by Joye C. Anestis
Significant bodies of literature support the use of CBT and pharmacotherapy in the treatment of insomnia, and CBT is considered an EST for primary insomnia. As is the case with a number of conditions, medication treats insomnia in the short-term but has questionable long-term stability, whereas CBT takes longer to take effect but its effects are maintained in the long-term. In a new study published in the Journal of the American Medical Association (JAMA), Morin and colleagues investigated the efficacy of combining CBT and pharmacotherapy. They also investigated whether, when combining CBT and medication, it is best to discontinue medication after the initial treatment or continue medication on an intermittent schedule.
Let's talk about the sample first. It's important to note that this was a study investigating treatments for chronic, primary insomnia...meaning they excluded almost anyone with an illness that could also contribute to the insomnia (e.g., bipolar disorder, current depression; there were many additional exclusion criteria as well - check the article for more information). Primary insomnia occurs in a significant number of people (1-10% of the general adult population; APA, 2000) and is related to a number of short and long-term consequences, such as increased risk for an affective disorder and hypertenison, overall decreased quality of life, and significant impairments of daytime functioning (Ford et al., 1989; Ozminkowski et al., 2007; Simon et al., 1997). In the current study, the random assignment of subjects (n = 160; 97 women & 63 men) was a bit complicated (but make for a really great study):
- 80 subjects were assigned to 6 weeks of CBT. At the end of 6 weeks, these 80 subjects were randomly assigned a second time to either:
- extended CBT for 6 months or
- no additional treatment
- 80 subjects were assigned to CBT + 10 mg of zolpidem (Ambien) nightly. At the end of 6 weeks, these 80 subjects were randomly assigned a second time to either:
- extended CBT for 6 months with no additional zolpidem or
- extended CBT for 6 months plus zolpidem to be used on an as needed basis (i.e., no longer nightly)
The 6-week CBT involved behavioral, cognitive, and educational components common in CBT protocols for insomnia (e.g., sleep hygiene, examination of faulty beliefs held about sleep, psychoeducation about the nature of sleep and variables that affect it). This was administered in 6 weekly 90-minute group therapy sessions. Those subjects assigned to the 6-month extended CBT then received 6 monthly, individually tailored CBT sessions. Subjects assigned to the initial CBT + zolpidem condition received the same group CBT above, as well as medication provided in weekly consultation sessions with a primary care physician. During the 6-month extended treatment phase, those assigned to the extended CBT with no additional 
zolpidem just received the monthly individual CBT. Those assigned to the additional zolpidem condition met with a physician monthly and received 10 pills a month to be used as needed. At the end of 6 months, zolpidem was tapered off. The investigators did an incredible job assessing outcome in this study, including participant sleep diaries, sleep laboratory evaluation, and objective self-report measures, done before, during, and after treatment.
Before describing the treatment results, I want to quickly comment on one of the demographic findings. In this study, individuals under age 30 were excluded and the mean insomnia duration for this group was 16.4 years (standard deviation of 13.6 years)! What an incredibly long time to not be able to sleep! I was just a little blown away by that statistic.
Due to the copious amount of information gathered in their assessments, Morin and colleagues reported a huge number of findings. I am only going to talk about the big picture results and recommend that you check out the article for more specific information. Primarily, they found that CBT, both alone and with zolpidem, was efficacious in treating primary insomnia in the short-term (i.e., the initial 6-weeks). Improvements include decreased sleep latency, time awake after sleep onset, and sleep efficiency. Both CBT alone and in combination with medication produced similar rates of treatment responders and remissions. In fact, the authors note that any differences found between the 2 groups were marginal and not clinically significant. The best long-term outcome was obtained by the clients who received the combination treatment initially, followed by CBT alone. So, this study suggests that combined treatment is best at changing sleep patterns in the short-term and these gains are maintained by continuing psychotherapy and discontinuing the medication. Naturally, many more studies are needed to flesh out the efficacy of combination treatment further, as well as its utility in a more natural sample (i.e., an effectiveness study), but it provides an essential step toward determining best practices in treating a debilitating problem.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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