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Cognitive behavioral therapy appears more effective than sleep medication for treating insomnia

June 28, 2006

Patients with insomnia who implemented cognitive behavioral therapy interventions such as relaxation techniques had greater improvement in their sleep than patients who received the sleep medication zopiclone, according to a study in the June 28 issue of JAMA.

Insomnia is usually defined as subjective complaints of poor sleep accompanied by impairment in daytime function. It is common in people aged older than 55 years (9 percent-25 percent are affected) and is associated with reduced quality of life, depression, and more physician visits. Despite these links to individuals' lives and societal costs, most people with chronic insomnia—up to 85 percent—remain untreated, according to background information in the article. Two-thirds of individuals with insomnia report having poor knowledge of available treatment options, and as many as one fifth resort to either untested over-the-counter medications or alcohol in attempts to improve their condition. Among primary care physicians, the treatment of choice for insomnia has commonly been prescription medication. Cognitive behavioral therapy (CBT) is the most widely used psychological intervention for insomnia. No studies have compared the newer non-benzodiazepine sleep medications with nonpharmacological treatments.

Borge Sivertsen, Psy.D., of the University of Bergen, Norway, and colleagues conducted a randomized controlled trial between January 2004 and December 2005 to compare the short- and long-term clinical efficacy of CBT and the non-benzodiazepine sleep medication zopiclone. The trial included 46 adults (average age 60.8 years; 22 women) with chronic primary insomnia. The participants received either the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation technique; n = 18), sleep medication (7.5 mg zopiclone each night; n = 16), or placebo medication (n = 12). All treatment duration was 6 weeks, and the 2 active treatments were followed up at 6 months. Clinical polysomnographic data and sleep diaries were used to determine total wake time, total sleep time, sleep efficiency, and slow-wave sleep (only assessed using polysomnography [PSG; monitoring of physiological activity during sleep]).

Using PSG testing, the total time spent awake during the night for the CBT group improved significantly more than both the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. The zopiclone group did not differ significantly from the placebo group. Total wake time at 6 weeks was reduced 52 percent in the CBT group compared with 4 percent and 16 percent in the zopiclone and placebo groups on PSG testing, respectively. On average, participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, compared with a decline of 1 percent in the zopiclone group, a difference that the authors stated was both statistically and clinically significant.

Total sleep time measured using both PSG and sleep diary increased significantly in the CBT group at 6 months compared with 6 weeks. The zopiclone group showed no significant change at 6 months on PSG, maintaining improvements seen at 6 weeks. Comparing the 2 active treatment conditions, total wake time, sleep efficiency, and slow-wave sleep were all significantly better in the CBT group than in the zopiclone group as assessed using PSG; total sleep time was not significantly different .

" the present findings have important implications for the clinical management of chronic primary insomnia in older adults. Given the increasing amount of evidence of the lasting clinical effects of CBT and lack of evidence of long-term efficacy of hypnotics, clinicians should consider prescribing hypnotics only for acute insomnia. At present, CBT-based interventions for insomnia are not widely available in clinical practice, and future research should focus on implementing low-threshold treatment options for insomnia in primary care settings. As recently demonstrated by Bastien et al, telephone consultations and CBT-based group therapy for younger patients with insomnia produced equally significant improvements as individual therapy sessions. In another study, CBT delivered via the Internet in a self-help format showed significant improvements in individuals with chronic insomnia," the authors write. "Finally, future research should seek to identify which single factors in the CBT regimen produce the best results and to what extent booster sessions at 1 to 2 years after initial treatment may be necessary to maintain improvements."

JAMA and Archives Journals