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Cognitive behavioral therapies for insomnia and hypnotic medications : considerations and controversies

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- Insomnia is a prevalent and costly health problem that often remains untreated or is treated inadequately. There are, however, several evidence-based treatment options, including cognitive behavioral therapies (CBTs) and pharmacologic therapies, each with its own advantages and limitations. - Medications with specific indications for insomnia produce rapid symptomatic relief, but there is little to no evidence that sleep improvements are maintained after drug discontinuation or long-term, continued usage. Conversely, CBT takes longer than drugs to produce sleep improvements, but these improvements are well sustained over time. - Aside from their short-term and long-term benefits, other key considerations need to be taken into account when selecting among the different insomnia therapies. These include patients’ treatment preferences, how best to deliver CBT, whether to combine or sequence CBTs and medication therapies, and who should treat insomnia. These considerations may have a significant impact on efficacy, compliance, attrition, and access to treatment. - Several innovative treatment delivery methods relying on digital technology are increasingly used to treat insomnia. Although these self-help approaches may reduce cost and human resources and increase access, an important shortcoming is the high attrition rate during the course of these self-guided approaches. - The publications of clinical practice guidelines by several international medical and sleep organizations have reached the same recommendation, that is, CBT should be the first-line treatment of insomnia, and only when such treatment is not available or not effective should medication be considered for treating persistent insomnia. It is hoped that such strong and uniform endorsement by the medical and sleep community will help narrow the current gap between the available research evidence and clinical practices.
Sleep Medicine Clinics, Vol. 14 (2), 253-265 (2019)
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Cognitive behavioral therapy for insomnia , Pharmacotherapy , Stepped care , Treatment preference , Combination therapy , Treatment sequencing
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