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Am Fam Physician. 2005;72(2):330

Insomnia, which is difficulty initiating or maintaining sleep with associated impaired daytime functioning, is fairly common; 35 percent of adults report having insomnia every night and 58 percent report insomnia at least a few nights per week. The usual intervention for insomnia has been pharmacotherapy, but long-term use of sedative-hypnotics is contraindicated. In addition, no long-term studies have examined the use of sedative-hypnotics for chronic insomnia. One randomized trial compared cognitive behavior therapy (CBT) with pharmacotherapy for the treatment of insomnia. However, no studies have evaluated CBT in the treatment of sleep-onset insomnia in young or middle-aged adults. Jacobs and colleagues compared the use of CBT and pharmacotherapy, alone and in combination, for the treatment of sleep-onset insomnia.

The trial was a randomized, placebo-controlled study of young and middle-aged adults who had chronic sleep-onset insomnia. Patients were randomized to receive CBT, pharmacotherapy, a combination of both, or placebo. Patients who received CBT attended four 30-minute treatment sessions and had one telephone treatment session over six weeks. Pharmacotherapy consisted of zolpidem (Ambien) at a dosage of 10 mg nightly for 28 days, then 5 mg nightly for seven days, then 5 mg every other night for seven days. The main outcomes measured included sleep-onset latency assessed by sleep diaries. Secondary outcomes included sleep diary measures of sleep efficiency and total sleep time, plus objective sleep variables measured by a sleep monitor.

A total of 54 participants completed the study. All dropouts were secondary to lack of interest in the study. The CBT group had the greatest change in sleep-onset latency and sleep efficiency. The CBT group also had a larger number of normal sleepers after treatment and this group maintained therapeutic gains at the long-term follow-up appointment. The combination of CBT and zolpidem provided no more benefit than CBT alone. Zolpidem therapy alone produced fewer sleep benefits than CBT, and participants who received this medication alone returned to their baseline sleep pattern after the medication was discontinued.

The authors conclude that CBT has a better impact on sleep-onset insomnia in young and middle-aged adults than does pharmacotherapy. They add that CBT should be considered first-line therapy for chronic insomnia in these age groups.

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