Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia : a randomized controlled trial

Authors: Morin, Charles M.Vallières, AnnieGuay, BernardIvers, HansSavard, JoséeMérette, ChantalBastien, Célyne H.Baillargeon, Lucie
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) ofzolpidemforaninitial6-weektherapy,followedbyextended6-monththerapy.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.
Document Type: Article de recherche
Issue Date: 20 May 2009
Open Access Date: 16 June 2016
Document version: VoR
This document was published in: JAMA: the Journal of the American Medical Association, Vol. 301 (19), 2005-2015 (2009)
American Medical Association
Alternative version: 10.1001/jama.2009.682
Collection:Articles publiés dans des revues avec comité de lecture

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