Counseling may beat sleeping pills for insomnia

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People with chronic insomnia are more likely to find relief with a few sessions of psychological counseling than with sleeping pills, especially in the long run, according to the results of a small study.

The investigators say their study findings show that counseling, in the form of cognitive behavioral therapy, should replace drugs as the insomnia treatment of choice.

"You don’t have to live with insomnia, and the most effective treatments are non-drug,” said lead study author Dr. Gregg D. Jacobs, an insomnia specialist at Beth Israel Deaconess Medical Center in Boston.

When applied to insomnia, cognitive behavioral therapy aims to change people’s thoughts and behaviors regarding sleep. In short, it addresses the roots of a person’s sleep difficulties, Jacobs told Reuters Health.

Unlike sleeping pills, he said, cognitive behavioral therapy can offer insomniacs a permanent solution. In general, sleep medications should be taken only for a short time, as patients can develop a tolerance to the drugs’ effects or become dependent on them.

According to Jacobs, “there’s no rationale” for prescribing sleep pills before trying a non-drug approach like cognitive behavioral therapy.

He and his colleagues report their findings in Monday’s issue of the Archives of Internal Medicine.

For the study, the researchers randomly assigned 63 young or middle-age adults with chronic insomnia to one of four groups: Ambien (zolpidem) for six weeks, with doses tapered off over the last two weeks; cognitive behavioral therapy five times over the same period; a combination of the two treatments; and a “control” group that received inactive pills.

Ambien is the most-prescribed sleep aid in the U.S., and the researchers chose to study it in part because it’s believed to have fewer side effects and a lower potential for abuse than other sleep medications.

When Jacobs and his colleagues assessed the study patients two weeks after their treatment ended, they found that 57 percent of those in the cognitive behavioral therapy group were falling asleep within the normal range of 30 minutes—as were 46 percent in the combined-therapy group. In contrast, only 15 percent on drug treatment fell into the “normal” range, similar to the number who received no treatment.

One year later, patients who had improved with cognitive behavior therapy were generally still falling asleep faster.

Jacobs said that as his team expected, Ambien patients did rest easier during treatment, but the benefits quickly diminished once the drug was stopped.

What was surprising, the researcher added, was that cognitive behavior therapy was more effective than the drug during treatment as well as after. For example, at the mid-point of treatment, 36 percent of Ambien patients were falling asleep within 30 minutes, versus half of the counseling patients.

Cognitive behavior therapy in this study took a total of two-and-one-half hours, with four in-person sessions with a counselor and one telephone session. The therapy aimed to change patients’ thoughts regarding sleep—helping them, for instance, to stop ruminating over how they would function the next day if they failed to fall asleep quickly that night.

The “behavior” aspect of the therapy taught them practical measures such as going to bed only when drowsy and getting out of bed and doing something else if they failed to fall asleep in 20 to 30 minutes.

While Jacobs believes that cognitive behavioral therapy should be the “first-line” treatment for insomnia, a big obstacle is availability. Many sleep clinics, he said, now offer the therapy, but people often lack access to specialized clinics.

SOURCE: Archives of Internal Medicine, September 27, 2004. 

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