Sequencing Behavioral And Drug Therapy Effectively Treats Insomnia

Behavioral therapy and zolpidem are equally effective for insomnia, and adding a second modality for nonresponders was beneficial in a randomized controlled trial comparing treatment sequences.

"Using one or two or three drugs may seem the most time-efficient and cost-saving approach in the short-term," Dr. Charles Morin of Laval University, Quebec City told Reuters Health by email. "However, this study and others have shown that the most efficient long-term strategy for treating chronic insomnia is to use cognitive behavior therapy. This specific study found that the best treatment sequence in the long run was starting with behavior therapy and, for those who did not respond, adding cognitive therapy or medication."

"The issue of treatment preference is very important," he added. "The current study indicates that the highest dropout rates were observed in conditions where patients were treated only with medications - especially the sequence starting with zolpidem and followed by trazodone - whereas the lowest dropout was observed in the treatment sequences involving behavior therapy followed by cognitive therapy."

As reported in JAMA Psychiatry, for their sequential multiple-assignment randomized trial, Dr. Morin and colleagues enrolled 211 patients with chronic insomnia (mean age, 47; 63% women), 74% of whom had a comorbid anxiety or mood disorder.

Participants were assigned to first-stage therapy with either behavioral therapy (BT) or sublingual zolpidem (5 mg to 10 mg, taken nightly at bedtime); those who did not remit received a second treatment involving either zolpidem or trazodone (50 mg -150 mg taken 30 minutes before bedtime) or psychological therapy (BT or cognitive therapy).

After six weeks of therapy, those in remission were followed up for the next 12 months while receiving maintenance therapy. Nonremitters were randomized to a second-stage psychological or drug therapy.

First-stage therapy with BT or zolpidem produced equivalent weighted percentages of responders (BT, 45.5%; zolpidem, 49.7%; OR, 1.18) and remitters (BT, 38.03%; zolpidem, 30.3%; OR, 1.41).

Second-stage therapy led to significant increases in responders for those who started with BT and moved on to zolpidem (40.6% to 62.7%; OR, 2.46) and those who went from BT to CT (50.1% to 68.2%; OR, 2.09). By contrast, no significant changes in response rates were seen for those who moved from zolpidem to BT or zolpidem to trazodone.

However, the addition of second-stage therapy produced significant increases in the percentage of remitters among those who went from BT to zolpidem (38.1% to 55.9%; OR, 2.06) and a nonsignificant increase in those who took zolpidem then trazodone (31.4%to 49.4%; OR, 2.13).

Although response/remission rates were lower among those who had a psychiatric comorbidity, treatment sequences for insomnia that involved BT followed by CT or zolpidem followed by trazodone yielded better outcomes.

Response and remission rates were sustained through the 12-month follow-up.

Notably, however, as Dr. Morin indicated, cumulative attrition was significantly higher for the two treatment sequences starting with zolpidem relative to those starting with BT.

Dr. Beth Malow, Director, Sleep Disorders Division at Vanderbilt University Medical Center in Nashville commented in an email to Reuters Health, "I like the approach that the investigators took of a sequential treatment method. The approach does seem promising and fits into what might be done in standard clinical practice."

"They identify in the last part of the paper my two thoughts for future work: personalized treatment and insomnia phenotypes/presence of hyperarousal," she added.

—Marilynn Larkin

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