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Study says therapy
is better than pills for insomnia
(December
2004 Issue)
By Nan Shnitzler
As little as two hours of cognitive behavioral therapy (CBT) can
do more to relieve chronic sleep-onset insomnia than the most widely
prescribed sleeping pill, according to results of a federally funded
study published in the Sept. 27 issue of the Archives of Internal
Medicine.
"Sleeping pills are the most frequent treatment for insomnia, yet
CBT techniques clearly were more successful in helping the majority
of study participants become normal sleepers," says study leader
Gregg Jacobs, Ph.D., of the Sleep Disorders Center at Beth Israel
Deaconess Medical Center in Boston, Mass.
The study at Harvard Medical School, where Jacobs is an assistant
professor of psychiatry, evaluated the separate and combined effects
of CBT and medication in 63 participants aged 25 to 64. Participants
divided in four random groups received Ambien (zolpidem), four half-hour
sessions of CBT, a combination, or placebo. Participants kept sleep
diaries to record such measures as sleep-onset latency, sleep efficiency
(time slept divided by time allotted for sleep), and total sleep
time. A Nightcap-brand sleep monitor recorded variables at baseline
and at the end of the treatment period.
Results showed no advantage of combined treatment over CBT alone.
At the four-week mid-treatment point, the CBT and combined groups
showed 44 percent reduction in sleep-onset latency, compared with
29 percent for the Ambien group and 10 percent for the placebo group.
At six weeks, Ambien subjects tapered medication to discontinuation.
At eight weeks, CBT and combination treatment showed a further reduction
in sleep-onset latency to 52 percent.
However, measured against the sleep-onset latency norm of 30 minutes
and sleep efficiency of 85 percent, CBT subjects did better than
the combined group after eight weeks, 57 versus 46 percent and 57
versus 54 percent respectively. By the end of the eight-week period,
insomnia experienced by the Ambien group returned to baseline levels,
similar to the placebo group.
An earlier study, also funded by the National Institutes of Health,
published March 1999 in the Journal of the American Medical Association
by Charles Morin, Ph.D. tested elderly participants with sleep-maintenance
insomnia and found that a combination of sleeping pills and therapy
worked best short term, but therapy alone provided longer-lasting
benefits.
Young and middle-aged adults was a significant population that
hadn't been tested before," Jacobs says.
Based on these results and meta-analyses of 60 peer-reviewed empirical
studies, Jacobs is satisfied that behavioral therapy to help change
sleep habits should be the first line treatment for the one-third
of the nation's adults that complain of insomnia and figures 75
percent of patients would derive significant clinical benefit.
"This was the final study that was needed," Jacobs says. "Now we
have two independent, federally funded studies whose outcome data
show therapy is more effective than pills."
Jacobs' next step is to provide access to CBT as easily as doctors
prescribe sleeping pills. In addition to books, such as Jacobs'
own "Say Goodnight to Insomnia" (Holt 1999), the Internet is the
obvious choice.
"We know we can take CBT and turn it into a six-week structured
interactive program to use long term. That's our goal," Jacobs says.
Carl Hunt, M.D., director of the NIH National Center on Sleep Disorders
Research thinks Jacobs study "helps reinforce the important role
CBT has in the treatment of insomnia."
However, Hunt says, "This study doesn't address difficulty staying
asleep, which is more common than difficulty getting to sleep, with
increased frequency and severity as we get older. It should not
be assumed the results would be the same."
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