Advertisement

Treatment effect of cognitive-behavior therapy for insomnia combined with usual medication

  • Ya-Wen Jan
  • Chien-Ming YangEmail author
  • Shou-Hung Huang
  • Hsin-Chien Lee
Original Article
  • 15 Downloads

Abstract

While the efficacy of cognitive behavior therapy for insomnia (CBT-I) has been established with well-controlled studies, its effectiveness in typical clinical practice remains to be determined. We examined the effect of CBT-I combined with usual medication on night-time sleep, daytime functioning, and the discontinuation of hypnotic drugs. The study recruited 103 patients with insomnia, who were divided into three groups: CBT-I only (CBT-I, N = 30), CBT-I combined with usual medication (COM, N = 48), and usual medication only (TAU, N = 25). A six-session CBT-I program was delivered in the CBT and COM groups, and patients in the COM and TAU groups continued to take the medication prescribed by their physicians. All groups showed significant improvements in the Insomnia Severity Inventory. The CBT-I and COM groups showed significant improvements on two subscales (vitality and physical role functioning) of the 36-item Short Form Health Survey. There was no significant improvement in the daytime functioning of the TAU group. Moreover, significantly more participants in the COM group discontinued their use of hypnotics. CBT-I in addition to regular medication is an effective treatment option in clinical settings. It can improve not only night-time sleep, but also daytime functioning. Furthermore, it can be helpful in facilitating the discontinuation of medication. Our results support the utility of CBT-I in clinical settings, and it can be integrated into the patients’ usual treatment protocol.

Keywords

Cognitive behavior therapy for insomnia Daytime functioning Insomnia disorder 

Notes

Funding

Funding was provided by National Science Council (Grant nos. NSC95-2413-H-004-020-MY3, NSC104-2410-H-004-044-MY3).

Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Buysse DJ, Thompson W, Scott J, et al. Daytime symptoms in primary insomnia: a prospective analysis using ecological momentary assessment. Sleep Med. 2007;8(3):198–208.Google Scholar
  2. 2.
    Leger D, Scheuermaier K, Philip P, et al. SF-36: evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosom Med. 2001;63(1):49–55.Google Scholar
  3. 3.
    Schneider C, Fulda S, Schulz H. Daytime variation in performance and tiredness/sleepiness ratings in patients with insomnia, narcolepsy, sleep apnea and normal controls. J Sleep Res. 2004;13(4):373–83.Google Scholar
  4. 4.
    Hohagen F, Rink K, Kappler C, et al. Prevalence and treatment of insomnia in general practice: a longitudinal study. Eur Arch Psychiatry Clin Neurosci. 1993;242:329–36.Google Scholar
  5. 5.
    Morin CM, LeBlanc M, Daley M, et al. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7(2):123–30.Google Scholar
  6. 6.
    Krystal AD. The changing perspective on chronic insomnia management. J Clin Psychiatry. 2004;65(Suppl 8):20–5.Google Scholar
  7. 7.
    Ong J, Suh S. Utilizing cognitive-behavioral therapy for insomnia to facilitate discontinuation of sleep medication in chronic insomnia patients. Sleep Med Res. 2012;3(1):1–6.Google Scholar
  8. 8.
    Edinger JD, Means MK. Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev. 2005;25(5):539–58.Google Scholar
  9. 9.
    Kyle SD, Morgan K, Spiegelhalder K, et al. No pain, no gain: an exploratory within-subjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT) for insomnia. Sleep Med. 2011;12(8):735–47.Google Scholar
  10. 10.
    Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999;281(11):991–9.Google Scholar
  11. 11.
    Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol. 1995;63(1):79–89.Google Scholar
  12. 12.
    Koffel EA, Koffel JB, Gehrman PR. A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep Med Rev. 2015;19:6–16.Google Scholar
  13. 13.
    Trauer JM, Qian MY, Doyle JS, et al. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(3):191–204.Google Scholar
  14. 14.
    Okajima I, Komada Y, Inoue Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep Biol Rhythms. 2011;9(1):24–34.Google Scholar
  15. 15.
    Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164(17):1888–96.Google Scholar
  16. 16.
    Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159(1):5–11.Google Scholar
  17. 17.
    Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(24):2851–8.Google Scholar
  18. 18.
    Mitchell MD, Gehrman P, Perlis M, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;25:13–40.Google Scholar
  19. 19.
    Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;151(8):1172–80.Google Scholar
  20. 20.
    U. S. Department of Health and Human Services, National Institutes of Health. NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults. NIH Consens State Sci Statements. 2005;22(2):1–30.Google Scholar
  21. 21.
    Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165:125–33.Google Scholar
  22. 22.
    Wilson SJ, Nutt DJ, Alford C, et al. British association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24:1577–601.Google Scholar
  23. 23.
    Waters WF, Hurry MJ, Binks PG, et al. Behavioral and hypnotic treatments for insomnia subtypes. Behav Sleep Med. 2003;1:81–101.Google Scholar
  24. 24.
    American Psychological Association. Criteria for evaluating treatment guidelines. Am Psychol. 2002;57(12):1052–9.Google Scholar
  25. 25.
    Hunsley J. Addressing key challenges in evidence-based practice in psychology. Prof Psychol Res Pract. 2007;39:113–21.Google Scholar
  26. 26.
    Hunsley J, Lee CM. Research-informed benchmarks for psychological treatments: efficacy studies, effectiveness studies, and beyond. Prof Psychol Res Pract. 2007;38:1–33.Google Scholar
  27. 27.
    Rounsaville BJ, Carroll KM, Onken LS. A stage model of behavioral therapies research: getting started and moving on from Stage 1. Clin Psychol. 2001;8:133–42.Google Scholar
  28. 28.
    Perlis M, Aloia M, Boehmler J, et al. Behavior treatment of insomnia: a clinical case series study. J Behav Med. 2000;23(2):149–61.Google Scholar
  29. 29.
    Omvik S, Sivertsen B, Pallesen S, et al. Daytime functioning in older patients suffering from chronic insomnia: treatment outcome in a randomized controlled trial comparing CBT with Zopiclone. Behav Res Ther. 2008;46(5):623–41.Google Scholar
  30. 30.
    Okajima I, Nakamura M, Nishida S, et al. Cognitive behavioural therapy with behavioural analysis for pharmacological treatment-resistant chronic insomnia. Psychiatry Res. 2013;210(2):515–21.Google Scholar
  31. 31.
    Taylor HL, Rybarczyk BD, Nay W, Leszczyszyn D. Effectiveness of a CBT intervention for persistent insomnia and hypnotic dependency in an outpatient psychiatry clinic. J Clin Psychol. 2015;71(7):666–83.Google Scholar
  32. 32.
    Morin CM. Insomnia: psychological assessment and management. New York: Guilford; 1993.Google Scholar
  33. 33.
    Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10(1):45–56.Google Scholar
  34. 34.
    Bootzin RR. A stimulus control treatment for insomnia. In: Proceedings of the American Psychological Association. 1972. pp. 395–396.Google Scholar
  35. 35.
    Yang CM, Hsu SC, Lin SC, Chou YY, Chen IY. Reliability and validity of the Chinese version of insomnia severity index. Arch Clin Psychol. 2009;4(2):95–104 (in Chinese).Google Scholar
  36. 36.
    Buysse DJ, Ancoli-Israel S, Edinger JD, et al. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29:1155–73.Google Scholar
  37. 37.
    Spielberger CD. Conceptual and methodological issues in anxiety research. In: Spielberger CD, editor. Anxiety: current trends in theory and research. New York: Academic Press; 1972. pp. 23–49.Google Scholar
  38. 38.
    Spielberger CD, Sydeman SJ, Owen AE, et al. Measuring anxiety and anger with the State-Trait Anxiety Inventory (STAI) and the State-Trait Anger Expression Inventory (STAXI). In: Maruish ME, editor. The use of psychological testing for treatment planning and outcomes assessment. 2nd ed. Hillsdale: Lawrence Erlbaum Associates Publishers; 1999. pp. 993–1021.Google Scholar
  39. 39.
    Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36): I. conceptual framework and item selection. Med Care. 1992;30(6):473–83.Google Scholar
  40. 40.
    Yang CM, Wu CH. The situational fatigue scale: a different approach to measuring fatigue. Qual Life Res. 2005;14(5):1357–62.Google Scholar
  41. 41.
    Inada T, Inagaki A. Psychotropic dose equivalence in Japan. Psychiatry Clin Neurosci. 2015;69(8):440–7.  https://doi.org/10.1111/pcn.12275 (Epub 2015 Feb 14).Google Scholar
  42. 42.
    Léger D, Morin CM, Uchiyama M, et al. Chronic insomnia, quality-of-life, and utility scores: comparison with good sleepers in a cross-sectional international survey. Sleep Med. 2012;13(1):43–51.Google Scholar
  43. 43.
    Belleville G, Guay C, Guay B, et al. Hypnotic taper with or without self-help treatment of insomnia: a randomized clinical trial. J Consult Clin Psychol. 2007;75(2):325–35.Google Scholar
  44. 44.
    Espie CA, Inglis SJ, Tessier S, et al. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther. 2001;39(1):45–60.Google Scholar
  45. 45.
    Ong JC, Kuo TF, Manber R. Who is at risk for dropout from group cognitive-behavior therapy for insomnia? J Psychosom Res. 2008;64:419–25.Google Scholar
  46. 46.
    Matthews EE, Schmiege SJ, Cook PF, Berger AM, Aloia MS. Adherence to cognitive behavioral therapy for insomnia (CBTI) among women following primary breast cancer treatment: a pilot study. Behav Sleep Med. 2012;10:217–29.Google Scholar
  47. 47.
    Bouchard S, Bastien C, Morin CM. Self-efficacy and adherence to cognitive-behavioral treatment of insomnia. Behav Sleep Med. 2003;1:187–99.Google Scholar
  48. 48.
    Baillargeon L, Landreville P, Verreault R, et al. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. Can Med Assoc J. 2003;169:1015–20.Google Scholar
  49. 49.
    Morin CM, Bastien C, Guay B, et al. Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. Am J Psychiatry. 2004;161(2):332–42.Google Scholar
  50. 50.
    Morin CM, Belanger L, Bastien C, et al. Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse. Behav Res Ther. 2005;43(1):1–14.Google Scholar
  51. 51.
    Barker MJ, Greenwood KM, Jackson M, et al. Cognitive effects of long-term benzodiazepine use. CNS Drugs. 2004;18(1):37–48.Google Scholar
  52. 52.
    Burke KC, Meek WJ, Krych R, et al. Medical services use by patients before and after detoxification from benzodiazepine dependence. Psychiatr Serv. 1995;46(2):157–9.Google Scholar
  53. 53.
    Kripke DF. Risks of chronic hypnotic use. In: Lader MH, Cardinali DP, Pandi-Perumal SR, editors. Sleep and sleep disorders—a neuropsychopharmacological approach. New York: Springer; 2006. pp. 141–5.Google Scholar
  54. 54.
    Morgan K, Dixon S, Mathers N, et al. Psychological treatment for insomnia in the regulation of long-term hypnotic drug use. Health Technol Assess. 2004;8(8):1–68.Google Scholar

Copyright information

© Japanese Society of Sleep Research 2019

Authors and Affiliations

  1. 1.Department of PsychologyChung Yuan Christian UniversityTaoyüanTaiwan
  2. 2.Department of Clinical PsychologyFu-Jen Catholic UniversityTaipeiTaiwan
  3. 3.Department of PsychologyNational Cheng-Chi UniversityTaipeiTaiwan
  4. 4.The Research Center for Mind Brain and LearningNational Cheng-Chi UniversityTaipeiTaiwan
  5. 5.Sleep Research CenterTaipei Medical University HospitalTaipeiTaiwan
  6. 6.Department of PsychiatryTaipei Medical University HospitalTaipeiTaiwan
  7. 7.Department of Psychiatry, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan
  8. 8.Department of PsychiatryTaipei Medical University Shuang-Ho HospitalTaipeiTaiwan
  9. 9.Research Center of Sleep Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan

Personalised recommendations