Pills-therapy combination work best at treating insomnia, study says

By Letitia Stein, Times Staff Writer
In Print: Wednesday, May 20, 2009

Losing sleep over the economy? For the growing numbers of Americans tossing and turning at night, a new study on treating sleep disorders may offer hope.

But like the repair of the financial markets, there is no quick fix to insomnia. Treatment, according to a report released Tuesday in the Journal of the American Medical Association, can be most effective when combining a brief spell on sleeping pills with extended therapy to change bedtime behaviors that exacerbate sleep disorders.

Dr. Mac Anderson, director of the University of South Florida’s sleep medicine training program, said this approach bridges a patient’s desire to get quick results with the long-lasting benefits from behavioral therapy.

“Most Americans, in our culture, it’s a pill for everything,” said Anderson, who is also the medical director of Tampa General Hospital’s Sleep Disorders Center. “That may help people get started on their treatment for insomnia, but those physiological behaviors that have to be learned and taught are what’s going to, in my opinion, help them the most over a long period of time — not the medicine.”

The new insight into insomnia treatment comes at a time when many Americans report trouble sleeping. In a recent poll by the National Sleep Foundation, more than one in four people surveyed said they had lost sleep worrying about personal finances and employment, the U.S. economy and health care costs.

Even in good times, an estimated 50 million to 70 million Americans suffer from ongoing sleep disorders, affecting their daily ability to function, the Institute of Medicine reported in 2006. It called the cumulative affect of sleep loss and insomnia “an under-recognized public health problem,” one associated with diabetes, obesity, depression, heart attack and stroke.

More than just a pill

Both behavioral therapy and prescription medication are effective treatment options, experts say. The new study in JAMA examined the effectiveness of using them together on chronic insomniacs.

For the first six weeks, half of the participants received a regimen of “cognitive behavioral therapy,” a short-term therapy that focuses on sleep habits and attitudes about sleep. The rest received a nightly dose of Ambien, a well-known sleeping medication, combined with the behavioral therapy.

After the initial treatment phase, half of the therapy-only group continued the therapy for the next six months. The rest discontinued it.

The patients taking Ambien were also divided into two groups — one that stuck with behavioral therapy and discontinued drug use. The other received ongoing therapy, and were allowed to use Ambien if needed.

Six months later, researchers found the best results among the patients who initially received a combination of behavioral therapy and sleeping medication, but then stopped taking Ambien entirely.

“We can’t expect that just with a sleeping pill, we will cure the problem forever,” said Charles Morin, the lead author and a professor of psychology at Laval University in Canada. “When we discontinue the treatment, usually people get back to where they were initially, whereas with CBT, it’s based on teaching behavior principals and psychological principals — and once we end the teaching, what people have learned does not disappear.”

No overnight change

It takes time to see results with CBT’s multi-pronged approach to changing bedtime habits, which includes “sleep hygiene” education and correcting misconceptions that could aggravate an insomniac’s distress. For example, many people think they should sleep eight hours a night, but sleep needs vary.

The study, conducted in the Quebec City area, involved 160 white men and women with chronic insomnia ranging in age from 30 to 72.

After the initial six-week phase, more than half of participants in both treatment groups were sleeping better. Those who combined behavioral therapy with Ambien (a brand of zolpidem), part of a newer generation of sleeping medications that are generally not addictive, slept a little longer than the other groups.

But after the next six months of treatment, the best results were seen in participants who stopped taking medication, and continued their behavioral therapy.

Behavioral therapy seeks to correct a vicious cycle in which the stress of losing sleep can lead to further insomnia.

“The thought of going into the bedroom and having a sleepless night creates anxiety,” said Anderson, the USF sleep specialist. “Tossing and turning, worrying about not being able to sleep and worrying about tomorrow and not being able to perform at work, wakes the brain up.”

Medication is effective, Anderson noted, but “in some patients, the effectiveness may wear off with time.” And most of the prescription drugs approved for insomnia treatment are labeled for short-term use.

The nonprofit National Sleep Foundation, which receives a mixture of public and private funding, cautions against a do-it-yourself approach to insomnia treatment. It advises consulting a health professional.

Sleep medications range widely, and it is wise to research a drug before taking it. Most over-the-counter drugs use antihistamines, which have the potential for side effects including continued daytime sedation, dry mouth and incontinence problems.


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