |
| Suicidality → Favorable attitude to hypnotics | 0.14 | 3.02 | 0.003 | 0.05 to 0.22 |
| Age → Insomnia | −0.21 | −4.91 | < 0.001 | −0.29 to −0.12 |
| Age → Suicidality | −0.14 | −3.29 | 0.001 | −0.22 to −0.05 |
| Age → Favorable attitude to hypnotics | −0.06 | −1.31 | 0.192 | −0.14 to 0.03 |
| TIB/d → Insomnia | 0.02 | 0.45 | 0.655 | −0.06 to 0.10 |
| TIB/d → Suicidality | 0.05 | 1.13 | 0.261 | −0.03 to 0.12 |
| TIB/d → Favorable attitude to hypnotics | 0.10 | 2.37 | 0.018 | 0.02 to 0.18 |
| Total effect: | ||||
| Insomnia → Favorable attitude to hypnotics | 0.08 | 1.92 | 0.055 | −0.002 to 0.17 |
TIB/d time in bed during 24 h
Fig. 1.
Mediation model showing the pathway from the effect of insomnia on favorable attitude to taking hypnotics through suicidality. *p < 0.05; **p < 0.01
Discussion
In this study, we found that favorable attitude toward hypnotic use was associated with younger age, longer TIB per day, greater insomnia severity, higher suicidality scores, and current use of hypnotics. However, in the logistic regression analysis, only longer TIB and higher suicidality were significantly associated with favorable attitudes toward hypnotics. Mediation analysis indicated that suicidality significantly mediated the relationship between insomnia and favorable attitude toward hypnotic use. These findings suggest that suicidality may be a relevant psychological factor in shaping attitudes toward hypnotic use among individuals with insomnia.
Participants with a favorable attitude toward hypnotic use for insomnia tended to be younger, had a history of more extensive psychiatric treatment, and were more likely to be current users of hypnotic medications. A previous study suggested that individuals may prefer hypnotics not only to alleviate nocturnal symptoms, but also to maintain daytime functioning and to avoid the discomfort associated with drug withdrawal [34]. Greater insomnia severity has also been associated with stronger preferences for hypnotic use [35], indicating that individuals experiencing heightened psychological distress may rely on medication as a means of emotional regulation. While hypnotics may offer short-term symptomatic relief, their long-term use has been associated with diminished efficacy and potential disruption of circadian rhythms and overall functioning.
In line with these findings, we observed that while desired bedtime and desired wake-up time differed significantly between the groups with favorable and unfavorable attitude toward hypnotic use, no group differences were found in the desired total sleep time or the desired TIB. Additionally, the actual TIB during the nighttime did not differ significantly. However, when considering the total TIB across the entire 24-h period, participants with a favorable attitude toward hypnotic use reported significantly longer durations. This observation may reflect multiple underlying mechanisms. First, the higher prevalence of current hypnotic use in this group may lead to residual drug effects, such as morning drowsiness or cognitive dulling, resulting in prolonged bedrest [36, 37]. Second, participants with more severe insomnia and extended TIB may experience a disruption of the boundary between sleep and wakefulness [33], potentially reinforcing conditioned arousal and perpetuating sleep difficulties despite longer TIB. This pattern may contribute a drug-dependent attitude toward sleep. Third, the higher levels of suicidality observed in this group may be partially explained by prolonged bedrest as a behavior manifestation of low energy, social withdrawal, and avoidance of daily responsibilities. In such cases, hypnotics may function not only as a sleep aid but also as a coping strategy for managing psychological distress.
In this study, suicidality mediated the relationship between insomnia and favorable attitudes toward hypnotics. Consistent with previous findings on the association between sleep disturbance, suicidality, and hypnotic use [38, 39], insomnia in our sample was associated with higher suicidality. Although hypnotics are commonly prescribed to treat insomnia, several studies have raised concerns that their use may be linked to increased suicidal thinking and behaviors, even after analyses adjusted for measures of mental health [40, 41]. In fact, the U.S. Food and Drug Administration has issued a black-box warning regarding the potential for suicidality associated with certain hypnotics. However, because our data did not include information on participants’ actual medication history data, it is not possible to determine whether hypnotics themselves cause or exacerbate suicidal tendencies.
Our findings suggest that patients with higher suicidality may be more inclined to prefer hypnotic medications, though the direction of this preference, whether it reflects a desire for insomnia relief or other factors, cannot be determined from cross-sectional data. While CBT-I remains the first-line treatment, pharmacological approaches are often considered when CBT-I is not accessible or effective. Patients who express a strong preference for pharmacological treatment may lack awareness of CBT-I or may prioritize immediate relief over long-term management. The use of hypnotics may carry additional risk in patients with high suicidality as these medications can be intentionally or unintentionally misused [42] as a means of self-harm. The absence of a significant direct path from insomnia to favorable attitudes is consistent with an indirect-only mediation pattern, suggesting that insomnia influences attitudes primarily through suicidality rather than through a direct effect. Because depressive symptoms are closely linked to suicidal ideation, depression may influence both suicidality and attitudes toward hypnotics, As depressive symptoms were not included in our mediation model, the extent to which depression severity for the observed associations remains unclear. Future studies should incorporate measures of depressive severity to determine whether the mediation persists after adjusting for this potential confounder.
Our results indicate that suicidality plays an important psychological role in shaping patients’ attitudes toward the use of hypnotics in the context of insomnia. Therefore, careful clinical evaluation of suicidality is necessary when considering hypnotic prescriptions and the importance of increasing access to and awareness of CBT-I as a safer and evidence-based intervention.
This study has several limitations. First, the cross-sectional design cannot present the causal relationship among insomnia, suicidality, and attitudes toward hypnotics. Second, all data were obtained from self-reported questionnaires, which may be subject to recall bias or social desirability bias. Third, although we examined relevant covariates, potential confounding factors such as access to healthcare services, or previous experiences with hypnotics may not have been fully accounted for. Fourth, we did not differentiate between types of hypnotics. Preferences and attitudes of patients with insomnia may vary depending on the specific type or class of hypnotic agents. Fifth, information on participant’ somatic disease and actual use of hypnotics was not collected, which limits contextual interpretation and may affect the generalizability of the findings.
Despite these limitations, our study provides insight into the psychological mechanisms underlying attitudes toward hypnotics in patients with insomnia. The mediation model confirmed suicidality as a key factor that shapes individuals’ preferences for pharmacological treatment. These findings have important clinical implications, emphasizing the need for routine assessment of suicidality in patients presenting with insomnia, especially when considering hypnotic prescriptions. Furthermore, increasing awareness and accessibility of CBT-I may offer safer and more sustainable treatment options. Future longitudinal and intervention-based studies are warranted to clarify causal pathways and to develop targeted strategies that address both insomnia and suicidality in an integrated manner.
Acknowledgements
None.
Abbreviations
- CBT-I
Cognitive behavioral therapy for insomnia
- SOL
Sleep onset latency
- BZRAs
Benzodiazepine receptor agonists
- ORAs
Orexin receptor antagonists
- MRAs
Melatonin receptor
- MOTIF
Multimodal Optimized Treatment for Insomnia Framework
- DBST index
Discrepancy between desired time in bed and desired total sleep time
- TIB
Time in bed
- TST
Total sleep time
- ISI
Insomnia Severity Index
- PHQ-9
Patient Health Questionnaire-9
- DBAS-6
Dysfunctional Beliefs and Attitudes about Sleep-6
- SRBQ-10
Sleep-Related Behavior Questionnaire-10
- DSI-SS
Depressive Symptoms Inventory–Suicidality Scale
Authors’ contributions
Conceptualization: Myung Hee Ahn and Seockhoon Chung. Data curation: Seockhoon Chung. Methodology: Myung Hee Ahn and Seockhoon Chung. Data analysis: Myung Hee Ahn and Seockhoon Chung. Writing—original draft: Myung Hee Ahn and Seockhoon Chung. Writing—review & editing: Myung Hee Ahn and Seockhoon Chung.
Funding
None.
Data availability
Data will be available from the authors when requested.
Declarations
Ethics approval and consent to participate
The study protocol was formally approved by the Institutional Review Board of the Asan Medical Center (2025 − 0607), obtaining written informed consent was waived, and participants can begin the survey when they select “yes” to the questions on agreement to participate. The study was conducted according to the declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Data will be available from the authors when requested.