Sleep Initiation and Maintenance Disorders: Morin CM

Morin CM. · No affiliation provided · Sleep Med Rev. · Pubmed #15062206 No free full text.

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Morin CM. · No affiliation provided · Psychosom Med. · Pubmed #10949092 links to  free full text

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Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. · Université Laval, Québec, Canada. · Sleep. · Pubmed #17162986 No free full text.

Abstract: BACKGROUND: Recognition that psychological and behavioral factors play an important role in insomnia has led to increased interest in therapies targeting these factors. A review paper published in 1999 summarized the evidence regarding the efficacy of psychological and behavioral treatments for persistent insomnia. The present review provides an update of the evidence published since the original paper. As with the original paper, this review was conducted by a task force commissioned by the American Academy of Sleep Medicine in order to update its practice parameters on psychological and behavioral therapies for insomnia. METHODS: A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients) published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline searches. Each study was systematically reviewed with a standard coding sheet and the following information was extracted: Study design, sample (number of participants, age, gender), diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings. Criteria for inclusion of a study were as follows: (a) the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment condition was psychological or behavioral in content, (c) the study design was a randomized controlled trial, a nonrandomized group design, a clinical case series or a single subject experimental design with a minimum of 10 subjects, and (d) the study included at least 1 of the following as dependent variables: sleep onset latency, number and/or duration of awakenings, total sleep time, sleep efficiency, or sleep quality. RESULTS: Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders. Nine studies documented the benefits of insomnia treatment in older adults or for facilitating discontinuation of medication among chronic hypnotic users. Sleep improvements achieved with treatment were well sustained over time; however, with the exception of reduced psychological symptoms/ distress, there was limited evidence that improved sleep led to clinically meaningful changes in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria for empirically-supported psychological treatments for insomnia: Stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior therapy. DISCUSSION: These updated findings provide additional evidence in support of the original review's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia. Nonetheless, further research is needed to develop therapies that would optimize outcomes and reduce morbidity, as would studies of treatment mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also needed to validate those therapies when implemented in clinical settings (primary care), by non-sleep specialists. There is also a need to disseminate more effectively the available evidence in support of psychological and behavioral interventions to health-care practitioners working on the front line.

Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. · Department of Psychiatry, University of Pittsburgh School of Medicine, PA, USA. · Sleep. · Pubmed #17040003 No free full text.

Abstract: STUDY OBJECTIVES: To present expert consensus recommendations for a standard set of research assessments in insomnia, reporting standards for these assessments, and recommendations for future research. PARTICIPANTS: N/A. INTERVENTIONS: N/A. METHODS AND RESULTS: An expert panel of 25 researchers reviewed the available literature on insomnia research assessments. Preliminary recommendations were reviewed and discussed at a meeting on March 10-11, 2005. These recommendations were further refined during writing of the current paper. The resulting key recommendations for standard research assessment of insomnia disorders include definitions/diagnosis of insomnia and comorbid conditions; measures of sleep and insomnia, including qualitative insomnia measures, diary, polysomnography, and actigraphy; and measures of the waking correlates and consequences of insomnia disorders, such as fatigue, sleepiness, mood, performance, and quality of life. CONCLUSIONS: Adoption of a standard research assessment of insomnia disorders will facilitate comparisons among different studies and advance the state of knowledge. These recommendations are not intended to be static but must be periodically revised to accommodate further developments and evidence in the field.

Belanger L, Savard J, Morin CM. · Ecole de Psychologie, Universite Laval, Quebec, Canada. · Behav Sleep Med. · Pubmed #16879081 No free full text.

Abstract: Cognitive therapy has been shown effective in the treatment of several psychological and health-related disorders. It is also increasingly used in the management of insomnia. This article outlines some principles and applications of this therapeutic approach as adapted to the treatment of insomnia. Based on Beck's model, this psychotherapeutic approach seeks to modify sleep-related dysfunctional beliefs and thoughts and maladaptive cognitive processes involved in the exacerbation and perpetuation of insomnia. This is accomplished through the use of several cognitive restructuring procedures. After outlining a conceptual model of insomnia, which emphasizes the mediating role of dysfunctional cognitions in the development and maintenance of chronic insomnia, the rationale and general principles of cognitive therapy for insomnia are presented, followed by a description of the treatment procedures, clinical case illustrations, and practical implementation issues. Future directions include the need to refine cognitive interventions and to examine the unique contribution of this therapeutic component to the overall efficacy of multifaceted cognitive-behavioral therapy.

Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, Jamieson AO, McCall WV, Morin CM, Stepanski EJ, Anonymous00028. · VA Medical Center, Durham, NC, USA. · Sleep. · Pubmed #15683149 No free full text.

Abstract: Insomnia is a highly prevalent, often debilitating, and economically burdensome form of sleep disturbance caused by various situational, medical, emotional, environmental and behavioral factors. Although several consensually-derived nosologies have described numerous insomnia phenotypes, research concerning these phenotypes has been greatly hampered by a lack of widely accepted operational research diagnostic criteria (RDC) for their definition. The lack of RDC has, in turn, led to inconsistent research findings for most phenotypes largely due to the variable definitions used for their ascertainment. Given this problem, the American Academy of Sleep Medicine (AASM) commissioned a Work Group (WG) to review the literature and identify those insomnia phenotypes that appear most valid and tenable. In addition, this WG was asked to derive standardized RDC for these phenotypes and recommend assessment procedures for their ascertainment. This report outlines the WG's findings, the insomnia RDC derived, and research assessment procedures the WG recommends for identifying study participants who meet these RDC.

Ouellet MC, Savard J, Morin CM. · Ecole de Psychologie, Centre d'Etude des Troubles du Sommeil, Université Laval, Québec, Canada. <> · Neurorehabil Neural Repair. · Pubmed #15669131 No free full text.

Abstract: Sleep disturbances after a traumatic brain injury (TBI) have received very little scientific attention despite the fact that several studies indicate that they may occur in 30% to 70% of patients. For individuals with TBI, problems falling asleep or maintaining sleep can exacerbate other symptoms such as pain, cognitive deficits, fatigue, or irritability. Sleep disturbances can thus compromise the rehabilitation process and the ability to return to work. This article reviews the evidence on the epidemiology, etiology, and treatment of insomnia in the context of TBI and proposes areas for future research. Prevalence estimates of insomnia complaints in TBI patients are summarized. Potential etiological factors (i.e., lesions to the nervous system, anxiety) and possible consequences of insomnia (i.e., fatigue, cognitive problems) in the context of TBI are discussed. Finally, pharmacological and psychological treatments previously shown effective to treat insomnia in healthy individuals are discussed as valuable treatment options for TBI patients. Increased knowledge about the high prevalence, diagnosis, and potential etiological factors of insomnia following TBI may promote a better identification, evaluation, and treatment of sleeping difficulties in this population.

Morin CM. · Sleep Disorders Center, Laval University, Quebec, Canada. · J Clin Psychiatry. · Pubmed #15575803 No free full text.

Abstract: Insomnia is a pervasive condition with various causes, manifestations, and health consequences. Regardless of the initial cause or event that precipitates insomnia, it is perpetuated into a chronic condition through learned behaviors and cognitions that foster sleeplessness. This article reviews the rationale and objectives of cognitive-behavioral therapy (CBT), a safe and effective treatment for insomnia that may be used to augment hypnotic drugs or as a monotherapy. Cognitive-behavioral management of insomnia includes 3 components--behavioral, cognitive, and educational modules--and is usually presented in a group or individual therapy setting. Each treatment procedure is detailed herein, and recommendations for implementation are given. The evidence supporting this behavioral approach shows that CBT is effective for 70% to 80% of patients and that it can significantly reduce several measures of insomnia, including sleep-onset latency and wake-after-sleep onset. Aside from the clinically measurable changes, this therapy system enables many patients to regain a feeling of control over their sleep, thereby reducing the emotional distress that sleep disturbances cause. Some clinical and practical issues that often arise when implementing this therapeutic approach for insomnia are also discussed.

Morin CM. · Université Laval, Québec, Canada. · Sleep Med Rev. · Pubmed #12927124 No free full text.

Abstract: Significant efforts have been made in the last decade to develop evidence-based guidelines for the treatment of insomnia and other sleep disorders. Despite such progress, there are still no standard assessment methods to document outcome and no accepted criteria to define what should be a successful outcome in the treatment of insomnia. This paper reviews methodological and conceptual issues related to the measurement of outcomes in clinical trials of insomnia. Selected studies of behavioral and pharmacological therapies of insomnia are summarized to illustrate the types of dependent variables and assessment instruments used to document treatment efficacy. Additional outcome variables and assessment methods of potential interest are discussed, and criteria for interpreting and reporting outcomes are summarized. As most studies have relied on fairly narrow criteria to define an effective treatment, the need to broaden the scope of outcome assessment is highlighted. For instance, it is essential to document treatment efficacy beyond the simple reduction of insomnia symptoms and to incorporate additional indicators of success. Given that insomnia is associated with significant morbidity, an effective treatment should not only improve sleep parameters, but it should also produce clinically meaningful changes in daytime functioning, fatigue, mood, and quality of life. The need to evaluate outcome from multiple perspectives and to develop a core-assessment battery that would consider efficacy, clinical significance, and cost-effectiveness are discussed.

Morin CM. · Université Laval, Ecole de psychologie, Pavillon F.A.S., Sainte-Foy, Québec, Canada G1K 7P4. · Rev Neurol (Paris). · Pubmed #11924042 No free full text.

Abstract: Insomnia in widespread health with important personal, occupational, and economic consequences. Multiple causes (psychologic, medical, pharmacologic, environmental) are recognized, but little is known about risks predisposing certain individuals to chronic insomnia. For instance, what is the role of psychological vulnerability? Although the response to this question might appear obvious, valid scientific evidence is lacking. We present a conceptual model of insomnia distinguishing vulnerability, triggering and maintaining factors. We also discuss different types of evidence supporting the notion of psychological vulnerability in insomnia. Finally, we examine the clinical implications and propose avenues of future research.

Savard J, Morin CM. · Laval University Cancer Research Center, Université Laval, Québec, Québec, Canada. · J Clin Oncol. · Pubmed #11157043 No free full text.

Abstract: This article reviews the evidence on the diagnosis, epidemiology, etiology, and treatment of insomnia in the context of cancer and proposes several areas for future research. Clinical and diagnostic features of insomnia are described and prevalence estimates of insomnia complaints in cancer patients are summarized. Then, potential etiologic factors (ie, predisposing, precipitating, and perpetuating factors) and consequences of insomnia (ie, psychologic, behavioral, and health impact) in the context of cancer are discussed. Finally, pharmacologic and psychologic treatments previously shown effective to treat insomnia in healthy individuals are discussed as valuable treatment options for cancer patients as well. Because long-term use of hypnotic medications is associated with some risks (eg, dependence), it is argued that psychologic interventions (eg, stimulus control, sleep restriction, cognitive therapy) are the treatment of choice for sleep disturbances in the context of cancer, especially when it has reached a chronic course. However, the efficacy of these treatments has yet to be verified specifically in cancer patients.

Sateia MJ, Doghramji K, Hauri PJ, Morin CM. · Sleeps Disorders Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. · Sleep. · Pubmed #10737342 No free full text.

Abstract: Insomnia is a condition which affects millions of individuals, giving rise to emotional distress, daytime fatigue, and loss of productivity. Despite its prevalence, it has received scant clinical attention. An adequate evaluation of persistent insomnia requires detailed historical information as well as medical, psychological and psychiatric assessment. Use of a classification system for sleep disorders and familiarity with major diagnostic groups will facilitate the clinician's evaluation and treatment. Thorough assessment also requires attention to the unique aspects of presentation and specific set of etiologies which are associated with particular age groups.

Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. · Université Laval, Ecole de Psychologie, Ste-Foy, Quebec, Canada. · Sleep. · Pubmed #10617176 No free full text.

Abstract: This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.

Morin CM, Mimeault V, Gagné A. · Université Laval, Québec, Canada. · J Psychosom Res. · Pubmed #10098820 No free full text.

Abstract: This article reviews the evidence regarding the efficacy of nonpharmacological interventions for the treatment of late-life insomnia. Outcome data from more than a dozen treatment studies conducted with community-dwelling older adults indicate that behavioral approaches produce reliable and durable therapeutic benefits. as evidenced by improved sleep efficiency and continuity and enhanced satisfaction with sleep patterns. Treatment is also helpful for reducing hypnotic usage among older adults who are dependent on sleep medications. Treatment methods such as stimulus control and sleep restriction, which target maladaptive sleep habits, are especially beneficial for older insomniacs, whereas relaxation-based interventions. aimed at decreasing arousal, produce more limited effects. Cognitive and educational interventions are instrumental in altering age-related dysfunctional beliefs and attitudes about sleep. Integrated behavioral and pharmacological therapies have received very little empirical attention thus far. Although a limited number of older adults resume "normal" sleep patterns after treatment, outcome is clinically meaningful as most patients report greater satisfaction with their sleep patterns, use less medications, and display less psychological distress and concerns about sleep.

Ouellet MC, Morin CM. · Axe de Recherche en Traumatologie et Médecine d'Urgence, Centre de Recherche du Centre Hospitalier Affilié Universitaire de Québec, Québec, QC, Canada. · Arch Phys Med Rehabil. · Pubmed #18047872 No free full text.

Abstract: OBJECTIVE: To test the efficacy of a cognitive-behavioral therapy (CBT) for insomnia in persons having sustained traumatic brain injury (TBI). DESIGN: Single-case design with multiple baselines across participants. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Eleven subjects having sustained mild to severe TBI who developed insomnia after the injury. INTERVENTION: Eight-week CBT for insomnia including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management. MAIN OUTCOME MEASURES: Total wake time, sleep efficiency, and diagnostic criteria. RESULTS: Visual analyses, corroborated by intervention time series analyses and t tests, revealed clinically and statistically significant reductions in total wake time and sleep efficiency for 8 (73%) of 11 participants. An average reduction of 53.9% in total wake time was observed across participants from pre- to post-treatment. Progress was in general well maintained at the 1-month and 3-month follow-ups. The average sleep efficiency augmented significantly from pretreatment (77.2%) to post-treatment (87.9%), and also by the 3-month follow-up (90.9%). Improvements in sleep were accompanied by a reduction in symptoms of general and physical fatigue. CONCLUSIONS: The results of this study show that psychologic interventions for insomnia are a promising therapeutic avenue for TBI survivors.

Savard J, Simard S, Ivers H, Morin CM. · Laval University Cancer Research Center, 11 Côte du Palais, Québec, Québec, Canada, G1R 2J6. · J Clin Oncol. · Pubmed #16135476 No free full text.

Abstract: PURPOSE: Cross-sectional studies suggest that clinical insomnia is associated with immune downregulation. However, there is a definite need for experimental studies on this question. The goal of this randomized controlled study was to assess the effect of an 8-week cognitive-behavioral therapy (CBT) for chronic insomnia on immune functioning of breast cancer survivors. Previous analyses of this study showed that CBT was associated with improved sleep and quality of life, and reduced psychological distress. PATIENTS AND METHODS: Fifty-seven women with chronic insomnia secondary to breast cancer were randomly assigned to CBT (n = 27) or to a waiting-list control condition (WLC; n = 30). Peripheral-blood samples were taken at baseline and post-treatment (and postwaiting for WLC patients), as well as at 3-, 6-, and 12-month follow-up for immune measures, including enumeration of blood cell counts (ie, WBCs, monocytes, lymphocytes, CD3+, CD4+, CD8+, and CD16+/CD56+) and cytokine production (ie, interleukin-1-beta [IL-1beta] and interferon gamma [IFN-gamma]). RESULTS: Patients treated with CBT had higher secretion of IFN-gamma and lower increase of lymphocytes at post-treatment compared with control patients. Pooled data from both treated groups indicated significantly increased levels of IFN-gamma and IL-1beta from pre- to post-treatment. In addition, significant changes in WBCs, lymphocytes, and IFN-gamma were found at follow-up compared with post-treatment. CONCLUSION: This study provides some support to the hypothesis of a causal relationship between clinical insomnia and immune functioning. Future studies are needed to investigate the clinical impact of such immune alterations.

Savard J, Simard S, Ivers H, Morin CM. · Laval University Cancer Research Center, 11 Côte du Palais, Québec, Québec, G1R 2J6 Canada. · J Clin Oncol. · Pubmed #16135475 No free full text.

Abstract: PURPOSE: Chronic insomnia is highly prevalent in cancer patients. Cognitive-behavioral therapy (CBT) is considered the treatment of choice for chronic primary insomnia. However, no randomized controlled study has been conducted on its efficacy for insomnia secondary to cancer. Using a randomized controlled design, this study conducted among breast cancer survivors evaluated the effect of CBT on sleep, assessed both subjectively and objectively, and on hypnotic medication use, psychological distress, and quality of life. PATIENTS AND METHODS: Fifty-seven women with insomnia caused or aggravated by breast cancer were randomly assigned to CBT (n = 27) or a waiting-list control condition (n = 30). The treatment consisted of eight weekly sessions administered in a group and combined the use of stimulus control, sleep restriction, cognitive therapy, sleep hygiene, and fatigue management. Follow-up evaluations were carried out 3, 6, and 12 months after the treatment. RESULTS: Participants who received the insomnia treatment had significantly better subjective sleep indices (daily sleep diary, Insomnia Severity Index), a lower frequency of medicated nights, lower levels of depression and anxiety, and greater global quality of life at post-treatment compared with participants of the control group after their waiting period. Results were more equivocal on polysomnographic indices. Therapeutic effects were well maintained up to 12 months after the intervention and generally were clinically significant. CONCLUSION: This study supports the efficacy of CBT for insomnia secondary to breast cancer.

Bélanger L, Morin CM, Bastien C, Ladouceur R. · Ecole de Psychologie, Université Laval, Québec, Canada. · Health Psychol. · Pubmed #15898864 No free full text.

Abstract: Better understanding of compliance with BZD taper is warranted. Compliance with a taper program and perceived self-efficacy (SE) in being able to comply with hypnotic reduction goals was monitored weekly in 52 older adults (mean age: 63.0 years) with chronic insomnia (average duration: 21.9 years) who underwent a 10-week physician-supervised medication tapering. One group received cognitive- behavior therapy for insomnia during discontinuation, whereas the other did not. Compliant patients showed higher SE ratings at Weeks 6, 8, 9, and 10. Medication-free patients at the end of the treatment also reported higher mean SE ratings at those 4 weeks. Differences remained significant when withdrawal symptoms and sleep efficiency were controlled for. These results have important clinical implications because SE may indicate key time points when patients are experiencing more difficulty during discontinuation.

Vallières A, Morin CM, Guay B, Bastien CH, LeBlanc M. · Ecole de Psychologie, Université Laval, Québec, Canada. · Behav Sleep Med. · Pubmed #15600227 No free full text.

Abstract: This article explores the efficacy of sequential treatment involving medication and cognitive behavioral treatment (CBT) for insomnia. In a multiple baseline across-subjects design, 6 participants with primary chronic insomnia received 1 of the following treatment sequences: (a) concurrent combination of medication and CBT for the 10-week treatment duration (Combined); (b) medication for the first 5 weeks, with introduction of CBT at week 4 and medication withdrawal after the 5th week resulting in treatment overlap during weeks 4 and 5 (Overlapping: Medication --> Combined --> CBT); and (c) medication alone for the first 5 weeks followed by CBT alone for an additional 5 weeks (Medication --> CBT). Each sequence led to significant sleep improvements, but these improvements occurred at different times during the intervention. Participants in the Combined and in the Overlapping sequences improved their sleep during the 1st phase of treatment, whereas those in the Medication --> CBT sequence improved mostly during the 2nd phase of treatment. These preliminary results suggest that a sequential treatment is effective for chronic insomnia. In addition, the results suggest that sleep improvements are more likely to emerge when CBT is introduced, with an Overlapping sequence showing a slight advantage over the other sequences. Additional clinical trials should be conducted with larger samples to replicate these preliminary findings.

Bastien CH, Morin CM, Ouellet MC, Blais FC, Bouchard S. · Ecole de Psychologie, Universite Laval, Quebec, Ste-Foy, PQ, Canada. · J Consult Clin Psychol. · Pubmed #15301650 No free full text.

Abstract: Forty-five adults with primary insomnia received cognitive-behavioral therapy (CBT) implemented in a group therapy format, in individual face-to-face therapy or through brief individual telephone consultations. The results indicate that CBT was effective in improving sleep parameters with all 3 methods of treatment implementation, and there was no significant difference across methods of implementation. All 3 treatment modalities produced improvements in sleep that were maintained for 6 months after treatment completion. These results suggest that group therapy and telephone consultations represent cost-effective alternatives to individual therapy for the management of insomnia.

Savard J, Davidson JR, Ivers H, Quesnel C, Rioux D, Dupéré V, Lasnier M, Simard S, Morin CM. · Laval University Cancer Research Center and School of Psychology, Quebec City, Quebec, Canada. · J Pain Symptom Manage. · Pubmed #15165649 No free full text.

Abstract: This study examined the relationship between objectively measured nocturnal hot flashes and objectively measured sleep in breast cancer survivors with insomnia. Twenty-four women who had completed treatment for non-metastatic breast cancer participated. All were enrolled in a study of cognitive-behavioral treatment for chronic insomnia. Nocturnal hot flashes and sleep were measured by skin conductance and polysomnography, respectively. The 10-minute periods around hot flashes were found to have significantly more wake time, and more stage changes to lighter sleep, than other 10-minute periods during the night. Nights with hot flashes had a significantly higher percentage of wake time, a lower percentage of Stage 2 sleep, and a longer REM latency compared to nights without hot flashes. Overall, hot flashes were found to be associated with less efficient, more disrupted sleep. Nocturnal hot flashes, or their underlying mechanisms, should be considered as potential contributors to sleep disruption in women with breast cancer who report poor sleep.

Morin CM, Bastien C, Guay B, Radouco-Thomas M, Leblanc J, Vallières A. · Ecole de Psychologie, Université Laval, Sainte-Foy, Québec, Canada. · Am J Psychiatry. · Pubmed #14754783 links to  free full text

Abstract: OBJECTIVE: This study evaluated the effectiveness of a supervised benzodiazepine taper, singly and combined with cognitive behavior therapy, for benzodiazepine discontinuation in older adults with chronic insomnia. METHOD: Seventy-six older adult outpatients (38 women, 38 men; mean age of 62.5 years) with chronic insomnia and prolonged use (mean duration of 19.3 years) of benzodiazepine medication for sleep were randomly assigned for a 10-week intervention consisting of a supervised benzodiazepine withdrawal program (N=25), cognitive behavior therapy for insomnia (N=24), or supervised withdrawal plus cognitive behavior therapy (N=27). Follow-up assessments were conducted at 3 and 12 months. The main outcome measures were benzodiazepine use, sleep parameters, and anxiety and depressive symptoms. RESULTS: All three interventions produced significant reductions in both the quantity (90% reduction) and frequency (80% reduction) of benzodiazepine use, and 63% of the patients were drug-free within an average of 7 weeks. More patients who received medication taper plus cognitive behavior therapy (85%) were benzodiazepine-free after the initial intervention, compared to those who received medication taper alone (48%) and cognitive behavior therapy alone (54%). The patients in the two groups that received cognitive behavior therapy perceived greater subjective sleep improvements than those who received medication taper alone. Polysomnographic data showed an increase in the amount of time spent in stages 3 and 4 sleep and REM sleep and a decrease in total sleep time across all three conditions from baseline to posttreatment. Initial benzodiazepine reductions were well maintained up to the 12-month follow-up, and sleep improvements became more noticeable over this period. No significant withdrawal symptoms or adverse events were associated with benzodiazepine tapering. CONCLUSIONS: A structured, time-limited intervention is effective in assisting chronic users of benzodiazepine medication to discontinue or reduce their use of medication. The addition of cognitive behavior therapy alleviates insomnia, but sleep improvements may become noticeable only after several months of benzodiazepine abstinence.

Baillargeon L, Landreville P, Verreault R, Beauchemin JP, Grégoire JP, Morin CM. · Department of Family Medicine, Laval University, Sainte-Foy, Que. · CMAJ. · Pubmed #14609970 links to  free full text

Abstract: BACKGROUND: Long-term use of hypnotics is not recommended because of risks of dependency and adverse effects on health. The usual clinical management of benzodiazepine dependency is gradual tapering, but when used alone this method is not highly effective in achieving long-term discontinuation. We compared the efficacy of tapering plus cognitive-behavioural therapy for insomnia with tapering alone in reducing the use of hypnotics by older adults with insomnia. METHODS: People with chronic insomnia who had been taking a benzodiazepine every night for more than 3 months were recruited through media advertisements or were referred by their family doctors. They were randomly assigned to undergo either cognitive-behavioural therapy plus gradual tapering of the drug (combined treatment) or gradual tapering only. The cognitive-behavioural therapy was provided by a psychologist in 8 weekly small-group sessions. The tapering was supervised by a physician, who met weekly with each participant over an 8-week period. The main outcome measure was benzodiazepine discontinuation, confirmed by blood screening performed at each of 3 measurement points (immediately after completion of treatment and at 3- and 12-month follow-ups). RESULTS: Of the 344 potential participants, 65 (mean age 67.4 years) met the inclusion criteria and entered the study. The 2 study groups (35 subjects in the combined treatment group and 30 in the tapering group) were similar in terms of demographic characteristics, duration of insomnia and hypnotic dosage. Immediately after completion of treatment, a greater proportion of patients in the combined treatment group had withdrawn from benzodiazepine use completely (77% [26/34] v. 38% [11/29]; odds ratio [OR] 5.3, 95% confidence interval [CI] 1.8-16.2; OR after adjustment for initial benzodiazepine daily dose 7.9, 95% CI 2.4-30.9). At the 12-month follow-up, the favourable outcome persisted (70% [23/33] v. 24% [7/29]; OR 7.2, 95% CI 2.4-23.7; adjusted OR 7.6, 95% CI 2.5-26.6); similar results were obtained at 3 months. INTERPRETATION: A combination of cognitive-behavioural therapy and benzodiazepine tapering was superior to tapering alone in the management of patients with insomnia and chronic benzodiazepine use. The beneficial effects were sustained for up to 1 year. Applying this multidisciplinary approach in the community could help reduce benzodiazepine use by older people.

Quesnel C, Savard J, Simard S, Ivers H, Morin CM. · School of Psychology and Cancer Research Centre, Université Laval, Québec, Québec, Canada. · J Consult Clin Psychol. · Pubmed #12602439 No free full text.

Abstract: This study investigated the efficacy of a multimodal cognitive-behavioral intervention for women who had been treated for nonmetastatic breast cancer. Ten participants were enrolled in the treatment protocol in a multiple-baseline design. Intervention time series analyses of daily sleep diary data revealed significant improvements of sleep efficiency and total wake time. These results were corroborated by polysomnographic data. In addition, insomnia treatment was associated with significant improvements of mood, general and physical fatigue, and global and cognitive dimensions of quality of life. These findings suggest that cognitive-behavioral therapy, previously found effective for primary insomnia, is also of clinical benefit for insomnia secondary to cancer.

Morin CM, Bastien CH, Brink D, Brown TR. · Université Laval, Quebec, Canada. · Hum Psychopharmacol. · Pubmed #12532318 No free full text.

Abstract: BACKGROUND: Benzodiazepine-hypnotics are frequently used for treating insomnia in older adults; however, there is little information about adverse effects associated with their usage over several weeks, particularly in this segment of the population. OBJECTIVE: This study reports on the incidence of adverse effects of temazepam in older adults with chronic insomnia and examines whether the addition of cognitive-behaviour therapy (CBT) is associated with less drug used and fewer adverse effects. METHOD: Sixty patients with chronic and primary insomnia were randomized to temazepam (n = 20), placebo (n = 20) or temazepam plus CBT (n = 20). Data from the physicians' weekly assessments and patients' sleep diaries were used to evaluate adverse effects, the dose (7.5-30 mg) at which they occurred, and drug use patterns over the 8-week course of treatment. RESULTS: The incidence of adverse effects was infrequent, as shown by the low percentages of complaints reported by patients in the temazepam (7.8%), placebo (10.8%) and combination groups (8.3%). The severity of adverse events was mild and decreased over the course of treatment. The maximum dose was reached by 10 patients receiving temazepam, 14 placebo and 7 in the combined treatment. The average nightly dosage used was 20 mg for both the temazepam and placebo groups and 16 mg for the combined condition. Patients receiving temazepam plus CBT used less drugs, with approximately the same incidence of adverse effects. CONCLUSION: Temazepam is a safe hypnotic for use by older adults over an 8-week treatment period. There are few adverse effects and behavioural tolerance to those effects develop over time. The addition of cognitive-behavioural intervention reduced both the amount of medication used and the incidence of adverse effects, with comparable sleep improvements.