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Am Fam Physician. 1999;60(3):934-938

Studies suggest that fewer than 15 percent of patients with chronic insomnia receive treatment. Those who receive treatment are often given drug therapy. Short-term therapy with hypnotic agents is generally useful for treatment of acute insomnia, but little information is available on the long-term efficacy of this form of therapy. Morin and colleagues conducted a randomized controlled trial to compare the efficacy of behavioral therapy, drug therapy and a combination of the two in the treatment of chronic insomnia in older adults.

The 72 patients in the two-year study were at least 55 years old (mean age: 65 years) and had at least a six-month history of difficulty initiating sleep (sleep-onset latency of at least 30 minutes three or more times per week) or maintaining sleep (waking for at least 30 minutes after sleep had begun for at least three nights per week). Polysomnography was performed before treatment was started to ensure that another sleep disorder was not contributing to the insomnia.

Patients were randomized to receive placebo, cognitive-behavior therapy, drug therapy, or a combination of behavior and drug therapy. Cognitive-behavior therapy consisted of eight weekly 90-minute small group sessions that contained behavior, educational and cognitive elements. Drug therapy was initiated with 7.5 mg of temazepam at bedtime, taken at least twice a week but up to every night if necessary. The dosage was increased as needed to a maximum of 30 mg nightly. Patients who received tamezepam met once a week with a physician to discuss medication management. Patients in the combination therapy group received both temazepam and behavior therapy.

Data from the patients' sleep diaries revealed that the time awake after sleep onset, sleep efficiency, total wake time and total sleep time were significantly more improved in all three treatment groups compared with the placebo group. After two years' follow-up, patients who received either cognitive-behavior therapy or combination therapy rated themselves as significantly less impaired than those who received drug therapy alone or placebo. Follow-up results showed that behavior therapy yielded the most durable improvements in sleep patterns. Drug therapy gradually lost its clinical benefits over time.

The authors conclude that cognitive-behavior therapy that includes patient education about proper sleep hygiene effectively produces both short-term and long-term improvements in insomnia. While drug therapy may take less time to institute in the short run, it is probably not adequate as sole treatment for the long-term management of chronic insomnia.

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Copyright © 1999 by the American Academy of Family Physicians.

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