Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.

Abstract

CONTEXT:

Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome.

OBJECTIVES:

To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome.

DESIGN, SETTING, AND PATIENTS:

Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005.

INTERVENTIONS:

Participants received 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. Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only.

MAIN OUTCOME MEASURES:

Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes).

RESULTS:

Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P<.001); a larger increase of sleep time was obtained with the combined approach (P = .04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P = .84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P = .52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P = .05). 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 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P = .04).

CONCLUSION:

In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00042146.

• Authors: Charles M Morin, Annie Vallières, Bernard Guay, Hans Ivers, Josée Savard, Chantal Mérette, Célyne Bastien, Lucie Baillargeon
• Journal: JAMA (JAMA) Vol. 301 Issue 19 Pg. 2005-15 (May 20 2009) ISSN: 1538-3598 [Electronic] United States
• PMID: 19454639 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, N.I.H., Extramural)

Chemical References

• Hypnotics and Sedatives
• Pyridines
• Zolpidem

Topics

• Aged
• Cognitive Behavioral Therapy
• Combined Modality Therapy
• Female
• Humans
• Hypnotics and Sedatives (administration & dosage, therapeutic use)
• Male
• Middle Aged
• Polysomnography
• Pyridines (administration & dosage, therapeutic use)
• Sleep
• Sleep Initiation and Maintenance Disorders (therapy)
• Zolpidem