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Practical Implications of a Study on Treating Chronic Insomnia

(PSYCHIATRIC TIMES) - More than a thousand articles on mental disorders are published in medical journals each month! Also, clinicians have limited training, time, and inclination to keep up with reading research articles critically on a regular basis. Thus, a disturbing disconnect (for which there are no easy solutions) exists between clinical research and usual clinical practice.

Only a very small fraction of research articles report findings with immediate clinical utility. In this new column, I will present succinct descriptions of selected research articles and discuss their clinical implications. I will also use discussion of these articles to provide tips about interpreting and applying research findings. Please e-mail me at with your questions and comments.

This month’s column focuses on a recent JAMA article1 on the treatment of chronic insomnia—an important condition because it affects millions of people in this country.2

Summary of the study

Both cognitive-behavioral therapy (CBT) and hypnotics are effective in chronic insomnia, but many patients have incomplete improvement with either treatment alone. Also, many patients may need continued treatment after the acute phase.

Because of these 2 issues, this study addressed the following questions:

• Is there any benefit from adding a hypnotic to CBT in the acute phase?

• Does adding a hypnotic to CBT in the acute phase improve the longer-term outcome over 6 months?

• For patients treated in the acute phase with a combination of CBT and a hypnotic, should the hypnotic be discontinued after the acute phase is over?

• For patients treated with CBT alone in the acute phase, are further intermittent “maintenance” CBT sessions over 6 months helpful?

This was a randomized, controlled trial involving 160 patients (mean age, 50 years) with chronic insomnia (ie, insomnia lasting 6 months or more). Patients whose insomnia was secondary to another specific illness (eg, progressive medical illness, a medication adverse effect, current major depressive disorder, sleep apnea, restless legs syndrome) were excluded. For the 6-week acute phase, patients were randomized to CBT alone (1 group session per week) or combined treatment (CBT plus zolpidem, 10 mg at bedtime). Details of the type of CBT used have been described elsewhere.3

After the acute phase, patients were again randomized to different treatment groups for the next 6 months. Those who had received CBT alone in the acute phase received either 1 maintenance group CBT session per month or no further treatment.

Patients who had received combined treatment in the acute phase received either combined treatment (CBT plus zolpidem, with zolpidem now being used intermittently) or CBT alone.

To summarize: on the basis of treatment received during the acute and maintenance phases, patients were divided into 4 categories: CBT-CBT, CBT–no treatment, combined-combined, and combined-CBT.

TIP: In any clinical trial, look for the completion rate overall and in each treatment group, because “dropouts” can significantly bias a study unless this can be effectively controlled for statistically.

About 80% of the patients completed the study—a rate similar across the treatment groups.


Is there any benefit to adding a hypnotic to CBT in the acute phase?

In the acute phase, both the CBT alone and the combined treatment groups showed equal mean improvement in mean sleep latency, time awake after sleep onset, and sleep efficiency (from daily diaries).


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