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Cognitive behavior therapy, temazepam, or both improved short-term
outcomes for older adults with persistent insomnia
Morin CM, Colecchi C, Stone J, Sooci
R, Brink D. Behavioral and pharmacological therapies for late-life insomnia. A randomized controlled
trial. JAMA. 1999 Mar 17:281:991-9.
Question
In older adults with persistent insomnia, is cognitive behavior therapy (CBT)
or temazepam, alone or together, effective for improving sleep patterns and
habits?
Design
Randomized, placebo-controlled, 8-week
trial with follow-up at 3, 12, and 24
months.
Setting
The outpatient clinic of a Canadian
academic medical center.
Patients
78 older adults (mean age 65 y, 64%
women, 90% white, average duration
of insomnia 17 y) were studied. Inclusion criteria were age > 55 years, sleep
onset or maintenance insomnia, duration of insomnia > 6 months, and > 1
negative effect of insomnia during waking hours. Exclusion criteria were insomnia caused by disease or medication,
sleep apnea, regular use of hypnotic or
psychotropic medication, current psychotherapy, presence of major depres-
sion or other serious psychiatric conditions, or confirmed cognitive impairment. Follow-up ranged from 92% at
8 weeks to 63% at 2 years.
Intervention
18 adults were allocated to CBT alone,
20 to temazepam alone, 20 to both, and
20 to placebo, CBT was designed to
change habits of and beliefs about sleep
by using weekly 90-minute small-group
sessions with behavioral, cognitive, and
educational components. Individual
action plans were implemented. Temazepam therapy was started at 7.5 mg/
night and was gradually increased to 3 0
mg/night as needed. All treatments were
given for 8 weeks.
zepam or placebo, as measured by sleep
diaries (Table). Polysomnography
showed that sleep improved in the short
term in all active treatment groups; the
combined therapy group improved
more than the others. CBT alone maintained improvement in sleep measures
better than combined treatment, which
was better than temazepam alone, aldiough follow-up beyond 8 weeks was
< 80%.
Conclusion
Cognitive behavior therapy, temazepam, or both improved short-term out- .
comes in older adults with persistent,,
insomnia.
:.
Main results
Source of funding: National Institute of Menial
Health Clinical Research Center.
''•'. .
For correspondence: Dr. CM. Morin, Uwverske..
Laval, Book de Psychokgie, Pavillion FAS;
Samte-Foy, Quebec GIK 7P4, Canada. FM:
: :
418-656-5152,
" <-
Groups receiving CBT initially improved more than those receiving tema-
Abstract anti Commentary also published in.
ACP Journal Club. 1999;131:3S.
"•.;'.'.;;;.
Main outcome measures
Sleep diary reports, polysomnography,
and sleep impairment index.
Older adults with persistent insomnia who achieved > 85% sleep efficiency
(time asleep/time in bed) after 8 weeks of cognitive behavior therapy (CBT),
temazepam, or both*
Group
CBT
Temazepam
Both
Treatment
Placebo
RBI (95% CI)
NNT(GI)::'
55.6%
47.1%
68.4%
22.2%
22.2%
22.2%
150% (3.8 to 561)
112% (-17 to 477)
208% (36 to 689)
3 (2 to 96). :;:
Not significant;
3 (2 to;7):/.: ;.
*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in articfe:
Commentary
This exciting, exquisitely done study from
an academic medical center has several implications forfront-lineclinicians. First, many
older adults with sleep problems have underlying clinical problems that should be treated
directly: medical disease states, medication
that causes insomnia, depression and other
psychiatric disorders, sleep apnea or periodic
limb movements during sleep, and inability
to decrease the dose of a presently taken hypnotic. These patients (85 of 168 screened)
were excluded from this study.
Second, long-term control of later-life sleep
problems is probably best achieved through
a psychological educational approach rather
than a pharmacologic approach. Although ibis
implication is based on results widi < 80%
follow-up, I feel it is sensible and justified.
146
Therapeutics
Third, short-tenn (< 2 mo) control of insomnia may be treated with similar efficacy
widi educational efforts, medicines, or both.
However, this trial was not large enough to
address important concerns about benzodiazepine therapy, including falis, cognitive
impairment, and dependence.
One shortcoming is that the extensive
CBT classes used in the study are not generally available. Excellent teaching of sleep
hygiene has long been encouraged by most
texts as the preferred method for promoting healthy sleep. An aid for teaching sleep
hygiene is the patient education page that
appears in the same issue ofJAMA (1); this
aid, the article itself, and an accompanying
editorial (2) are also available on the AMJ&
Web site (www.ama-assn.org). Unfortu-
nately, substituting the teaching of sleep.hj^ .• .•
giene for CBT and expecting similar resultsinvolves a leap of faith. I would like to see.
a parallel study using an abbreviated fprtnpf;::
CBT, such as the teaching of sleep hygi<%.::
This teaching would probably be morepra^.; ;•
tical for busy clinicians who are notpsy^ji i:trists. In the meantime, we can discuss: g o .
common-sense principles of CBTyrttfc|ft: V
patients as outlined in the article..
• $ . .
Robert
Southbridge,,
References
. : .. Ann;:. :.
1. JAMA patient page: insomnia. JAMA-4™.:|:;::::.::
281:1056.
2. Reynolds CF 3d, Bwysse DJ,
JAMA. 1999;281:1034-5.
Evidence-Based Medicine
Ssptemfaerj
Downloaded from http://ebm.bmj.com/ on July 31, 2017 - Published by group.bmj.com
Cognitive behavior therapy, temazepam, or
both improved short-term outcomes for older
adults with persistent insomnia
Evid Based Med 1999 4: 146
doi: 10.1136/ebm.1999.4.146
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