Cognitive-behavioral therapy (CBT) has been found to be more effective than
the drug zopiclone (Imovane) in short- and long-term management of insomnia in
On average, patients who received CBT improved their "sleep
efficiency"—a ratio of total time spent asleep to actual time
spent in bed, multiplied by 100—by 9 percent, compared with a decline of
1 percent in the group receiving zopiclone. These statistically and clinically
significant improvements in the CBT group were maintained at six-month
follow-up, according to a report in the June 28 Journal of the American
"Given the increasing amount of evidence of the lasting clinical
effects of CBT and lack of evidence of long-term efficacy of hypnotics,
clinicians should consider prescribing hypnotics only for acute
insomnia," wrote lead author Berge Svertsen, Psy.D., and colleagues."
At present, CBT-based interventions for insomnia are not widely
available in clinical practice, and future research should focus on
implementing low-threshold treatment options for insomnia in primary care
settings.... Future research should seek to identify which single factors in
the CBT regimen produce the best results and to what extent booster sessions
at one to two years after initial treatment may be necessary to maintain
Svertsen and colleagues are with the University of Bergen in Norway.
In the study, 46 adults with an average age of 60.8 years were randomly
assigned to either CBT (18), a medication regimen of 7.5 mg. zopiclone nightly
(16), or placebo medication (12).
Five learning modules were included in the CBT condition: sleep-hygiene
education, sleep restriction, stimulus control, cognitive therapy, and
progressive relaxation technique.
In the sleep-hygiene education module, the patient learns about the impact
of lifestyle habits such as exercise, diet, and alcohol use and the influence
of environmental factors such as light, noise, and temperature. The
sleep-restriction module involves a strict schedule of bedtimes and rising
times with the aim of increasing "sleepdrive" through partial
In the stimulus-control module, the aim is to break associations between
the sleep environment and wakefulness by teaching the participant not to
engage in bedroom activities incompatible with sleep and to stay in the
bedroom only when asleep or sleepy. The cognitive-therapy module aims to
identify, challenge, and replace beliefs and fears regarding sleep or the loss
of sleep with realistic expectations regarding sleep and daytime function.
Finally, the progressive relaxation technique teaches the patient to
recognize and control muscular tension through the use of exercise
instructions on audiotape or compact disc, and to practice the technique at
home on a daily basis.
Ambulant clinical polysomnographic (PSG) data and sleep diaries were used
in the assessment of four outcome measures: total wake time, total sleep time,
sleep efficiency, and slow-wave sleep (time spent in sleep stages 3 and
At six weeks, the total wake time for the CBT group improved significantly
more than for both the placebo group and the zopiclone group; zopiclone was
not significantly better than placebo. And the amount of PSG-recorded
slow-wave sleep improved significantly in the CBT group compared with the
placebo and zopiclone groups.
At six month follow-up, total wake time, sleep efficiency, and slow-wave
sleep were all significantly better in the CBT group than in the zopiclone
group. Similar to PSG, the sleep diaries showed an increase in total sleep
time in the CBT group at six months compared with six-week follow-up.
"This study demonstrated superior benefits of CBT over zopiclone for
treatment of chronic insomnia in older adults at six-week and six-month
follow-up," the authors wrote. "Future research should require
effects in slow-wave sleep and define effects on daytime
The study was funded by grants from the University of Bergen, Meltzer Fund,
and Norwegian Foundation for Health and Rehabilitation.
An abstract of "Cognitive-Behavioral Therapy vs. Zopiclone for
Treatment of Chronic Primary Insomnia in Older Adults" is posted at<http://jama.ama-assn.org/cgi/content/abstract/295/24/2851>.▪