Sequential psychological, medication therapies effective for insomnia disorder
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Sequential cognitive behavioral therapy and medication treatments appeared effective for insomnia management, according to results of a randomized clinical trial published in JAMA Psychiatry.
“Currently, there is no single treatment, whether psychological or pharmacological, that is acceptable or effective for all patients with insomnia,” Charles M. Morin, PhD, Canada research chair at Laval University’s Cervo Brain Research Centre in Quebec, told Healio Psychiatry. “Health care professionals often use a trial and error strategy to find the best treatment/combination of treatments. This study was designed to test different treatment sequences combining psychological therapies, such as cognitive behavioral therapy, and medication therapies.”
Thus far, to the researchers’ knowledge, no study has examined the efficacy of first-stage treatments for different insomnias with and without comorbidity and the efficacy of second-stage treatment for patients whose insomnia fails to remit with psychological medication first-stage therapy.
To address this research gap, Morin and colleagues aimed to compare efficacy of four treatment sequences that involved psychological and medication therapies for insomnia, as well as to examine psychiatric disorders’ moderating effect on insomnia outcomes.
The investigators conducted a sequential multiple-assignment randomized trial in which they assigned patients to first-stage therapy that involved either behavioral therapy (n = 104) or zolpidem (n = 107). Those who did not remit were given a second treatment that involved either zolpidem or trazodone, or behavioral therapy or cognitive therapy. Treatment response and remission rates, defined by the Insomnia Severity Index total score, served as the primary end points.
Among 211 adults with a chronic insomnia disorder, including 74 patients with a comorbid anxiety or mood disorder, first-stage therapy with behavioral therapy or zolpidem led to equivalent weighted percentages of responders and remitters. For the two conditions, second-stage therapy led to significant increases in responders, starting with behavioral therapy, but no significant change after zolpidem treatment. The investigators observed significant increase in percentage of remitters among two of four therapy sequences, including behavioral therapy to zolpidem and behavioral therapy to cognitive therapy.
Response and remission rates were lower among patients with psychiatric comorbidity; however, treatment sequences that involved behavioral therapy and subsequent cognitive therapy or zolpidem followed by trazodone produced better outcomes for patients with comorbid insomnia. Through the 12-month follow-up, response and remission rates were well sustained.
“Behavioral therapy and zolpidem produced equivalent benefits in the short-term (after 6 weeks), but adding a second course of treatment for an additional 6 weeks significantly improved the overall outcome of insomnia treatment (ie, number of individuals with a response or who remit from insomnia),” Morin told Healio Psychiatry. “Thus, one should not give up if the first therapy does not work. Insomnia is a highly prevalent condition that increases risk in the long-term for depression, hypertension and work disability; therefore, it is important to have effective and acceptable therapies for patients with chronic insomnia.”