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Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.
JAMA 2009; 301(19):2005-15JAMA

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+Show Affiliations

Université Laval, Ecole de Psychologie, Pavillon F A S, Québec, Québec, Canada G1K 0A6. cmorin@psy.ulaval.caNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

19454639

Citation

Morin, Charles M., et al. "Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia: a Randomized Controlled Trial." JAMA, vol. 301, no. 19, 2009, pp. 2005-15.
Morin CM, Vallières A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005-15.
Morin, C. M., Vallières, A., Guay, B., Ivers, H., Savard, J., Mérette, C., ... Baillargeon, L. (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA, 301(19), pp. 2005-15. doi:10.1001/jama.2009.682.
Morin CM, et al. Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia: a Randomized Controlled Trial. JAMA. 2009 May 20;301(19):2005-15. PubMed PMID: 19454639.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. AU - Morin,Charles M, AU - Vallières,Annie, AU - Guay,Bernard, AU - Ivers,Hans, AU - Savard,Josée, AU - Mérette,Chantal, AU - Bastien,Célyne, AU - Baillargeon,Lucie, PY - 2009/5/21/entrez PY - 2009/5/21/pubmed PY - 2009/5/22/medline SP - 2005 EP - 15 JF - JAMA JO - JAMA VL - 301 IS - 19 N2 - 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. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/19454639/Cognitive_behavioral_therapy_singly_and_combined_with_medication_for_persistent_insomnia:_a_randomized_controlled_trial_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2009.682 DB - PRIME DP - Unbound Medicine ER -