CBT Is More Effective Than Sleeping Pills

Summarized by Robert W. Griffith, MD
August 16, 2006

Summary

Older people with chronic insomnia do better with a course of cognitive behavioral therapy than with a sleeping pill (zopiclone), after both 6 weeks and 6 months.

Introduction

Insomnia is a disease of civilization that is estimated to generate medical costs of almost $14 billion a year in the USA. Treatment advocated by physicians usually consists of the latest medication, which is almost certainly effective in the short term. However, long-term medication involves risks of dependency and tolerance (decreasing efficacy with continued use). Cognitive behavioral therapy, or CBT¹, is the most widely used psychological approach to insomnia. There's been only one randomized controlled clinical trail comparing the clinical effectiveness of a sleep medication (temazepam) and CBT in older patients with insomnia. Now that newer non-benzodiazepine medications are available, it's time for another direct head-to-head comparison. This has been done by Norwegian researchers, and reported in the Journal of the American Medical Association; here's a summary.

What was done

Volunteers were recruited through newspaper advertisements. They had to be 55 or over, have insomnia of at least 3 months' duration, and complain of impaired daytime functioning. And they had to have no evidence of psychiatric problems or sleep apnea, and not be working night shifts.

After screening interviews the participants underwent two polysomnography exams². Those entering the study were randomly assigned to one of three treatment groups: CBT (18 participants), 7.5 mg zopiclone medication each night (18 participants), or matching placebo medication (12 participants). Treatments were taken for 6 weeks. Examinations were made at the end of treatment, and after 6 months (for the two active groups, only).

CBT consisted of the following:

• sleep hygiene education - impact of lifestyle habits and environmental factors
• sleep restriction - strict scheduling of bedtimes and rising times
• stimulus control - breaking associations between sleep environment and wakefulness (e.g. no TV in the bedroom)
• cognitive therapy - identify and replace beliefs and fears about sleep
• progressive relaxation techniques - exercise instructions to reduce muscle tension.

Participants attended 6 weekly individual sessions, each lasting about 50 minutes. Sleep diaries were kept for 2 weeks at all three examination points (pre-test, 6 weeks, and 6 months (active groups only).

What was found

The average age of participants was 61; there were 22 women and 24 men.

Polysomnography results: After 6 weeks, total awake time showed significant improvement for the CBT group over both zopiclone and placebo groups - 52% vs. 4% and 16%, respectively. Total sleep time was unchanged in all three groups, but sleep efficiency was significantly greater with CBT than placebo.

At the 6-month follow-up total sleep time was significantly increased with CBT compared with the 6 weeks value. Zopiclone was unchanged from the 6-week value. Total wake time and sleep efficacy were both significantly better in the CBT group than in the zopiclone group.

Sleep diary results: After 6 weeks, total wake time, total sleep time, and sleep efficiency were all improved over their pretreatment values, but there were no differences between treatment groups. At 6 months, total sleep time increased in the CBT group beyond its 6-week value. Total wake time was less in the CBT than in the zopiclone group.

Side effects were only reported in the zopiclone group participants and one person in the placebo group. They were slight - bitter taste, dry mouth, daytime drowsiness, slight nausea, headache, and chest pain.

What these results mean

The clinical significance of the results could be assessed by calculating the proportion of participants who reached sleep efficiency levels of 85% or more. In the CBT group, 13 of 18 subjects reached this level at 6 weeks, and 14 had reached it at 6 months. This was clearly better than the efficiency of zopiclone, which had only 7 of 18 subjects reaching this level at 6 weeks, and only 6 at 6 months.

Zopiclone is not available in the USA, yet, but Lunesta^® - eszopiclone, the active component of zopiclone - has been available for the last two years. One may assume that the results of this study are representative of those that would be obtained with Lunesta. It should be noted that this study only included subjects with chronic insomnia; there's no doubt that drugs like zopiclone can help problems of short-term insomnia, and should continue to be used for this.

The obvious question is whether CBT should become recognized as the treatment of choice for insomnia. At present it's not widely available in clinical practice, although this will probably change. The authors of this study say "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 and 2 years after initial treatment may be necessary to maintain improvements".

Two other studies point the way to the future. In one, telephone consultations and CBT-based group therapy produced equally significant benefits in younger insomniacs as individual sessions³. In the other, CBT was delivered via the Internet in a self-help format, and was found to provide significant benefits in chronic insomniacs ⁴. Clearly, psychological help is going to rival, if not replace, other 'cures' for a sleepless night.

Source

• Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults. B. Sivertsen, S. Omvik, S. Pallesan,  et al., JAMA, 2006, vol. 295, pp. 2851--2858

Footnotes
1. Cognitive behavior therapy (CBT) combines two very effective kinds of psychotherapy - cognitive therapy and behavior therapy. Cognitive therapy shows you how certain thinking patterns are causing your symptoms by giving you a distorted picture of what's going on. Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them. It teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions. When combined into CBT, cognitive therapy and behavior therapy provide powerful tools for stopping your symptoms and getting your life on a more satisfying track.
2. Polysomnography is done in a sleep lab. For studying insomnia, it measures total wake time, total sleep time, sleep efficiency (time spent asleep as percentage of time spent in bed), and slow-wave sleep.
3. Bastien CH, Morin CM, Ouellet MC, et al. Cognitive behavioral therapy for insomnia: comparison o findividual therapy, group therapy, and telephone consultations. J Consult Clin Psychol 2004;72:653-659
4. Strom L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol 2004;72:113-120

Related Links
American Insomnia Association
Internet Based Treatment for Insomnia
Online CBT for Insomnia