Quality of Life of Patients with Oral Squamous Cell Carcinoma.

Background: Oral squamous cell carcinoma (OSCC) has numerous physical, psychosocial and financial implications, which significantly affect patients' quality of life. We aimed to determine the health-related quality of life (HRQoL) and identify quality of life (QoL) predictors in patients with OSCC. Methods: We included 64 consecutive patients aged 40 to 80 yr treated for OSCC from Jan to Dec 2021. Health-related QoL was evaluated using the 30-item Cancer Quality of Life Questionnaire (QLQ-C30) and the 35-item Head and Neck Cancer-Quality of Life Questionnaire (QLQ-H&N35). The demographic questionnaire and clinical parameters were also presented. Results: The functioning scale in the QLQ-C30 questionnaire with the lowest average score was Global health status. The mean QLQ-C30 summary score (80.92 ± 10.4) was higher than the Global health status score (50.5 ± 22.2). In the QLQ-H&N35 questionnaire, the symptoms with highest scores were weight loss, dry mouth, and social eating. Linear regression analysis demonstrated that Global health status score was associated with education level [ß-coefficient = 19.33 (95% CI: 10.7-24.9, P=0.004], alcohol consumption [ß-coefficient=10.04 (95% CI: 4.5-14.8), P=0.023] and invasive surgical procedure [ß-coefficient=22.75 (95% CI: 15.0-30.5), P=0.002]. The QLQ-C30 summary score was associated with living alone [ß-coefficient= -20.05 (95% CI: -29.91-(-10.21), P=0.018], smoking status [ß-coefficient=4.35 (95% CI: 1.8-6.91), P=0.043] and alcohol consumption [ß-coefficient =4.59 (95% CI: 1.99-7.19), P=0.037]. Conclusion: We found several significant predictors of worse perception of HRQoL among patients with OSCC, which may be useful for specific prevention and treatment in order to achieve better QoL.

Assessment of the Frequency, Causes, Degree and Consequences of Violence against Health Workers in Psychiatric Institutions.

(1) Background: The prevalence of workplace violence within the health sector varies between 50 and 88%. Depending on the health care environment, the percentages mentioned can be much higher. (2) The aim of this study was to determine the prevalence, characteristics, factors, and consequences of violence against healthcare workers (physicians, nurses, and technicians) in psychiatric institutions in the Republic of Serbia. Additionally, this study should validate the Serbian version of the aggression questionnaire, which could be a significant tool in recognizing and assessing any type of violence against health care workers in psychiatric institutions. (3) Methods: This study was designed as an observational questionnaire study that included 191 health workers (physicians, medical technicians, workers in kitchens or maintenance, and others) from three psychiatric institutions. As an instrument, this study validated and used the Serbian version of the aggression standardized questionnaire. We observed the primary and secondary outcomes of potential violence in psychiatric institutions against healthcare workers using different parameters. (4) Results: The internal consistency of each item as well as the instrument was very good (the mean Cronbach alfa = 0.91). A total of 104 of the participants never experienced physical violence, while more than five times that had 20 health workers (10.5%). We observed the statistical significance of gender, age, working status (permanent/limited) and professional status (physician/medical technician/worker etc.) on physical attack incidence. (5) Conclusions: The incidence of violence against healthcare workers is very high, especially in terms of physical assault and threats in the workplace. The majority of the victims were women who work as medical technicians, attacked by male patients with unknown motivation. A number of changes in the structure and organizational culture of the hospital are required. All hospital employees, employers, patients, and their families share responsibility for the creation of a safe workplace.

Internet use during coronavirus disease of 2019 pandemic: Psychiatric history and sociodemographics as predictors.

Coronavirus disease of 2019 (COVID-19) pandemic and related containment measures have grossly affected the daily living and created a need for alternative ways of social communication and entertainment. The aim of this study was to explore the use of various Internet contents depending on sociodemographics and on psychiatric history of participants. This cross-sectional, population-based study is a part of a wider international multicenter study. A total of 1275 participants across Serbia (71.1% of females; average age = 41.81 ± 12.52 years) were recruited using two-level chain-referral sampling method. The participants filled in an anonymous online questionnaire that included questions on sociodemographic data, psychiatric history, and various aspects of increased Internet use since the pandemic. The data were analyzed using a series of multiple logistic regressions. About two-thirds of the sample reported using Internet more during the pandemic. All of the tested regression models, apart from models predicting browsing religion and travel/tourism, were significant, explaining from about 2% (for the contents specific for COVID-19) up to 34.4% (for the sexual content) of variance of use. Reporting a previously diagnosed psychiatric disorder was a significant predictor of greater Instagram use and browsing sexual and sport-related content since the pandemic. To the best of our knowledge, the study is the first to report on the relationship between Internet using and mental health, during COVID-19 pandemic, in the Balkan region. The findings showed various patterns of the increased use of Internet contents since the pandemic referring to both potentially positive and negative Internet influences.

Individual and Gender Differences in Personality Influence the Diagnosis of Major Depressive Disorder.

BACKGROUND: In order to explore whether gender differences are present in self-reports on personality measures when all Major Depressive Disorder (MDD) participants are diagnosed at an equal intensity, the aim of this study was to investigate individual and gender differences in personality between healthy participants and those suffering from severe feature MDD. SUBJECTS AND METHODS: The sample consisted of 632 participants: 385 in the healthy control group and 247 MDD, the latter comprised of patients in their first diagnosed episode or recurrent. The Hamilton Depression Rating Scale (HAM-D) was used to measure symptom severity. Beck's Depression Inventory was administered when depression symptoms had lessened, establishing it as minor when filling out the personality questionnaire (NEO-PI-R). RESULTS: The results indicate a broad difference in personality between the healthy control and the MDD groups. High neuroticism and low extraversion, accompanied by low scores on openness and conscientiousness, were the most important personality dimensions in understanding distinctions. While agreeableness did not indicate any important role, it did significantly influence the understanding of gender differences within groups. Females were found more agreeable in both groups, but those from the healthy group were also more open and conscientiousness than healthy males. Females from the MDD group were found to be also higher on neuroticism than males of the same group. CONCLUSIONS: A general conclusion from the study is that personality dimensions are more important in understanding vulnerability to depression in comparison to gender differences in personality within groups. As females in the MDD group tend to self-report higher levels of agreeableness and neuroticism than do males in the same group when the level of their depression is categorized as equal MDD-severe type, this may influence practitioners to unequally diagnose depression in males and females.

Reliability and Validity of the Pittsburgh Sleep Quality Index-Serbian Translation.

The aim of this study was translating and exploring psychometric properties of Serbian Pittsburgh Sleep Quality Index (PSQI) in a sample of "good" and "bad" sleepers suffering from depression or obstructive sleep apnea (OSA). Formal translation and validation were performed on a sample of healthy controls, patients with untreated OSA, and with diagnosed major depressive disorder with evaluation of internal consistency, test-retest reliability, and construct and criterion validity. Controls and OSA subgroups were recruited from a larger sample of commercial drivers. One hundred and forty subjects, 84.3% male, 22-67 years old, were included. OSA subgroup had 59 subjects and depression subgroup had 40 subjects (22 females). Mean ± SD total PSQI was 3.5 ± 2.2 in controls, 4.9 ± 3.6 in OSA subjects, and 9.0 ± 4.9 in patients with depression. Cronbach's α for total PSQI was 0.791. Subscale scores were significantly correlated to global PSQI in all subgroups. Intraclass correlation coefficient for global PSQI was 0.997 ( p < .001). Epworth Sleepiness Scale score was significantly correlated to global PSQI (ρ = 0.333, p < .001). Three subgroups differed significantly in total PSQI and PSQI ≥ 5, even after adjustments for age and gender ( p < .001). OSA patients had higher mean PSQI than controls but not significantly ( p = .272). PSQI-reported sleep latency did not correlate with PSG-measured sleep latency ( r = .130, p = .204). Total PSQI was significantly correlated to OSA severity (ρ = 0.261, p < .05). Serbian PSQI showed good internal consistency, test-retest reproducibility, and adequate construct and criterion validity, which supports further exploration of its use as a sleep quality screening tool in different target populations.

Five-Factor Model Personality Profiles: The Differences between Alcohol and Opiate Addiction among Females.

BACKGROUND: The prevalence of female alcohol and substance abusers has markedly increased. The main objective of this research was to explore personality profiles among females who had alcohol and opiate dependence. AIM: The aim of the study is to analyse if there is differences in personality profiles of females addicted to alcohol and opiates. We hypothesized that there might be significant differences in personality profiles among subgroups of women who present with alcohol and opiate use disorders. SUBJECTS AND METHODS: Of 157 consecutive women with diagnosis of alcohol/opiate addiction, 62 fulfilled following inclusion criteria: age 19-45 years, abstinence from alcohol and opiates for at least 10 days prior to enrollment. Alcohol-dependent group consisted of 30 females, while opiate-dependent group consisted of 32 females. The control group involved 30 age-matched randomly chosen healthy women. The data were collected using the Revised NEO Personality Inventory (NEO-PI-R). The multiple stepwise discriminant analysis was used to determine relations between personality traits and the probability of belonging to one of the study groups. RESULTS: Significant differences in the NEO-PI-R scores were observed between groups for all main personality traits except for Openness to Experience. Compared with controls, substance-dependent women scored significantly higher on Neuroticism and lower on Conscientiousness. Opiate-dependent females scored the highest on Neuroticism and on Extraversion and lowest on Agreeableness and on Conscientiousness. Alcohol-dependent females scored higher on Conscientiousness and lower on Neuroticism compared to opiate-dependent women. CONCLUSIONS: The results of our study confirmed significant characteristics in personality profiles among females with alcohol and opiate dependence, as well as the difference between these two groups of substance abusers and their healthy controls. The distinct personality characteristics among different groups of substance addicted women should be taken into account when creating the most effective program of prevention and therapeutic approaches in this specific cohort.

Descartes and His Peculiar Sleep Pattern.

Rene Descartes (1596-1650) was a mathematician, philosopher, and scholar, whose work set a foundation for modern science. Among other interests, he focused on locating the "core and the seat of the soul" and concluded that the pineal gland was such a structure. Recent scientific findings validate Descartes' deep interest in pineal gland, appreciating its role as part of the circadian rhythm system. On the other hand, the biographical information suggests that Descartes had an aberration of the circadian rhythm (delayed sleep phase). Coincidentally, this meant that one of the most important things in his private life and one of the most significant areas of his research intersected in an overlooked way.

Assessment of self-perception of transsexual persons: pilot study of 15 patients.

BACKGROUND AND AIMS: There have been few studies in the area of Self-Perception in transsexual persons, except for the population of transsexual adolescents. Bearing in mind its importance not only in the assessment of personality but also in predicting adaptive capacity, the goal of our research is based on the examination of Self-Perception of adult transsexual persons. METHOD: The study was conducted using a Rorschach test, which provides an insight into various aspects of Self-Perception. The sample consisted of 15 transsexual persons, who passed the standard diagnostic procedure. RESULTS: The results suggest that transsexual persons manage to maintain Adequate Self-Esteem. Hypervigilance Index and Obsessive Style Index are negative, while the values showing a negative quality of Self-Regard and the capacity for introspection tend to increase. In the process of Self-Introspection, negative and painful emotional states are often perceived. CONCLUSION: The estimation of Self-Perception in adult transsexual persons indicates a trend of subjective perception of a personal imperfection or inadequacy. This is probably the result of experiencing discomfort for a number of years due to gender incongruence and dysphoria, in particular in persons who enter the sex reassignment procedure later in their adulthood.

[How do we treat generalized anxiety disorder?].

INTRODUCTION: In addition to significant prevalence of generalized anxiety disorder (GAD) and related consequences, it seems that this disorder has not been studied sufficiently in Serbia. OBJECTIVE: The aim of this study was to investigate the understanding of psychopathology and the adequate treatment of patients with GAD by psychiatrists in Serbia. METHODS: The study comprised 84 doctors - psychiatrists and neuropsychiatrists who were engaged in treatment of patients with GAD. Anonymous survey was used as the basic instrument, which collected information about the socio-demographic and professional data, experience in treating GAD and understanding psychopathology of GAD, as well as the first and the second choice therapy for patients with GAD. RESULTS: The majority of psychiatrists (62.2%) indicated the symptoms of distress/tension and slightly lower percent (36.6%) designated the symptoms of worry/anxiety as the key symptoms of GAD when it was diagnosed.The results showed that almost all patients (96.5%) had been treated with benzodiazepines before coming to psychiatrists. Most psychiatrists preferred the use of SSRI/SNRI antidepressants (76.2%), usually in combination with benzodiazepines (71.4%) for the treatment of patients with GAD; however, if these doctors got GAD, the preference of benzodiazepine use would be significantly lesser (45.2%) than for the treatment of their patients. Preference for the use of SSRI/SNRI antidepressants was significantly more frequent in physicians with completed residency. CONCLUSION: The understanding of psychopathology and treatment practice for patients with GAD in this sample of psychiatrists in Serbia is mostly consistent with the current trends for GAD treatment.

Volumetric analysis of amygdala, hippocampus, and prefrontal cortex in therapy-naive PTSD participants.

OBJECTIVE: In our study we have hypothesized that volume changes of amygdala, hippocampus, and prefrontal cortex are more pronounced in male posttraumatic stress disorder participants. MATERIAL AND METHODS: We have conducted a study of 79 male participants who underwent MRI brain scanning. PTSD diagnosis was confirmed in 49 participants. After MRI was taken all scans were software based volume computed and statistically processed. RESULTS: We found that left amygdala is the most significant parameter for distinction between PTSD participants and participants without PTSD. There were no significant differences in volumes of hippocampi and prefrontal cortices. Roc curve method outlined left amygdala AUC = 0.898 (95% CI = 0.830-0.967) and right amygdala AUC = 0.882 (95% CI = 0.810-0.954) in the group of PTSD participants which makes both variables highly statistically significant. CONCLUSION: The present investigation revealed significant volume decrease of left amygdala in PTSD patients. Concerning important functions of the amygdala and her neuroanatomical connections with other brain structures, we need to increase number of participants to clarify the correlation between impared amygdala and possible other different brain structures in participants with PTSD.

Electroconvulsive therapy practice in Serbia today.

This is the first survey of the practice of electroconvulsive therapy (ECT) in the Republic of Serbia. A retrospective chart review was undertaken including all patients having received ECT in Serbia in 2012. Only one center in Serbia offered ECT in 2012 to a total of 54 patients (54% women). Thirty-six (36) patients received acute ECT treatment and eighteen (18) patients maintenance ECT, yielding a ECT utilization rate of 0.05/100.000 population. ECT was delivered with a modern square-wave (brief pulse) machine with EEG and ECG monitoring. In all cases the electrode placement was bifrontal and treatment modified (with anesthesia). The most frequent indication was recurrent depressive disorder (66.7%) for both acute and maintenance treatment. The limited availability of ECT in Serbia raises serious concerns. Provision of updated and effective treatment modalities for severe psychiatric disorders is crucial and the need for additional ECT services in Serbia is urgent.

Personality disorders and anxiety disorders: what is the relationship?

PURPOSE OF REVIEW: To systematically review the recent studies which examined the co-occurrence and relationships between anxiety disorders and personality disorders. RECENT FINDINGS: The prevalence rates of personality disorders in patients with anxiety disorders are high, with 35% in posttraumatic stress disorder, 47% in panic disorder with agoraphobia and generalized anxiety disorder, 48% in social phobia, and 52% in obsessive-compulsive disorder. There is a high rate (39%) of the DSM cluster C personality disorders among individuals with anxiety disorders. Moreover, anxiety disorders are highly prevalent in samples of people with personality disorders, especially borderline personality disorder (80-84.8%). Personality disorders co-occurring with anxiety disorders have a number of clinical implications, including an increased risk of suicide, greater severity of anxiety disorders, and negative impact on the treatment outcome of anxiety disorders. SUMMARY: It is important for the clinicians to look for possible personality disorders among patients with anxiety disorders. Further studies need to ascertain how best to treat individuals suffering from both anxiety disorders and personality disorders and focus on the issue of causality when these conditions co-occur.

[Analysis of regulatory-ethical framework of clinical trials].

INTRODUCTION: Every clinical trial has to meet all ethical criteria in addition to the scientific ones. The basic ethical principles in the clinical trials are the following: nonmaleficence, beneficence, respect for autonomy and the principle of justice. OBJECTIVE: The aim of the study was to analyse clinical cases with the outcomes leading to the changes in regulatory-ethical framework related to the clinical trials, as well as the outcomes of key clinical trials that influenced the introduction of the ethical principles into clinical trials. METHODS: This was a descriptive research (methods of analysis and documentation; desk analysis of the secondary data). RESULTS: By analysing the cases from the secondary sources as well as clinical and ethical outcomes, it may be noticed that the codes, declarations and regulations have been often preceded by certain events that caused their adoption. Moral concern and public awareness of the ethical issues have initiated not only the development of numerous guidelines, codes, and declarations, but also their incorporation into the legislative acts. CONCLUSION: It is desirable that ethical instruments become legally binding documents, because only in this way will be possible to control all phases of the clinical trials and prevent abuse of the respondents.

Serbian translation of the 20-item Toronto Alexithymia Scale: psychometric properties and the new methodological approach in translating scales.

INTRODUCTION: Since inception of the alexithymia construct in 1970's, there has been a continuous effort to improve both its theoretical postulates and the clinical utility through development, standardization and validation of assessment scales. OBJECTIVE: The aim of this study was to validate the Serbian translation of the 20-item Toronto Alexithymia Scale (TAS-20) and to propose a new method of translation of scales with a property of temporal stability. METHODS: The scale was expertly translated by bilingual medical professionals and a linguist, and given to a sample of bilingual participants from the general population who completed both the English and the Serbian version of the scale one week apart. RESULTS: The findings showed that the Serbian version of the TAS-20 had a good internal consistency reliability regarding total scale (alpha=0.86), and acceptable reliability of the three factors (alpha=0.71-0.79). CONCLUSION: The analysis confirmed the validity and consistency of the Serbian translation of the scale, with observed weakness of the factorial structure consistent with studies in other languages. The results also showed that the method of utilizing a self-control bilingual subject is a useful alternative to the back-translation method, particularly in cases of linguistically and structurally sensitive scales, or in cases where a larger sample is not available. This method, dubbed as 'forth-translation' could be used to translate psychometric scales measuring properties which have temporal stability over the period of at least several weeks.

[Development of forensic psychiatry in Serbia].

The development of legislation in the field of mental health in our region is linked with the emergence and development of the oldest psychiatric hospitals in Serbia.The principle that the mentally ill who committed a criminal offense need to be placed in a psychiatric hospital instead of a prison was introduced at the same time as in the most developed European countries. The founders of the Serbian forensic psychiatry, Dr. Jovan Danic, Dr.Vojislav Subotic Jr. and Dr. Dusan Subotic, were all trained at the first Serbian Psychiatric Hospital ("Home for the Unsound of Mind") that was founded in 1861 in the part of Belgrade called Guberevac. Their successors were psychiatric enthusiasts Prof. Dr.Vladimir F.Vujic and Prof. Dr. Laza Stanojevic. A formal establishment of the School of Medicine of Belgrade, with acquirement of new experience and positive shifts within this field, based on the general act of the University in 1932, led to the formation of the Council of the School of Medicine, which, as a collective body passed expert opinions. Thus, the first Forensic Medicine Committee of the School of Medicine was formed and started its activities in 1931 when Forensic Medicine Committee Regulations were accepted. After the World War II prominent educators in the field of mental health, and who particularly contributed to further development of forensic psychiatry in Serbia were Prof. Dr. Uros Jekic, Prof Dr. Dusan Jevtic, Dr. Stevan Jovanovic, Prof. Dr. Borislav Kapamadzija, Prof. Dr. Maksim Sternic, Prof. Dr. Josif Vesel and Prof. Dr. Dimitrije Milovanovic.

Sleep-laughing--hypnogely.

OBJECTIVE: To explain relatively common phenomenon of laughing during sleep and help to better define criteria for differentiating between physiological and pathological sleep-laughing. METHODS: Observational study of patients who underwent a sleep assessment in a referential tertiary health facility. RESULTS: A total of ten patients exhibited sleep laughing, nine of whom had episodes associated with rapid eye movement (REM) sleep. Also, in one of the patients sleep-laughing was one of the symptoms of REM sleep Behaviour Disorder, and in another patient sleep-laughing was associated with NREM sleep arousal parasomnia. CONCLUSION: The collected data and review of literature suggests that hypnogely in majority of the cases presents as a benign physiological phenomenon related to dreaming and REM sleep. Typically, these dreams are odd, bizarre or even unfunny for a person when awake. Nevertheless, they bring a sense of mirth and a genuine behavioural response. In a minority of cases, sleep-laughing appears to be a symptom of neurological disorders affecting the central nervous system. In these patients the behavioural substrate differs when compared to physiological laughing, and the sense of mirth is usually absent.

Temperament and character modify risk of drug addiction and influence choice of drugs.

BACKGROUND: Drug addiction and alcoholism involve a complex etiopathogenesis with a variable degree of risk contributions from the host (person), environment, and addictive substances. In this work, temperament and character features of individuals addicted to opiates or alcohol are compared with normal controls to study personality factors in the overall risk for drug addiction. METHODS: The study was done in a permissive environment, with easy access to alcohol and heroin, which facilitated analyses of personality factors in drug choice. Participants included 412 consecutive patients (312 opiate addicts, 100 alcohol addicts) treated at the Specialized Hospital for Chemical Dependency in Belgrade, Serbia, and a community sample of 346 controls. RESULTS: Opiate addicts manifested antisocial temperament configuration (high Novelty Seeking, low Reward Dependence) coupled with high Self-transcendence (ie, susceptibility to fantasy and imagination). Alcohol addicts manifested sensitive temperament configuration (high Novelty Seeking coexisting with high Harm Avoidance). Immature personality was observed far more frequently in opiate addicts than in alcoholics or normals. CONCLUSIONS: Novelty Seeking appears to be a general risk factor for drug addiction. High Harm Avoidance appears to channel individuals with high Novelty Seeking towards alcoholism. Immature character traits and probable Personality Disorder increase the risk of illegal drugs. Based on equivalent research in nonpermissive environments, at least a portion of our opiate addicts could have developed alcoholism instead in environments with more limited access to opiates. Personality factors provide useful guidelines for preventive work with young individuals with personality risk factors for drug addiction.

[Dr. Atanasije Puljo: pioneer of Serbian dentistry].

This paper describes the life and work of Dr. Atanasije Puljo (1878-1944). He was a volunteer in the Balkan wars, an active participant in the First World War; he was the first who noted the importance of team-work of a dentist and a surgeon in the care of jaw and facial injuries. He established primacy in this field, as he came up with this brilliant idea three years before other colleagues. His method of treatment of the upper jaw neglected fractures, called the Balkan method, was recognized worldwide. Dr. Puljo is the pioneer of dental radiology in Serbia, founder of the Odontology Clinic of the Medical Faculty and main supporter of the establishment of the School of Dentistry. Merits of Dr. Atanasije Puljo, medical practitioner with a broad knowledge in different fields, remain within the academic institution that was founded by this pioneer of dentistry in Serbia.

Psychiatrists' psychotropic drug prescription preferences for themselves or their family members.

BACKGROUND: Psychiatrists' preference for certain medications is not only determined by their efficacy and side effect profile but may also depend on the psychiatrists' beliefs about specific therapeutic effects based on their own observation and experience. We aimed to evaluate which antipsychotic or antidepressant drugs psychiatrists would prefer for themselves, their partners and children in case of a mental illness. SUBJECTS AND METHODS: The study was conducted among psychiatrists in Serbia. The sample consisted of 90 psychiatrists who were asked to complete the questionnaire about their drug selection in hypothetical situations of becoming ill with schizophrenia or depression or these conditions occurring in their partners and children. RESULTS: In case of schizophrenia, risperidone was the first choice made by most psychiatrists for themselves, their partners or children, followed by clozapine, haloperidol and olanzapine. In case of depression, SSRIs and SNRIs were generally favored, with sertraline and escitalopram being the preferred medications for psychiatrists, partners and their children. With regards to depression, 82.3% of participants would opt for an antidepressant as monotherapy or in combination, but 13.3% would opt for anxiolytic monotherapy. The preferred doses were slightly lower than the recommended ones, especially for antipsychotic agents. CONCLUSIONS: Most psychiatrists would take or administer atypical antipsychotics or SSRIs as the first choice for themselves, their partners or children. These preferences are mostly in accordance with current treatment guidelines, but there is still room to narrow the gap between guideline recommendations and psychiatrists' medication choices in personally meaningful situations.

[The influence of psychopharmaceuticals on sleep].

The review presents current information on how pharmacological compounds influence sleep. Different mechanisms of action were discussed, including sedative and stimulative effect that different medications have on sleep, and also specific changes in sleep architecture, paroxismal events and other sleep parameters. There is a particular emphasis on conventional and alternative hypnotics, with a mention of older and less used medications.