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Consider CBT and hypnotics for persisent insomnia

By Lilian Anekwe

GPs should consider a combination of cognitive behavioural therapy and hypnotic medication for patients with persistent insomnia, a new study concludes.

The prospective randomised controlled trial found CBT was effective for treating persistent insomnia, and adding in medication to CBT gave further benefits.

NICE has never issued a clinical guideline on insomnia, but did release an appraisal on use of hypnotic drugs in its management, simply recommending GPs use the option with the lowest acquisition cost.

But the appraisal permits prescribing for short periods of time only, and precludes prescribing an alternative drug to patients who do not respond to the first – often leaving GPs short of options for patients with persistent insomnia.

The new trial, published in the latest issue of JAMA, included 160 adults randomised to either CBT alone or CBT plus 10mg daily zolpidem for an initial six weeks, followed by a six-month period of either CBT, combination treatment or no treatment at all.

The CBT course included recommendations on how to improve sleep and education regarding faulty beliefs and misconceptions about sleep.

After six weeks, the proportion of patients who responded to CBT alone or CBT plus zolpidem was similar, at 60% and 61% respectively.

Combined therapy initially followed by CBT alone gave the best long-term outcome, with six-month remission rates of 68%, compared with 42% for patients who continued to take zolpidem during extended therapy.

Study leader Dr Charles Morin, director of the Sleep Research Center at Laval University in Canada,: ‘The present findings are promising, but additional studies are needed to develop treatment algorithms to guide practitioners in insomnia management.'

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