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Behavioral Therapy or Medication for Sleep?

Cognitive behavioral therapy is better than drug therapy for short- and long-term management of insomnia.

Despite a high prevalence of sleep problems and associated adverse effects, most medications for insomnia have either short- or long-term side effects, and few studies have been designed to examine nonpharmacologic approaches. Norwegian investigators randomly assigned 46 adults (mean age, 61) with chronic primary insomnia to receive cognitive-behavioral therapy (CBT), nightly zopiclone (7.5 mg), or placebo for 6 weeks. Zopiclone (Imovane), a racemic mixture of two stereoisomers, is unavailable in the U.S.; its active stereoisomer, eszopiclone (Lunesta), is available in the U.S.

Only people without recent hypnotic medication use, dementia, depression, sleep apnea, or unusual work shifts were included. CBT consisted of weekly treatment sessions that addressed sleep hygiene, sleep-promoting behaviors, relaxation training, and problem-focused education. At 6 weeks, total sleep time was similar in all groups. However, slow-wave sleep (stages 3 and 4) improved significantly in the CBT group (mean increase, 27%) but declined in the zopiclone and placebo groups (mean decreases, 20% and 13%, respectively). At 6 months, total sleep time continued to increase in the CBT group (but not in the zopiclone group), and overall sleep efficiency also improved significantly in the CBT group compared with the zopiclone group.

Comment: Although the CBT intervention in this trial was not blinded, the objective polysomnographic measures of improvement strengthened the conclusion that appropriate counseling and education are superior to a commonly used hypnotic for improving long-term sleep, particularly restorative sleep.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine July 18, 2006

Citation(s):

Sivertsen B et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. JAMA 2006 Jun 28; 295:2851-8.

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