Sleep: Is It Overrated?

Phillips, Barbara A.
September 2009
Neurology Alert;Sep2009, Vol. 28 Issue 1, p5
THIS STUDY IS A PROSPECTIVE EVALUATION OF COGNItive behavioral therapy (CBT) with a hypnotic (zolpidem, 10 mg) in 160 patients with chronic insomnia. For this study, chronic insomnia was defined as: 1) difficulties initiating and/or maintaining sleep, defined as a sleep onset latency and/or wake after sleep onset greater than 30 minutes, with a corresponding sleep time of less than 6.5 hours at least three nights per week (as measured by daily sleep diaries); 2) insomnia duration longer than six months; and 3) significant distress or impairment of daytime functioning (rating of 2 on item 5 of the Insomnia Severity Index [ISI]). In an effort to eliminate those with lifestyles or underlying medical or mental illnesses that are known to be associated with sleep complaints, there were many exclusion criteria, and potential subjects underwent a history and physical examination, sleep testing examination, and screening for psychiatric illness. Indeed, two-thirds of those screened for the study had to be excluded for one of these reasons. Participants were initially randomized to CBT alone or combined therapy of CBT plus 10 mg of zolpidem nightly. After the first six weeks ("acute treatment"), they were again randomized (and split into four groups) for the next six months ("maintenance treatment"). The patients who were treated with CBT alone during the acute treatment phase were randomized to either CBT alone for six months or to no additional treatment. The patients who were treated with CBT plus zolpidem during the acute phase were randomized to CBT plus zolpidem to be used on an as-needed basis or to CBT alone with no additional zolpidem. CBT was delivered as weekly 90-minute group sessions during the six-week acute treatment phase, then monthly individual sessions during the six-month maintenance phase. CBT during the acute phase included recommendations to restrict time in bed to the actual time slept and gradually increase it back as sleep improved. In addition, patients were instructed to go to bed only when sleepy at night; to use the bed and bedroom only for sleep and sex; to get out of bed and go in another room whenever they were unable to fall asleep or return to sleep within 20 minutes and return to bed only when sleepy again; and to get up at the same time every morning. Patients were also instructed in the elements of sleep hygiene. Cognitive behavioral therapy aimed to address unrealistic sleep expectations and amplification of the consequences of insomnia. CBT during the maintenance phase was individualized; techniques of relaxation, worry management, and problem solving were used as needed. CBT was administered by master's level clinical psychologists who used a treatment manual. The subjects assigned to receive zolpidem received 10 mg/night of zolpidem, which they were instructed to take 30 minutes before bedtime. The medication was provided weekly during brief visits with a primary care physician. These sessions focused on reviewing sleep diaries and insomnia symptoms during the previous week, as well as monitoring potential adverse effects. During the maintenance phase, those assigned to receive zolpidem prn met with the physician monthly and received 10 zolpidem pills per month with the instruction to take a pill only when it was needed. At the end of the six-month extended CBT phase, zolpidem was tapered according to a written withdrawal schedule (decrease the dose from 10 mg to 5 mg during the first week and then take 5 mg every other night until they ran out). Assessments were conducted at baseline, at the end of the initial six-week phase, at the end of the six-month extended treatment phase, and six months after all treatment ended. Measurements used during assessments included sleep diaries and sleep studies at baseline, two weeks after the acute treatment, and at the end of the six months of maintenance treatment.…



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