Combining Different Treatments

For most sleep disorders, behavioral/psychotherapeutic and pharmacological approaches are not incompatible and can be effectively combined to maximize therapeutic benefits. For example, hypnotic medications may improve sleep patterns more rapidly than some behavioral interventions (McClusky et al. 1991) and are particularly useful for acute and situational insomnia. However, clinical gains achieved after completion of treatment are better maintained for behavioral treatment compared with pharmacotherapy or in combination with pharmacotherapy (Milby et al. 1993; Morin et al. 1993a). In practice, the clinician could capitalize on the more immediate results from pharmacotherapy to break the vicious cycle of insomnia and on the longer-lasting effects of cognitive-behavioral therapy to maintain improved sleep after discontinuation of hypnotic medications. Additional research is needed to define more precisely optimal methods for integrating behavioral and pharmacological therapies for insomnia (National Institutes of Health 1996).

Most nonpharmacological interventions are not mutually exclusive. Recognition of the interactive role of dysfunctional cognitions and maladaptive sleep habits has led to an increasing use of multimodal interventions targeting different facets of sleep disorders (Espie et al. 2001; G. D. Jacobs et al. 1996; Lacks and Morin 1992; Morin et al. 1993a, 1999). Although in the short term they may not be superior to single therapies such as stimulus control or sleep restriction, multicomponent interventions addressing various aspects of a sleep disorder may produce longer-lasting benefits. The recent emergence of structured, sleep-focused, and manualized treatment protocols is likely to improve treatment integrity and facilitate its implementation. It will be essential for the clinician, however, to tailor such clinical protocols to the nature of the sleep disorder, its controlling factors, and, most important, the patient's clinical characteristics (Espie 1991). Combinations of medications (such as antidepressants and benzodiazepines) are sometimes indicated and can often be used safely and effectively for patients with sleep disorders. A common example is the concurrent use of SSRI antidepressants and short-acting benzodiazepine receptor agonists or trazodone (see subsection later in this chapter, "Insomnia Related to Another Mental Disorder" [Pharmacological treatment]).