CBT vs Meds vs Combination for Late-Life Insomnia

TREATING LATE-LIFE INSOMNIA

"If only I could get a good night's sleep" is a common lament, particularly among older Americans. Many older adults have trouble falling asleep and staying asleep. They awaken often during the night, can't get back to sleep, and rise before dawn, symptoms that can cause daytime fatigue, impair normal functioning, and increase health-care costs. Some 12 to 25 percent of healthy seniors report chronic insomnia, but despite their weariness, less than 15 percent receive treatment.

Now National Institute of Mental Health-funded research appearing in the March 17 issue of the "Journal of the American Medical Association" shows that insomnia in later years is treatable. By changing habits and attitudes, older adults can sleep better and longer, the study reports. A team of scientists at the Medical College of Virginia/Virginia Commonwealth University led by Charles M. Morin, Ph.D., now at Laval University, Quebec City, used behavioral and drug therapies, alone or in combination, to treat late-life insomnia. Results suggest that combined behavioral and drug therapies are effective for short-term management of late-life insomnia, and behavioral therapy alone is more effective for long-term improvement in sleep patterns.

Seventy-eight adults with insomnia, including 50 women and 28 men, participated in the study. Subjects had to be 55 or older with insomnia for 6 months or more. They had to take longer than 30 minutes to fall asleep and stay awake longer than 30 minutes after sleep onset for at least 3 nights a week; and they also had to cite at least one negative effect during waking hours, such as fatigue, impaired functioning, or mood disturbance. Eighteen subjects received cognitive-behavioral therapy (CBT); 20 received drug therapy (temazepam); 20 had both treatments; and 20 received placebo.

The cognitive therapy component was designed to alter faulty beliefs and behaviors that often make insomnia worse, such as trying to sleep 8 hours each night, blaming all daytime mishaps on poor sleep, and spending too much time in bed before sleeping. Participants also learned about the effects of diet, age, exercise, caffeine, alcohol, and environmental factors on their sleep habits.

Those receiving CBT attended 8 weekly 90-minute therapy sessions conducted in small groups. Methods involved regulating sleep-wake schedules and associating the bed, bedroom, and bedtime with sleep, rather than with the frustration and anxiety connected with lying in bed trying to sleep. The procedures were:

1. Go to bed only when sleepy
2. Use the bed and bedroom for sleep and sex only--no reading, watching TV, or worrying in bed or in the bedroom
3. Get out of bed and go to another room when unable to fall asleep within 15 to 20 minutes
4. Repeat this step as often as necessary when trying to fall asleep or to get back to sleep
5. Rise at the same time every morning, regardless of the amount of sleep during the previous night

Subjects assigned to the active medication received temazepam (Restoril), because it is well tolerated by older adults and has minimal side effects. Medication subjects met once a week for consultation with the study physician, who reviewed therapeutic responses and adverse affects.

Participants in the third group received both temazepam and CBT. They attended 8 weekly individual therapy sessions with a psychiatrist to discuss medication management and 8 weekly group therapy sessions with a psychologist to review cognitive behavioral procedures.

Those receiving placebo were offered an active treatment after completing the 3-month follow-up.

Results showed that the three active treatments were more effective than placebo, with the combined approach more effective than either of the 2 single components. Improvements occurred in time awake after sleep onset, sleep efficiency, and total sleep time. For example, the percentage of reduced time awake after sleep onset was highest for cognitive-behavioral therapy combined with drug therapy (63%), followed by cognitive-behavioral therapy (55%), drug therapy (46.5%), and placebo (16.9%). At the end of treatment, the following percentages of subjects no longer even met insomnia criteria: 78% (CBT); 56% (medication); 75% (combined), and 14% (placebo).

Those treated only with behavioral therapy maintained their gains at follow-ups, but those treated with drug therapy alone did not. Behavioral treatment, singly or combined, was rated by subjects, significant others, and clinicians as more effective than drug therapy alone. Subjects were also more satisfied with the behavioral approach.

Participants kept diaries to monitor bedtime, rising time, waking after sleep onset, and taking study medication. Time awake after sleep onset and sleep efficiency recorded in both diaries and overnight sleep laboratory evaluations were measured, along with ratings from subjects, significant others, and clinicians. The patients were monitored for sleep states before and after treatment.

Also participating in the study were Cheryl Colecchi, Ph.D., Jackie Stone, Ph.D., Rakesh Sood, M.D., and Douglas Brink, Pharm.D.

Replies:

Assessment and treatment of Insomnia, by Jim Pretzer, 03/12/04

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