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Psychotherapy, Pharmacotherapy, or Both for Chronic Insomnia?

Over the long term, CBT was more effective than either pharmacotherapy or combination treatment.

There have been few randomized comparisons of pharmacotherapy, cognitive-behavioral therapy, and their combination for treating chronic insomnia. In this randomized controlled trial, investigators in China examined 3- and 8-month outcomes of these treatments in 77 patients with chronic insomnia.

The four treatments, provided for 8 weeks, were temazepam 1 hour before bedtime (7.5 mg/night during week 1, titrated to a maximum of 30 mg, and then given at 15 mg during week 8); twice-weekly CBT (stimulus-control procedures, cognitive interventions, sleep hygiene, and sleep-restriction interventions); combination treatment (CBT plus pharmacotherapy); and pill placebo. Six patients dropped out before week 4. Among the 71 remaining patients, all active treatments were superior to placebo at week 8, with combination treatment and pharmacotherapy having the best outcomes; these also offered significantly better sleep outcomes (sleep onset latency and sleep efficiency on polysomnography) than CBT did. At the 3- and 8-month follow-up assessments, however, these results were reversed, and the CBT group had the best outcomes and demonstrated continued or maintained gains. In contrast, the pharmacotherapy and combination-treatment groups showed slippage toward baseline levels of insomnia severity.

Comment: These results are consistent with previous studies showing durable benefits with CBT for insomnia (see Journal Watch Psychiatry Jul 11 2006), although in the present trial a particularly intensive course of CBT was provided. Combination treatment appeared to speed therapeutic benefit but was associated with poorer long-term outcome than CBT alone. In these chronic insomniacs, the short-term benefits of pharmacotherapy were balanced after medication discontinuation by the loss of treatment gains over time.

— Michael W. Otto, PhD

Published in Journal Watch Psychiatry July 31, 2006

Citation(s):

Wu R et al. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother Psychosom 2006 Jun; 75:220-8.

• Medline abstract (Free)