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Study Backs Therapy Over Sleeping Pills

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TUESDAY, Sept. 28 (HealthDayNews) -- You may be tempted to reach for a sleeping pill if you continually have trouble nodding off, but a small new study indicates you might be better off with cognitive therapy.

"For people who have insomnia, there is now solid scientific evidence that the first-line treatment should be cognitive behavioral therapy, and not sleeping pills," said lead researcher Gregg Jacobs, an insomnia specialist at the Sleep Disorders Center of Beth Israel Deaconess Medical Center in Boston.

But because the study is so small, another expert is far from convinced that it will put the debate to rest anytime soon.

More than 70 million Americans suffer from insomnia, and it is one of the main reasons people see their doctors. According to the National Sleep Foundation's 2002 "Sleep in America" poll, 35 percent of all adults have symptoms of insomnia every night, and 58 percent report insomnia at least a few nights a week.

In their study, Jacobs and his team randomly assigned 63 patients with chronic insomnia to sleeping pills alone, sleeping pills plus cognitive behavioral therapy, cognitive behavioral therapy plus a dummy pill, or cognitive behavioral therapy alone.

With cognitive therapy, therapists taught participants to recognize, challenge and change patterns that kept them awake. They were told to maintain a regular time to go to bed -- but only if they felt drowsy -- and to get up in the morning. The bed was to be used only for sleep and sex: If they couldn't fall asleep within a half-hour, they should get up and engage in another quiet activity, such as reading.

Over eight weeks, the researchers found those receiving cognitive behavioral therapy alone or in combination with a sleeping pill or dummy pill had greatest improvement in the time it took to fall asleep.

For these patients, there was a 52 percent reduction in the time it took to get to sleep compared with 29 percent among patients taking sleeping pills alone, according to the report in the Sept. 27 issue of the Archives of Internal Medicine.

"Overall, the combined treatment of sleeping pills and cognitive behavioral therapy did not offer any significant advantage over cognitive behavioral therapy alone," Jacobs said. "That was surprising."

The bottom line is that cognitive behavioral therapy is more effective than the leading sleeping pill, Ambien, for treating insomnia, he said.

"Cognitive behavioral therapy is a short-term, sleep-focused treatment that involves techniques aimed at changing the thoughts and behaviors that cause insomnia," Jacobs noted.

Jacobs said that many sleep clinics that specialize in insomnia offer this treatment.

Sleeping pills are over-prescribed, Jacobs added: "Insomnia can be treated more effectively with non-drug approaches. Cognitive behavioral therapy is safe, has no side effects, and works long term with no relapse."

Andrew Krystal, director of the Sleep Research Laboratory and Insomnia Program at Duke University Medical Center, said this study won't change prescribing practices yet. Because it is small, "it is not the kind of definitive trial that should be the basis for a change in practice or recommendations to patients," he said.

He added that at the end of the study, those who took sleeping pills and had cognitive behavioral therapy and those who had cognitive behavioral therapy alone were improved compared with those who took the dummy pill.

"This points to what I see is the most important point that can be drawn from this small study: The combination treatment leads to a faster improvement than cognitive behavioral therapy alone," Krystal said.

"Cognitive behavioral therapy is an excellent therapy for many patients," Krystal said. "One of the limitations of cognitive behavioral therapy may be its relatively slow speed of response, which motivates the combination of cognitive behavioral therapy and short-term treatment with medication. This study adds to the body of literature supporting that conclusion."

Repeated calls to Sanofi-Synthelabo Inc., the maker of Ambien, were not returned.

More information

The National Sleep Foundation can tell you more about insomnia.

SOURCES: Gregg Jacobs, Ph.D., insomnia specialist, Sleep Disorders Center of Beth Israel Deaconess Medical Center, and assistant professor, psychiatry, Harvard Medical School, Boston; Andrew Krystal, M.D., director, Sleep Research Laboratory and Insomnia Program, and associate professor, psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.; Sept. 27, 2004, Archives of Internal Medicine
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