Cognitive behavior therapy may help long-term insomnia

For patients with persistent insomnia, a combination of cognitive behavior therapy (CBT) and the medication zolpidem for six weeks was associated with improvement in sleep, although for a longer treatment period CBT alone was more beneficial, according to a study in the May 20, 2009 issue of JAMA.

Insomnia is a prevalent public health problem affecting large segments of the population on a situational, recurrent, or chronic basis.

“Persistent insomnia is associated with significant impairments of daytime functioning, reduced quality of life, and when persistent insomnia is not treated, it heightens the risks for major depression and hypertension,” the authors write. CBT and some sleep medications are effective for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment.

It has been unclear whether combined therapies would improve outcomes.

Charles M. Morin, Ph.D., of the Université Laval, Quebec, Canada, and colleagues evaluated the short- and long-term effects of CBT, singly and combined with the medication zolpidem, for persistent insomnia, and compared treatment strategies to optimize long-term outcomes.

The trial included 160 adults, who were randomized to receive either CBT alone or CBT plus 10 mg/d (taken at bedtime) of zolpidem for an initial 6-week therapy, followed by extended 6-month therapy. The CBT included recommendations on how to improve sleep and education regarding faulty beliefs and misconceptions about sleep.

The researchers found that CBT used singly or in combination with zolpidem produced significant improvements in the amount of time that it took to fall asleep, time awake after falling to sleep, and sleep efficiency during initial therapy. A larger increase of sleep time was obtained with the combined approach.

After six weeks, the proportion of patients who responded to treatment of CBT alone (60 percent) or CBT plus zolpidem (61 percent) were similar, as were treatment remissions (39 percent for the CBT alone group; 44 percent for the CBT plus zolpidem group).

“The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the six-month follow-up compared with patients who continued to take zolpidem during extended therapy (68 percent vs. 42 percent),” the authors write.

“Although the present findings are promising, there is currently no treatment that works for every patient with insomnia and additional studies are needed to develop treatment algorithms to guide practitioners in the clinical management of insomnia.”

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