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Psychotherapy and pharmacotherapy: What is the proper treatment of insomnia?
“One hundred one, one hundred two…” The days of counting sheep until our eyelids shut are over thanks to scientific research. Unfortunately, for about twenty million people in the United States (Lamberg, 2007), those restless nights are habitual conditions. One-third of the adult population suffers from the most common sleep disorder known as insomnia, a condition that involves difficulties falling asleep or staying asleep during the night (http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_summary.html). Due to the high prevalence in our society of some type of insomnia, we should be concerned with how to most effectively treat the disorder so the quality of life of those affected can be improved. Therefore, my paper will first discuss the implications of the term insomnia, state the different types of treatments, and present their independent beneficial outcomes. Then, I will apply scientific investigations to validate certain claims about treatments of insomnia. Finally, I will discuss the most suitable approach for each type of insomniac so that a patient may make an informed decision for treating his sleeping disorder.
Background of insomnia
Since millions of people exhibit the symptom of sleep disturbance, insomnia has been divided into categories. First, in regard to the causes, a patient’s disorder can be considered as primary or secondary insomnia. According to the Diagnostic and Statistical Manual of Mental Disorders IV, if the person exhibits difficulty in the initiation or maintenance of sleep for at least one month, and his normal social and occupational functioning is impaired, he is diagnosed with primary insomnia. Another necessary criterion for the diagnosis of primary insomnia requires the sleeping disturbance to not occur exclusively with another sleep disorder or with a mental disorder. Finally, the patient’s symptoms must not be direct effects of a medical or substance condition (Morin 2001, p. 112-113). The conditions of secondary insomnia, the more common type, are derived from its name: the sleep difficulties are associated with and caused by another medical, psychiatric, or sleep disorder (Morin, 2001, p. 113).
In addition to the categorization of insomnia by its underlying cause, the sleep disorder is also classified according to the amount of time the symptoms are present. Acute insomnia is short-term, or lasting for less than a month. Once the disorder continues for over a month and at least three times a week, a person is said to be a chronic insomniac. Statistics have shown that chronic insomnia is now prevalent in one out of every ten adults (http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_summary.html).
As with most mental and behavioral disorders, risk factors of insomnia do exist, and through statistical analysis, certain people have been found to suffer from the disease more than others. Incidences of insomnia occur more often in women, older adults, and people under stress (http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_summary.html). Risk factors include psychiatric problems (induces secondary insomnia), working during the night, and the intake of alcohol and caffeine. Lifestyle habits of drinking, eating a heavy meal, or exercising before bed are also not beneficial for one’s sleep routine (Morin, 2001, p. 119). In addition, environmental factors such as light, temperature, and noise can affect the onset and quality of sleep (http://www.foxnews.com/story/0,2933,201216,00.html).
To address the risk and environmental factors of insomnia, as well as combat the symptoms, three main treatments have been implemented. The three methods are lifestyle changes, pharmacological medicine, and psychological therapies (http://www.nhlbi.nih.gov/health/dci/Diseases/inso/inso_summary.html). Lifestyle changes provide simple guidelines involving sleep routine and diet, but one of the other two treatments is usually necessary to treat a sleeping disorder. Pharmacological medicine includes benzodiazepines, non-benzodiazepines hypnotics, antidepressants that contain sedating properties, and over-the-counter medications (Morin, 2001, p. 113-114). In fact, hypnotic medication is prescribed to almost fifty percent of people being treating for insomnia (Morin, 2001, p. 112), and Americans are spending 4.5 billion dollars a year on sleep medicine (http://www.nytimes.com/2007/10/23/health/23drug.html). Lastly, psychological therapies are commonly classified together and defined as cognitive behavioral therapy, or CBT. CBT is a group of behavioral techniques that can be learned “to improve one’s ability to initiate and to maintain sleep” (http://www.buzzle.com/articles/treatment-for-chronic-insomnia.html). Due to the existence of multiple treatment methods, a medical practitioner needs to find the best solution for each type of patient because no single approach has the ability to treat all insomniacs in a given period of time. Therefore, scientists have investigated the treatments in order to supply practitioners the proper evidence to support their prescriptions. Measures taken into account for the purpose of discussing and comparing the effects of the different treatments are conditions such as the time it takes one to fall asleep (sleep onset latency-SOL), wake after sleep onset (WASO), night-time awakening (NA), total sleep time (TST), and the quality of sleep (QUAL).
I would first like to discuss the function of sleep medication and its independent success in treating insomnia. Two non-benzodiazepines my paper focuses on are zolpidem, or Ambien, and eszopiclone, or Lunesta. These sleep aids are more specific or selective than benzodiazepines (Morin, 2001, p. 114), and they work in our bodies by increasing activity of an amino acid known as Gamma-Aminobutyric Acid (GABA). When the amino acid is activated, our brain activity slows down and enables our body to relax and fall asleep (http://www.lunesta.com/index.cfm). Lunesta’s website claims that its product differs from other sleep aids because fewer awakenings interrupt a user’s sleep, the effects are present even after six months, and the medication is approved for long-term use. Upon searching for data evidence of these claims, I was able to attain statistics of the effectiveness of sleeping aids in treating the symptoms of insomniacs. In 2002, benzodiazepines were found to reduce sleep onset latency by about ten minutes, and they increased total sleep time by one hour (Morin, 2001, p. 116). Another analysis, performed last year, stated that sleeping pills, as a group, caused a patient to fall asleep about 12.8 minutes faster than a placebo pill, and the patient received only 11.4 more minutes of total sleep (http://www.nytimes.com/2007/10/23/health/23drug.html). In addition to these discouraging results, there are also many limitations to using only hypnotic medicines to treat insomnia. Long-term use of medication to treat chronic insomnia can cause residual daytime effects such as sedation and memory impairment, an increase in chance of death, falling, dependency on medication, and tolerance development (Kramer, 2000).
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy is comprised of five main mechanisms: sleep hygiene, cognitive therapy, progressive relaxation technique, sleep restriction, and stimulus control. The principles of sleep hygiene include the education of important lifestyle changes to improve sleep and the acknowledgement of environmental risk factors of insomnia. Common sleep hygiene practices are avoiding stimulants and alcohol, exercising regularly although not too close to bedtime, and not eating heavy meals or spicy food right before sleeping. To address the environmental factors of light, noise, and temperature, patients are told to make their bedrooms a “dark, quiet, and comfortable” environment (Morin, 2001, p. 119). The goal of cognitive therapy is to change a patient’s dysfunctional attitudes, beliefs, or expectations about sleep. Cognitive therapy helps insomniacs by alleviating feelings of helplessness, anxiety, and emotional arousal that impairs a good night’s sleep (Morin, 2001, p. 121). Progressive relaxation technique, the most commonly used aspect of CBT, involves training of controlling muscular tension and reducing worries or intrusive thoughts that interfere with sleep. Examples include deep breathing exercises and meditation; both produce relaxation and controlled sleep (http://ezinearticles.com/?Non-Drug-And-Behavioral-Methods-For-Treating-Insomnia&id=819558). Sleep restriction increases sleepiness in patients as well as efficient sleep by actually depriving them of sleep. The sleep schedule of these participants is very rigid, and wake times are strict. The final mechanism of CBT, stimulus control, conditions the mind by associating all aspects of a patient’s bedroom with sleeping. This mechanism of CBT demands not only environmental but also temporal association with sleep (Morin, 2001, p. 120). Thus, an insomniac is presented with a precise rhythm of sleep times and is instructed to enter his bedroom only to sleep. From reports by a long-term user of CBT, the stimulus control and sleep restriction components were declared to be the most effective in reducing sleep onset latency time and the number of awakenings during the night (Harvey et al., 2002). Unfortunately, there are downsides of the treatment. One drawback of cognitive behavioral therapy is its availability. While about one-third of the adult population suffers from chronic insomnia, “only one hundred and seven specialists have earned the American Academy of Sleep Medicine’s certification in behavioral sleep medicine” (Lamberg, 2007). However, there are online self-help treatment websites specifically devoted to treating insomniacs with cognitive behavioral therapy (http://cbtforinsomnia.com/HomePage.html). Other difficulties with CBT are the lack of knowledge its existence, the necessary time commitment, and the cost of the therapy. Yet, once a patient does decide to undergo CBT treatment, the results have proven the treatment to be effective.
Undeniably, cognitive behavioral therapy outcomes are advantageous, especially in regards to long-term effects of chronic insomnia. Based on the results of a behavioral treatment that lasted an average of four to six weeks, the sleep onset latency of patients was reduced from approximately an hour to thirty-five minutes, the duration of awakenings decreased by about thirty minutes, and an increase in total sleep time occurred, but only by thirty minutes (Morin, 2001, p. 122). Sleep quality, however, was significantly raised. The average outcomes affected about seventy to eighty percent of the patients, proving CBT to be truly effective. Furthermore, changes were well maintained for up to two years following the initial therapy (Morin, 2001, p. 122)
Claims In regards to treating insomnia, I wanted to validate the claims of Lunesta’s website mentioned above as to the extent of the effects of sleeping medication (http://www.lunesta.com/index.cfm). I also wanted to investigate the truth behind the latest claim that cognitive behavioral therapy is a more effective method than sleeping aids (http://www.foxnews.com/story/0,2933,201216,00.htm). Finally, the belief of the National Institutes of Health that integration of both methods will produce better results for the patient will be discussed (Morin, 2001, p. 111). Concerning the choice of pharmacological treatment or CBT, there are two scientific research experiments that compared the therapy treatment to sleeping aids, one being zopiclone and the other being zolpidem. One experiment also investigates the results of integration, and both supply statistical results of sleep medication treatment. The first experiment I want to present is Sivertsen et al. (2006) in which cognitive behavioral therapy was investigated in comparison to zopiclone, which can be considered as the eszopiclone hypnotic medicine of Lunesta in the United States. Secondly, in 2004, Jacobs et al. designed a research experiment in which the effects of zolpidem, the non-benzodiazepine component of Ambien, were tested and evaluated along with the effects of CBT alone and CBT with the hypnotic medicine.
Scientific research and reviews
In 2006, Sivertsen et al. published results of their findings that CBT is superior to zopiclone in both short- and long-term aspects of chronic insomnia in adults. The experiment used forty-six adults who were randomly assigned to one of the following treatments for six weeks: cognitive behavioral therapy, prescription of 7.5 mg of zopiclone taken every night, and placebo sleep medication (Sivertsen et al., 2006). The researchers followed up on the CBT and zopiclone treatments after six months, and they used four measures to determine the success of the treatments: total wake time, sleep efficiency, total sleep time, and slow-wave sleep. CBT showed better results in three of the four measures. Total sleep time was the only component in which all three groups produced similar results. Sleep efficiency increased by almost ten percent in CBT patients, whereas the zopiclone users actually showed a slight decrease. (Sivertsen et al., 2006) The participants who were treated with the cognitive behavioral therapy experienced less time awake during the night, but what truly surprised the experimenters were the slow-wave sleep, or what we consider deep sleep, results. The amount of slow-wave sleep was highest in CBT participants, and six months after the initial treatment, patients showed a thirty-four percent increase. The surprising find was the twenty percent decrease in the amount of time that participants of zopiclone spent in deep sleep during the night (http://www.foxnews.com/story/0,2933,201216,00.html).
(Sivertsen et al., 2006)
Jacobs et al. (2004) investigated cognitive behavioral therapy and pharmacotherapy by using independent variables of CBT treatment, the use of the hypnotic drug called zolpidem but better known as Ambien, a combination of the two treatments, and a placebo. Important to note, this study involved sixty-three adult patients who were diagnosed with chronic insomnia. The CBT treatment was carried out in six weeks with five half-hour sessions. The pharmacotherapy approach lasted eight weeks; during the first half, patients were given 10 mg of Ambien each day. For the following two weeks, the prescription was decreased to 5 mg, and the pill was taken only every other day during the latter week. Ambien was discontinued for the final two weeks of the investigation (Jacobs et al., 2004).
In terms of sleep onset latency at the end of week eight, the CBT and combination patients exhibited the greatest improvements. These participants were able to fall asleep in a fifty-two percent reduction time, whereas the zolpidem users showed only a twenty-nine percent reduction (Rosack, 2004). Eighteen months after the therapy, effects of the combination and CBT methods were still being maintained. On the other hand, the improvements made by the zolpidem participants were no longer present. Jacobs even stated that “by the end of the eight-week treatment phase, insomnia returned to baseline levels and did not differ from [those of] the placebo group" (Rosack, 2004). Regarding the total sleep time measure, each of the four groups was successful in increasing the amount. However, not one of the treatments produced a significantly differing beneficial outcome (Jacobs et al., 2004). Despite this fact, cognitive behavioral therapy was deemed the best choice for insomnia treatment since it was the most consistent treatment that maintained the positive consequences of the therapy over a long period of time. The positive consequences included the largest yield of normal sleepers due to the treatment, the highest increase in sleep efficiency, and the greatest reduction in sleep onset latency (Rosack, 2004).
(Jacobs et al., 2004)
Theoretically, the combination of sleep medication and cognitive behavioral therapy would be the best treatment since the integration would optimize the advantages of both methods. Scientific investigation, however, has not fully validated this claim; the results of Jacobs et al. (2004) provided evidence that the integration had no significant advantages over drug therapy in a short time period and over the CBT treatment in a long period of time. Therefore, Morin (2006) has suggested that a sequential method may be preferred. Combining the methods in the beginning of the treatment and discontinuing the sleep medication later would allow a patient to experience not only the “rapid effects” of drugs but also the “sustained effect” of cognitive behavioral therapy (Morin, 2006).
Conclusion and discussion of the best treatment
In his 2006 article, Morin summarized the implications of scientific research on the topic of the proper treatment for insomnia.
For the foreseeable future, medications are likely to be more readily available and to produce more rapid relief of insomnia, so it may be the preferred treatment option for many patients with acute insomnia. For chronic or persistent insomnia, however, CBT is likely to address the perpetuating factors and to produce more sustained improvement, and is probably the treatment of choice in these patients. To optimize short- and long-term outcomes, therefore, a combined approach may be required. (Morin, 2006)
After reviewing scientific research, a patient can determine the proper approach to treating his own case of insomnia. If he is suffering from acute insomnia, the person may use pharmacological medicine in order to see fast and moderately successful results. If the insomnia persists, however, cognitive behavioral therapy is the prime choice of treatment for patients with chronic insomnia. There are three main points to explain this statement. First, while CBT is more time consuming, it addresses the “underlying mechanisms” of insomnia and thus produces more effective results for patients. Secondly, the therapy provides short- and long- term effects, meaning it is durable over time. Finally, in contrast to medication, there are few side effects involved with CBT (Edinger & Wohlgemuth, 1999). One can expect more investigations into combination methods from researchers in the future, but in the meantime, a patient may use a sequential approach to optimize both short- and long-term advantageous outcomes involving his sleeping patterns.
Edinger, J.D. & Wohlgemuth W.K. (1999). The significance and management of persistent primary insomnia: the past, present and future of behavioral insomnia therapies. Sleep Med Rev 3(2), 101-118.
Harvey, L., Inglis, S.J., & Espie, C.A. (2002) Insomniacs' reported use of CBT components and relationship to long-term clinical outcome. Behav Res Ther 40 (1), 75-83.
Jacobs, G.D., Pace-Schott, E.F., Stickgold, R., Otto, M.W. (2004). Cognitive Behavior Therapy and Pharmacotherapy for Insomnia.
Lamberg, L. (2007). Nonmedical Interventions Promising in Insomnia Treatment. Psychiatr News 42 (20), 18.
Morin, C. M. (2001). Combined treatments of insomnia. In Combined treatments for mental disorders: a guide to psychological and pharmacological interventions (pp. 114-126). Washington, DC: American Psychological Association.
Morin, C.M. (2006). Combined therapeutics for insomnia: Should our first approach be behavioral or pharmacological? Sleep 7 (1), S15-S19.
Rosack, J. (2004). Sleep Experts Wake Up to Value Of CBT for Insomnia. Psychiatr News 39 (23), 32.
Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O.E., Kvale, G., et al. (2006). Cognitive Behavioral Therapy vs. Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults. JAMA 295 (24), 2851-2858.
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