Is CBT Plus Medication the Best Treatment for Insomnia?

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When it comes to the long-term treatment of insomnia, a meta-analytic study suggests that cognitive behavioral therapy (CBT) “is at least as effective for treating insomnia when compared with sleep medications, and its effects may be more durable than medications” (Mitchell MD et al, BMC Fam Pract 2012;(May 25):13–40). But what is the impact of combining medication with CBT in the treatment of insomnia?

Two studies, led by Charles Morin, PhD, professor of psychology at Université Laval, in Québec, Canada, have considered that question. A 2009 study by Morin’s team showed that in the treatment of insomnia with CBT, adding sleep medication is found to be most beneficial if the medication is discontinued early in the course of treatment. In that study, researchers looked at the use of zolpidem (Ambien) and CBT, examining if the combination of medication and CBT is more beneficial than CBT alone (Morin CM et al, JAMA 2009;301(19)2005–2015).

The participants were 160 adults at least 30 years of age with chronic insomnia. In the initial phase of the study, participants were randomly assigned to receive either six weeks of CBT alone or combined therapy consisting of CBT plus 10 mg of zolpidem at bedtime. In a second phase, participants who initially received only CBT were randomly assigned to receive either monthly maintenance CBT or no additional treatment. Participants who initially received combined CBT and medication therapy were randomly assigned to receive either CBT plus intermittent use of zolpidem or CBT alone. The duration of the study’s second phase was six months.

The best long-term outcome occurred when the combination of CBT and medication therapy during the initial six-week phase was followed by a cessation of medication (ie, patients continuing with monthly CBT and without medication during the extended treatment phase). This is evidenced by the finding that, compared to the patients who continued to take medication during the extended treatment phase, patients who stopped medication were more likely to be in remission from insomnia at the six-month follow-up (68% vs 42%).

The researchers concluded that “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.”

In an earlier 1999 study, Morin and his colleagues randomly assigned participants with chronic and primary insomnia to either CBT for insomnia, temazepam (Restoril), a combination of the two, or placebo. The participants were 78 older adults—mean age 65—with persistent insomnia. The researchers found that combination therapy was more effective than either treatment alone. In the study, the percentage reduction of time awake after sleep onset was highest for the combined condition (63.5%), followed by CBT (55%), temazepam (46.5%), and placebo (16.9%) (Morin CM et al, JAMA 1999;281(11):991–999).

Does the study mean that combination therapy—CBT, plus medication—is the best option for patients with insomnia? “There really isn’t a single approach that works best for all patients,” Morin, told The Carlat Behavioral Health Report’s sister publication The Carlat Psychiatry Report in a November 2011 interview.

“We also don’t have good models in terms of sequential therapies,” Morin said. “But certainly if we have someone with acute insomnia, drug therapy is probably the best first choice, followed by CBT. If we have someone with chronic insomnia who has never used drugs, we would start with CBT because that is least likely to produce adverse effects. Ideally we would combine medication and CBT and after a few weeks gradually discontinue the medication and continue CBT to make sure that they integrate what they have learned during the course of CBT.”

As Morin noted in his interview, there are two basic components of CBT for insomnia—cognitive and behavioral. The cognitive component refers to changing beliefs and attitudes—in the case of insomnia, thoughts that are detrimental to sleep. The behavioral component focuses on maladaptive behavioral habits, such as poor sleep habits and irregular sleep schedules, which contribute to perpetuating insomnia over time.