Benzodiazepines for Chronic Insomnia: Systematic Review Finds Higher Depression and Anxiety With Long-Term Use
Benzodiazepines are among the most commonly prescribed medications for insomnia, but guidelines universally recommend against using them for more than a few weeks. A new systematic review and network meta-analysis published in the Journal of Sleep Research confirms why: the evidence for long-term safety is thin, and the associations are concerning.
The review, led by Dieter Riemann of the University of Freiburg, identified 27 studies published between 1987 and 2023 that evaluated the risks of using benzodiazepine medications for more than three months in adults with chronic insomnia. Five outcomes were suitable for quantitative meta-analysis: insomnia severity, sleep quality, fall incidence, depression, and anxiety.
The results paint a cautious picture. People taking benzodiazepines long-term had more severe insomnia than healthy sleepers, though less severe than individuals with untreated insomnia. The risk of falls was comparable between benzodiazepine users and non-users. But on mental health measures, the differences were significant: long-term benzodiazepine users experienced markedly higher levels of depression and anxiety compared to healthy sleepers.
What they found
The review defined chronic insomnia as ongoing dissatisfaction with sleep quantity or quality causing significant daytime distress and functional impairment, persisting for at least three months. It included studies in adults who had used benzodiazepines for longer than four weeks, the typical upper limit recommended by prescribing guidelines.
The most notable finding may be what was not found: a shortage of long-term studies. The authors highlight a striking lack of research on extended benzodiazepine use, given how common it is in clinical practice. Millions of patients worldwide take these medications for months or years, yet the evidence base for this practice is limited to 27 heterogeneous studies.
Where data do exist, the pattern is consistent. Long-term benzodiazepine users show worse mental health outcomes. Whether this reflects a direct pharmacological effect, the underlying severity of their insomnia, or confounding by other factors is not fully resolved by the available studies.
Why it matters
Benzodiazepines remain widely prescribed for insomnia despite decades of guidance urging restraint. Clinical practice guidelines from the American Academy of Sleep Medicine, the European Insomnia Guideline, and the American College of Physicians all recommend cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, with pharmacotherapy reserved for short-term or adjunctive use.
This review strengthens those recommendations by quantifying the risks associated with deviation from them. The findings on depression and anxiety are particularly relevant, given that insomnia itself is a well-established risk factor for mood disorders. If benzodiazepines intended to treat insomnia are instead associated with higher depression and anxiety, the therapeutic calculus shifts further toward behavioral alternatives.
The comparable fall risk between users and non-users is a more reassuring finding than some earlier studies have suggested, though the authors note that the evidence on this outcome was limited.
Limits
The included studies were heterogeneous in design, populations, and outcome measures. Many were observational, limiting causal inference. The review was funded by Idorsia Pharmaceuticals, a company that manufactures the dual orexin receptor antagonist daridorexant for insomnia, which should be considered when interpreting the comparative framing.
Bottom line
The evidence for long-term benzodiazepine use in chronic insomnia is surprisingly thin, and what exists raises concerns about higher depression and anxiety. The findings reinforce the standard message: use benzodiazepines sparingly and prioritize cognitive behavioral therapy as the foundation of insomnia treatment.
Source: Riemann D, Baglioni C, Nissen C, et al. Risks Associated With Benzodiazepine Long-Term Use in Chronic Insomnia: A Systematic Review and (Network) Meta-Analysis. Journal of Sleep Research. 2026;e70352. DOI: 10.1111/jsr.70352