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Q In older patients with both chronic insomnia and long term use of benzodiazepines (BDPs), is cognitive behavioural therapy (CBT) plus supervised medical tapering (SMT) (combined therapy [CT]) more effective than CBT or SMT alone for discontinuing BDPs?
Clinical impact ratings GP/FP/Primary care ★★★★★★☆ Mental Health ★★★★★☆☆
METHODS
Design:
randomised controlled trial.
Allocation:
Blinding:
blinded (technician who scored polysomnography sleep stages).*
Follow up period:
12 months
Setting:
a research based sleep clinic in a university hospital in Sainte-Foy, Québec, Canada.
Patients:
76 patients ⩾55 years of age (mean age 63 y, 50% women) with chronic insomnia (for ⩾6 months), impaired daytime functioning or mood disturbances, and benzodiazepine use (on >50% of nights) for ⩾3 months. Exclusion criteria included medical or psychiatric disorders known to cause insomnia, sleep apnoea, periodic limb movements during sleep and other psychiatric disorders or cognitive impairment.
Intervention:
10 weeks of CT (n = 27), CBT (n = 24), or SMT (n = 25). SMT in both CT and SMT alone groups aimed for dosage reductions of 25% at 2 week intervals until the lowest available dose of the BDP was reached. CBT (10 ninety minute weekly sessions) was designed to reinforce the bed as a cue for sleep, regularise sleep rhythm, enhance sleep efficiency, deal with thoughts that could exacerbate the sleep disorder, and educate about sleep and aging.
Outcomes:
change from baseline in BDP use (frequency, quantity, and drug free status) assessed immediately after treatment, and at 3 and 12 months of follow up.
Patient follow up:
all patients were included in the intention to treat analyses.
MAIN RESULTS
CT (compared with CBT and SMT) was associated with less frequent BDP use (number of nights of use per week) throughout the study (p = 0.02). At 10 weeks, more patients in the CT group than in the CBT or SMT group had discontinued BDP use; however, the groups did not differ at 3 and 12 months (table).
Benzodiazepine discontinuation rates for cognitive behavioural therapy (CBT) plus supervised medical tapering (SMT) (combined therapy [CT]) v CBT or SMT alone in chronic insomnia*
CONCLUSION
In older patients with chronic insomnia, cognitive behavioural therapy plus tapering was superior to either therapy alone for discontinuing benzodiazepines at 10 weeks but not in the longer term (3–12 months).
Commentary
The study by Morin et al provides 2 lessons. Firstly, 50% of eligible participants were excluded (many because of comorbid medical [mostly sleep apnoea] or psychiatric disorders), emphasising the need to screen for and treat these disorders before stopping BDPs. Secondly, the study showed that a structured discontinuation programme was effective at both stopping BDP use and improving sleep quality, even among patients who had been taking BDPs for up to 20 years.
Between group differences should be interpreted cautiously because the study did not have a “usual care” (ie, no discontinuation programme) group; the method of randomisation and the use of allocation concealment were not specified; and the patients were motivated volunteers. Also, the CBT was labour intensive, which may limit its feasibility in a typical practice environment. Previous research in this area has shown that less costly interventions, such as replacement of BDPs with other sleep aids (eg, tricyclic agents, zolpidem, and melatonin) or even a simple mailing of information about BDP discontinuation, are effective.1 Of particular note is that the CBT and SMT groups did not differ for BDP discontinuation at 12 months of follow up, a finding that is consistent with the results of another trial that did not show favourable effects of CBT over structured tapering.2 Finally, assessment of the effect on other important health outcomes such as falls and functional status was not done.
In conclusion, it is possible to successfully discontinue BDPs and improve sleep quality among motivated patients using structured discontinuation. The added value of CBT requires further study, including comparison with less costly strategies.