Medication Considerations

  • Colleen E. Carney
  • Jack D. Edinger
Part of the Series in Anxiety and Related Disorders book series (SARD)


Despite the general efficacy of CBT for insomnia, this form of therapy is generally not the first intervention chosen for the majority of treatment seeking insomnia sufferers. Most are seen in primary care settings where they usually are treated with some form of hypnotic medication. Many of those who eventually present for a trial of CBT do so while continuing hypnotic medications prescribed for their sleep difficulties. Additionally, many people with insomnia may continue using medications to manage their sleep problems for long periods of time despite less than optimal benefits and their ongoing desires to become medication free. Also, many insomnia sufferers use combinations of sedating anxiolytics and prescription hypnotics in an effort to reduce their sleep-related anxiety and sleep difficulties in general. These observations spawn a number of important questions in regard to the use of CBT with such individuals. First, it is important to consider whether these people derive similar benefits from CBT, as do those who enter treatment medication free. It also seems useful to question if there is an optimal treatment protocol for people who wish to combine CBT with pharmacotherapy for insomnia. Finally, it seems useful to ascertain if CBT and other psychological techniques are useful to those who exhibit hypnotic-dependence and ultimately wish to discontinue their sleep medication use.


Sleep Problem Sleep Difficulty Anterograde Amnesia Sleep Medication Hypnotic Medication 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Agostini, J. V., Leo-Summers, L. S., & Inouye, S. K. (2001). Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Archives of Internal Medicine, 161(17), 2091–2097.CrossRefPubMedGoogle Scholar
  2. Ancoli-Israel, S., & Roth, T. (1999). Characteristics of insomnia in the United States: Results of the 1991 National Sleep Foundation Survey I. Sleep, 2(Suppl.), S347–353.Google Scholar
  3. Backhaus, J., Hohagen, F., Voderholzer, U., & Riemann, D. (2001). Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia. European Archives of Psychiatry and Clinical Neuroscience, 251, 35–41.CrossRefPubMedGoogle Scholar
  4. Belleville, G., Guay, C., Guay, B., & Morin, C. M. (2007). Hypnotic taper with or without self-help treatment of insomnia: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 75(2), 325–335.CrossRefPubMedGoogle Scholar
  5. Brower, K. J., Aldrich, M., Robinson, E. A. R., Zucker, R. A., & Greden, J. F. (2001). Insomnia, self-medication, and relapse to alcoholism. The American Journal of Psychiatry, 158, 399–404.CrossRefPubMedGoogle Scholar
  6. Buscemi, N., Vandermeer, B., Pandya, R., Hooton, N., Tjosvold, L., Hartling, L., et al. (2004). Melatonin for treatment of sleep disorders. Evidence Report/Technology Assessment, 108, 1–7.PubMedGoogle Scholar
  7. Buysse, D. J., Germain, A., Moul, D., & Nofzinger, E. A. (2005). Insomnia. In D. J. Buysse (Ed.), Sleep disorders and psychiatry (pp. 29–75). Washington, DC: American Psychiatric Publishing.Google Scholar
  8. Carney, C. E., Edinger, J. D., Manber, R., Garson, C. S., & Segal, Z. V. (2007). Beliefs about sleep in disorders characterized by sleep and mood disturbance. Journal of Psychosomatic Research, 62(2), 179–188.CrossRefPubMedGoogle Scholar
  9. Dawson, A., Lehr, P., Bigby, B. G., & Mitler, M. M. (1993). Effect of bedtime ethanol on total inspiratory resistance and respiratory drive in normal nonsnoring men. Alcoholism, Clinical and Experimental Research, 17(2), 256–262.CrossRefPubMedGoogle Scholar
  10. Donath, F., Quispe, S., & Diefenbach, K. (2000). Critical evaluation of valerian extract on sleep structure and sleep quality. Pharmacopsychiatry, 33(2), 47–53.CrossRefPubMedGoogle Scholar
  11. Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive behavior therapy approach therapist guide. New York: Oxford University Press.Google Scholar
  12. Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: Implementation and evaluation of a sleep clinic in general medical practice. Behaviour Research and Therapy, 39, 45–60.CrossRefPubMedGoogle Scholar
  13. Espie, C. A., MacMahon, K., Kelly, H.-L., Broomfield, N. M., Douglas, N. J., Engleman, H. M., et al. (2007). Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep, 30(5), 574–584.PubMedGoogle Scholar
  14. Gillin, J. C., Drummond, S. P. A., Clark, C. P., & Moore, P. (2005). Medication and substance abuse. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (4th ed., pp. 1345–1358). Philadelphia: Elsevier Saunders.Google Scholar
  15. Greenblatt, D. (1991). Benzodiazepine hypnotics: Sorting the pharmacokinetic facts. Journal of Clinical Psychiatry, 52(Suppl.), 4–10.PubMedGoogle Scholar
  16. Greenblatt, D. J. (1992). Pharmacology of benzodiazepine hypnotics. Journal of Clinical Psychiatry, 53(Suppl.), 7–13.PubMedGoogle Scholar
  17. Hauri, P. (1996). No more sleepless nights. Wiley.Google Scholar
  18. Hemmelgarn, B., Suissa, S., Huang, A., Boivin, J. F., & Pinard, G. (1997). Benzodiazepine use and the risk of motor vehicle crash in the elderly. The Journal of the American Medical Association, 278, 27–31.CrossRefGoogle Scholar
  19. Hughes, R. J., Sack, R. L., & Lewy, A. J. (1998). The role of melatonin and circadian phase in age-related sleep-maintenance insomnia: Assessment in a clinical trial of melatonin replacement. Sleep, 21(1), 52–68.PubMedGoogle Scholar
  20. Jacobs, G. D. (1999). Good night to insomnia. New York: Owl Books.Google Scholar
  21. Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Archives of Internal Medicine, 164, 1888–1896.CrossRefPubMedGoogle Scholar
  22. Jonas, J. M., Coleman, B. S., Sheridan, A. Q., & Kalinske, R. W. (1992). Comparative clinical profiles of triazolam versus other shorter-acting hypnotics. The Journal of Clinical Psychiatry, 53, 19–31.PubMedGoogle Scholar
  23. Krystal, A. D., Walsh, J. K., Laska, E., Caron, J., Amato, D. A., Wessel, T. C., et al. (2003). Sustained efficacy of eszopiclone over six months of nightly treatment: Results of a randomized, double-blind, placebo controlled study in adults with chronic insomnia. Sleep, 26, 793–799.PubMedGoogle Scholar
  24. Lichstein, K. L., Peterson, B. A., Riedel, B. W., Means, M. K., Epperson, M. T., & Aguillard, R. N. (1999). Relaxation to assist sleep medication withdrawal. Behavior Modification, 23, 379–402.CrossRefPubMedGoogle Scholar
  25. Meoli, A. L., Rosen, C., Kristo, D., Kohrman, M., Gooneratne, N., Aguillard, R. N., et al. (2005). Oral nonprescription treatment for insomnia: An evaluation of products with limited evidence. Journal of Clinical Sleep Medicine, 1, 173–187.Google Scholar
  26. Morin, C. M., Bastien, C. H., Guay, B., Radouco-Thomas, M., Leblanc, J., & Vallieres, A. (2004). Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. American Journal of Psychiatry, 161, 332–342.CrossRefPubMedGoogle Scholar
  27. Morin, C. M., Beaulieu-Bonneau, S., LeBlanc, M., & Savard, J. (2005). Self-help treatment for insomnia: A randomized controlled trial. Sleep, 28(10), 1319–1327.PubMedGoogle Scholar
  28. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep, 29(11), 1398–1414.Google Scholar
  29. Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. The Journal of the American Medical Association, 281, 991–999.CrossRefGoogle Scholar
  30. Morin, C. M., Gaulier, B., Barry, T., & Kowatch, R. A. (1992). Patients’ acceptance of psychological and pharmacological therapies for insomnia. Sleep, 15, 302–305.PubMedGoogle Scholar
  31. Morin, C. M., Vallières, A., Guay, B., Ivers, H., Savard, J., & Mérette, C. (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. The Journal of the American Medical Association, 301(19), 2005–2015.CrossRefGoogle Scholar
  32. Morin, C. M., & Wooten, V. (1996). Psychological and pharmacological approaches to treating insomnia: Critical issues in assessing their separate and combined effects. Clinical Psychology Review, 16, 521–542.CrossRefGoogle Scholar
  33. Nowell, P. D., Mazumdar, S., Buysse, D. J., Dew, M. A., Reynolds, C. F. I., & Kupfer, D. J. (1997). Benzodiazepines and zolpidem for chronic insomnia: A meta-analysis of treatment efficacy. The Journal of the American Medical Association, 278, 2170–2177.CrossRefGoogle Scholar
  34. Ohayon, M. (1996). Epidemiological study on insomnia in the general population. Sleep, 3(Suppl. 19), S7–15.Google Scholar
  35. Ray, W. A. (1992). Psychotropic drugs and injuries among the elderly: A review. Journal of Clinical Psychopharmacology, 12(6), 386–396.PubMedGoogle Scholar
  36. Richardson, G. S. (2000). Managing insomnia in the primary care setting: Raising issues. Sleep, 23(Suppl. 1), S9-S12.PubMedGoogle Scholar
  37. Roehrs, T., Kribbs, N., Zorick, F., & Roth, T. (1986). Hypnotic residual effects of benzodiazepines with repeated administration. Sleep, 9, 309–316.PubMedGoogle Scholar
  38. Roth, T., & Roehrs, T. (1991). A review of the safety profiles of benzodiazepine hypnotics. Journal of Clinical Psychiatry, 52, 38–41.PubMedGoogle Scholar
  39. Roth, T., Stubbs, C., & Walsh, J. K. (2005). Ramelteon, a selective MT1/MT2-receptor agonist, reduces latency to persistent sleep in a model of transient insomnia related to a novel sleep environment. Sleep, 28, 303–307.PubMedGoogle Scholar
  40. Roth, T., Walsh, J., Krystal, A., Wessel, T., & Roehrs, T. (2005). An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Medicine, 6(6), 487–495.CrossRefPubMedGoogle Scholar
  41. Schramm, E., Hohagen, P., Grasshoff, M., Riemann, D., Hajak, G., Weess, H., et al. (1993). Test-retest reliability and validity of the Structured Interview for Sleep Disorders according to the DSM-III-R. American Journal of Psychiatry, 150, 867–872.PubMedGoogle Scholar
  42. Schulz, H., Stolz, C., & Müller, J. (1994). The effect of valerian extract on sleep polygraphy in poor sleepers: A pilot study. Pharmacopsychiatry, 27(4), 147–151.CrossRefPubMedGoogle Scholar
  43. Schweitzer, P. K. (2005). Drugs that disturb sleep and wakefulness. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (4th ed., pp. 499–518). Philadelphia: Elsevier Saunders.Google Scholar
  44. Sironi, V. A., Miserocchi, G., & De Rui, P. L. (1984). Clonazepam withdrawal syndrome. Acta Neurologica, 6(2), 134–139.PubMedGoogle Scholar
  45. US Food and Drug Administration. (2007). FDA requests label change for all sleep disorder drug products from
  46. Vallieres, A., Morin, C. M., & Guay, B. (2005). Sequential combinations of drug and cognitive behavioral therapy for chronic insomnia: An exploratory study. Behaviour Research and Therapy, 43(12), 1611–1630.CrossRefPubMedGoogle Scholar
  47. Verbeek, I., Schreuder, K., & Declerck, G. (1999). Evaluation of short-term non-pharmacological treatment of insomnia in a clinical setting. Journal of Psychosomatic Research, 47, 369–383.CrossRefPubMedGoogle Scholar
  48. Wagner, J., Wagner, M. L., & Hening, W. A. (1998). Beyond benzodiazepines: Alternative pharmacologic agents for the treatment of insomnia. The Annals of Pharmacotherapy, 32(6), 680–691.CrossRefPubMedGoogle Scholar
  49. Walsh, J. K., & Engelhardt, C. L. (1999). The direct economic costs of insomnia in the United States for 1995. Sleep, 22, S386-S393.PubMedGoogle Scholar
  50. Walsh, J. K., & Schweitzer, P. K. (1998). Ten-year trends in the pharmacological treatment of insomnia. Sleep, 22, 371–375.Google Scholar
  51. Wu, R., Jinfeng, B., Chungai, Z., & Chunling, L. (2006). Comparison of sleep condition and sleep-related psychological activity after cognitive behavior and pharmacological therapy for chronic insomnia. Psychotherapy and Psychosomatics, 75, 220–228.CrossRefPubMedGoogle Scholar
  52. Wysowski, D., & Barash, D. (1991). Adverse behavioral reactions attributed to triazolam in the Food and Drug Administration’s Spontaneous Reporting system. Archives of Internal Medicine, 151, 1779–1783.CrossRefPubMedGoogle Scholar
  53. Zhdanova, I. V., Wurtman, R. J., Regan, M. M., Taylor, J. A., Shi, J. P., & Leclair, O. U. (2001). Melatonin treatment for age-related insomnia. Journal of Clinical Endocrinology and Metabolism, 86, 4727–4730.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of PsychologyRyerson UniversityTorontoCanada
  2. 2.Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamUSA

Personalised recommendations