Cognitive Behavior Therapy (CBT) vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults

Abstract & Commentary

By Sarah L. Berga, MD, James Robert McCord Professor and Chair, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, is Associate Editor for OB/GYN Clinical Alert.

Dr. Berga is a consultant for Pfizer, Organon, and is involved in research for Berlex and Health Decisions, Inc.

Synopsis: Short-term and long-term measures of sleep improved more in those treated with CBT than with pharmacotherapy with a commonly prescribed hypnotic sleep medication unrelated to benzodiazepines or barbiturates.

Source: Sivertsen B et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295:2851-2858.

Primary insomnia unrelated to depression is a common and debilitating condition that heightens the risk for accidents, cardiovascular disease, and other long-term health conditions. About 10-25% of adults older than age 54 years report insomnia defined as subjective complaints of poor sleep accompanied by impairment in daytime functioning. Insomnia encompasses complaints of insufficient sleep, difficulty initiating sleep, interrupted sleep, and poor-quality or nonrestorative sleep. Most individuals with chronic insomnia remain untreated and optimal treatment for those who seek help is controversial. Most primary care physicians prescribe pharmacotherapy despite the recognition that long-term use involves risks of dependency and tolerance. Further, next-day sleepiness due to pharmacotherapy has been linked to an increase in traffic accidents. No studies have compared newer nonbenzodiazepine sleep medications with nonpharmacological treatments and none have documented the impact of pharmacotherapy upon slow--wave sleep, which is felt to be the most restorative component. Indeed, most trials comparing sleep medications have relied on subjective rather than state-of-the-art objective measures. This randomized, controlled trial compared the impact of cognitive behavior therapy (CBT) with placebo and zopiclone, a commonly prescribed hypnotic unrelated to benzodiazepines or barbiturates. Both subjective (sleep diaries) and objective (polysomnography) measures of sleep were collected at 3 time points: before, 6 weeks, and 6 months. Active treatment lasted 6 weeks. Rigorous inclusion and exclusion criteria were used, including exclusion of those with depression and sleep apnea. Ninety two subjects were screened to enroll 48 participants: the mean age was about 61 years and roughly half were women. CBT included sleep hygiene education, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation techniques.

At 6 weeks, total sleep time did not increase in any group but the amount of PSG-recorded slow-wave sleep (stages 3 and 4) improved significantly over time in the CBT group as compared with placebo and zopiclone groups. The zopiclone group had significantly less slow-wave sleep after treatment as compared with before. Subjective measures did not show any between-group differences. At 6 months, total sleep time increased significantly in the CBT group as compared with 6 weeks. There was no change at 6 months as compared with 6 weeks in the zopiclone group. Comparing the 2 active treatment conditions at 6 months, total wake-time, sleep efficiency, and slow-wave sleep were all significantly better in the CBT group than in the zopiclone group. In the CBT group, 72% had a sleep efficiency of at least 85% at 6 weeks while 78% fulfilled this criterion at 6 months. In contrast, only 47% of the participants in the zopiclone group had a sleep efficiency of at least 85% at 6 weeks and 40% at 6 months. The group differences were statistically significant at both 6 weeks and 6 months. In summary, CBT was more effective immediately and in the long term than both pharmacotherapy and placebo in older adults with chronic primary insomnia.

Commentary

Insomnia increases with age and is a common office complaint. I suspect that most of us do not feel comfortable with this topic, which is one reason to bring this study and its results to your attention. The other main reason for highlighting this study is that it demonstrates the enduring impact of cognitive behavior therapy versus pharmacotherapy in the treatment of nonpsychiatric conditions which compromise quality of life and increase health burden. So what is CBT really? In the most simplistic terms, CBT is a form of "psychoeducation" in which an individual learns to harness the power of the mind to address a targeted symptom with the objective of gaining a tangible health benefit. The instructor can be a psychologist, social worker, or physician; it can be, but does not have to be, conducted by psychiatrist. It is common to use structured forms of CBT in which there is a manualized learning plan with specific modules that cover critical topics. Typically the modules are tailored to the condition being treated. Common uses of CBT include the treatment of stress, anxiety, depression, hypertension, back pain, head ache, premenstrual syndrome, and stress-related amenorrhea and infertility. The most impressive aspect of CBT is that its treatment effects typically not only endure but grow with time. CBT is sometimes coupled with pharmacotherapy for more serious conditions such as major depression or anorexia nervosa.

If CBT is so good, why not use it more commonly to treat a host of common conditions? Cost is low, but reimbursement may be denied. Patients and physicians are often skeptical. It does require an investment of time by both the patient and the healer. Perhaps the most common barrier, however, is unfamiliarity. Assuming that the patient does have a functional rather than an organic etiology for the symptom or complaint, CBT ought to be the first line of treatment for many common psychosomatic conditions.