Behavioral Treatment for Chronic Insomnia Works

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December 29, 2006

Behavioral Treatment for Chronic Insomnia Works

  1. Peter Roy-Byrne, MD

Why won’t you suggest it?

  1. Peter Roy-Byrne, MD

Chronic insomnia, whether primary or associated with comorbid medical or psychiatric conditions, is a prevalent and disabling condition that increases with age. This past year, researchers have continued to document the efficacy of nonpharmacologic treatment methods and the potential adverse effects of chronic use of hypnotics in elderly individuals. These results are important in light of the infrequent use of behavioral methods to treat insomnia, coupled with the accelerating rate of hypnotic use in the U.S. population, especially in the elderly.

Two placebo-controlled, randomized trials examined the relative efficacy of cognitive-behavioral therapies, hypnotic medications, and pill placebo in treating primary chronic insomnia. One study also included an arm in which patients received both CBT and a hypnotic medication; the other involved older individuals, a previously understudied population in behavioral-treatment studies of insomnia. Results from both investigations showed that CBT was at least as effective as medication; the study in the elderly actually showed superiority for CBT over medication. Moreover, the study examining combination treatment showed a slight superiority for it acutely over either modality alone; but once medication had been stopped, its effect was inferior to that of CBT alone. Elsewhere, a meta-analysis of pharmacotherapy studies of insomnia in the elderly showed that the effects of hypnotic medications were evident, but modest. The number needed to treat was 13, corresponding to about an 8% increase in benefit between medication and placebo. Even more important, the adverse effect rate was fairly high and significant; only six people would need to be treated to harm one, corresponding to a 16% greater risk for adverse effects with medication than with placebo.

The results of the first two studies are concordant with a newly published systematic review (Sleep 2006 Nov 1; 29:1398-414), which supports the efficacy of various behavioral treatments for insomnia, whether primary or comorbid. The authors of this meta-analysis conclude that these treatment approaches are useful to facilitate a reduction in dose or to discontinue medication entirely in patients already taking hypnotic medications. The authors also conclude that a maximally effective behavioral treatment would contain several components (i.e., stimulus control, sleep restriction, sleep hygiene, and cognitive interventions). Finally, the authors emphasize that there is only limited evidence that the effectiveness of these nonmedication approaches extends to other indices of morbidity such as daytime fatigue or reduced quality of life.

Although the effectiveness of CBT methods for chronic insomnia has been described and documented for over a decade, these new studies and meta-analysis add to the weight of the evidence, which is now codified in practice parameters from the American Academy of Sleep Medicine (Sleep 2006 Nov 1; 29:1415-9). Despite this evidence, it is clear that these treatments are underused, a phenomenon that is not confined to the sleep field, because CBT for anxiety and depression is also underused. The greatest barrier to their use continues to be the availability of specialists knowledgeable about the techniques and able to deliver them effectively. However, an increasing number of sleep centers now have such specialists. Clinicians treating patients with chronic insomnia might consider referring their patients to sleep centers, not just for polysomnography, but also for the personnel who can deliver one of these evidence-based behavioral treatments for insomnia, whether as a primary treatment or as an aid for reducing or eliminating use of hypnotic medications. Also, by countering negative beliefs about the utility of behavioral methods to treat insomnia, these centers might educate patients who feel that only medication can help them.

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