Speed and trajectory of changes of insomnia symptoms during acute treatment with cognitive-behavioral therapy, singly and combined with medication

Abstract

Objectives: To examine the speed and trajectory of changes in sleep/wake parameters during short-term treatment of insomnia with cognitive-behavioral therapy (CBT) alone versus CBT combined with medication; and to explore the relationship between early treatment response and post-treatment recovery status.

Methods: Participants were 160 adults with insomnia (mean age, 50.3 years; 97 women, 63 men) who underwent a six-week course of CBT, singly or combined with 10 mg zolpidem nightly. The main dependent variables were sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and sleep quality, derived from sleep diaries completed daily by patients throughout the course of treatment.

Results: Participants treated with CBT plus medication exhibited faster sleep improvements as evidenced by the first week of treatment compared to those receiving CBT alone. Optimal sleep improvement was reached on average after only one week for the combined treatment compared to two to three weeks for CBT alone. Early treatment response did not reliably predict post-treatment recovery status.

Conclusions: Adding medication to CBT produces faster sleep improvement than CBT alone. However, the magnitude of early treatment response is not predictive of final response after the six-week therapy. Additional research is needed to examine mechanisms involved in this early treatment augmentation effect and its impact on long-term outcome.

Keywords: Cognitive–behavioral therapy; Combined therapy; Insomnia; Medication; Sleep; Treatment response.

Fig. 1

Weekly sleep diary data (adjusted means and standard errors) over two-week baseline and six-week acute treatment periods for sleep onset latency, wake time after sleep onset, total sleep time, sleep efficiency, and sleep quality for cognitive–behavioral therapy (CBT) alone and CBT plus zolpidem conditions. Contrasts (i.e. group effect for treatment weeks 1–6, and for change score from baseline to week 1, and from each treatment week to the following week) are flagged for statistical significance.

Fig. 1

Weekly sleep diary data (adjusted means and standard errors) over two-week baseline and six-week acute treatment periods for sleep onset latency, wake time after sleep onset, total sleep time, sleep efficiency, and sleep quality for cognitive–behavioral therapy (CBT) alone and CBT plus zolpidem conditions. Contrasts (i.e. group effect for treatment weeks 1–6, and for change score from baseline to week 1, and from each treatment week to the following week) are flagged for statistical significance.

Fig. 1

Weekly sleep diary data (adjusted means and standard errors) over two-week baseline and six-week acute treatment periods for sleep onset latency, wake time after sleep onset, total sleep time, sleep efficiency, and sleep quality for cognitive–behavioral therapy (CBT) alone and CBT plus zolpidem conditions. Contrasts (i.e. group effect for treatment weeks 1–6, and for change score from baseline to week 1, and from each treatment week to the following week) are flagged for statistical significance.