Insomnia and Anxiety (Series in Anxiety and Related Disorders) (20 page)

use and they have limited data supporting their efficacy either following prolonged

hypnotic usage or following treatment discontinuation. In contrast, CBT usually

has a slower rate of therapeutic action but has much more durable effects long after

active treatment (i.e., therapist contact) is discontinued. Therefore, the combination

of hypnotic medication with CBT might result in a more rapid treatment response

than seen with CBT alone and more durable treatment effects than when hypnotics

are used in isolation. As a consequence, such a treatment combination could prove

to be the “ideal” insomnia therapy.

Unfortunately, previous studies pertaining to CBT/hypnotic combination therapy

has provided somewhat mixed results. Three studies (Jacobs, Pace-Schott,

Stickgold, & Otto, 2004; Morin, Colecchi, Stone, Sood, & Brink, 1999; Wu,

Jinfeng, Chungai, & Chunling, 2006) with similar research designs compared treat-

ments consisting of CBT, hypnotic medication, a CBT + hypnotic treatment combi-

nation, and a placebo medication. In each of these studies, active treatment was

delivered for a fixed period of time (6–8 weeks) and then was discontinued during

an extended follow-up period. In each of these studies, those who received CBT

alone showed better long-term sleep improvements than did those who received the

other treatments including the combined CBT/medication therapy. Such results

imply that the presence of medication somehow dampens patients’ responses to

Sleep Medication Discontinuation Strategies

73

CBT perhaps because they rely on the medication effects rather than fully learning

and implementing the CBT strategies. However, more recent studies (Morin et al.,

2009; Vallieres, Morin, & Guay, 2005) have shown that a sequential treatment pro-

tocol, in which patients receive hypnotic medication during the initial stages of an

extended CBT protocol, produces better short- and long-term results than does a

treatment composed of CBT alone. Seemingly, this treatment combination does not

encourage as much dependence on medication and places greater emphasis on CBT

for longer-term insomnia improvements. Although more research of this nature is

needed, these findings suggest that a time-limited course of hypnotic medication at

the outset of CBT therapy may potentiate the treatment effects of this multimodal

behavioral intervention.

Sleep Medication Discontinuation Strategies

As noted earlier, many of those with hypnotic-dependence who present for psycho-

logical treatment of their insomnia have the immediate or long-term goal of being

able to break their dependence on medications for sleep. Those who typically

obtain satisfactory sleep on medications wish to maintain such patterns of medica-

tions, whereas those sleeping poorly on medications wish to come off of their medi-

cations and learn to sleep better without them. Hence, it is important to provide

both of these groups with the information and skills included in a psychological

insomnia treatment such as CBT so they can establish and maintain a satisfactory

sleep pattern free of medications. However, it is also important to provide a medi-

cation-tapering program that they can tolerate so as to enhance their chances of

achieving a medication-free status. Admittedly, both the psychological and medica-

tion tapering aspects of the overall treatment have some features that are unique and

specific to those who are hypnotic dependent, so it is useful to consider each of the

aspects of treatment separately.

Hypnotic-dependent insomnia sufferers display many of the unhelpful beliefs

and sleep-disruptive behaviors (e.g., napping, erratic sleep schedules, too much time

in bed, etc.) common to other forms of insomnia. As a result, they benefit from

the sleep education, stimulus control, and sleep restriction strategies included in

typical CBT protocols. However, these people also present with some specific

features that merit special treatment considerations. Clinical observations often

show that such individuals have a low sense of self-efficacy in regard to sleep and

tend to believe that they simply cannot sleep at night or function in the daytime

without their sleep medications. Intermittently, they may try to sleep without their

medications to test how they do without medication, but such attempts invariably

result in elevated sleep-focused anxiety and arousal that makes sleep more difficult

and inadvertently reinforces their unhelpful beliefs about sleep. In working with

these individuals, it is useful to discourage such “experiments” at least at the outset

of treatment to avoid the undesirable outcomes mentioned. Often, it is also useful

to help examine and challenge their beliefs and attitudes about sleep and about their

74

5 Medication Considerations

inability to sleep and cope with poor nights off of medications. For some, this may

be achieved through simple discussion, but many people benefit from structured

“homework” exercises designed to help them reframe their thoughts about their

sleep problems. For example, we (Edinger & Carney, 2008) have suggested using

“thought records” (presented more fully in Chap. 8) as a tool towards achieving this

end. This instrument helps to identify unhelpful sleep-related thoughts, weigh out

evidence for and against these beliefs, and then develop more balanced and con-

structive modes of thinking to manage their sleep-related distress. Figure 5.2 shows

how someone with hypnotic-dependence might complete this instrument to combat

unhelpful thinking about discontinuing sleep medication.

Along with these strategies, those exhibiting hypnotic-dependence benefit from

structured medication-tapering programs to assist them in striving toward eventual

medication abstinence. In implementing any medication-tapering program, it is

advisable to enlist the collaboration of a physician to guide the tapering process and

to address any adverse effects that may arise. Two approaches that have shown

some efficacy when combined with psychological insomnia therapies are those

reported by Lichstein et al. (1999) and Morin’s group (Belleville et al., 2007; Morin

et al., 2004). In the former approach, the patient’s usual p.r.n. hypnotic medication

dose at the time to treatment entry is first converted into the number of lowest

recommended dosage (LRD) as defined by the Physician’s Desk Reference (PDR).

For example, if the LRD for a particular medication is 5 mg, then the patient

would be taking 14 LRDs per week if the nightly dose taken was 10 mg. An indi-

vidual’s sleep medication is then gradually tapered by one nightly dose per week

(i.e., 1–2 LRDs per week depending on the starting dose), usually starting with the

Mood

Do you feel

(Intensity 0-

Evidence for the Evidence against Adaptive/Coping

any

Situation

100%)

Thoughts

thought

the thought

statement

differently?

Sitting

Frustrated thinking how

Last week I

I’ve slept

I may not be

Frustrated

in my

(100%)

sleepy I feel

fell asleep at

poorly and

at my best,

(50%)

office

I’m never going

my desk

felt the same

but the truth

after a

to be able to

several times

way even when is, I end up

night

Worried

sleep without

after night

I have taken

doing well at

Worried

without

(80%)

sleeping pills

without sleep

my sleeping

work anyway

(20%)

taking

medicine

pills

sleep

I’ve noticed

medicine

Tired

I’m guess I am

I’m starting

I often feel

there are

Tired

(100%)

stuck having to

to avoid

better once I

things I can

(85%)

take sleeping

doing things I

get myself

do to cope

pills forever

used to enjoy

started and

with the

end up

fatigue, so it

I can’t keep

enjoying what

I’ve been

is not

going on like

I choose to do

taking these

hopeless

this

socially

pills for two

years now

I am learning

some new

What’s wrong

skills that

with me?

should help me

be able to

sleep better

on my own

Fig. 5.2
Thought Record example for hypnotic-dependence

References

75

easiest nights and initially avoiding consecutive nights that are medication free.

The approach utilized by Morin’s group (Belleville et al., 2007; Morin et al., 2004)

includes the following: (a) patients initially establish a medication reduction goal

for each week; (b) those using more than one hypnotic first complete a stabilization

phase, which requires them to eliminate multiple hypnotics and to use of a single

hypnotic only; (c) the initial dosage is reduced by about 25% every 2 weeks until

the lowest therapeutic dose is reached; (d) drug-free nights are progressively intro-

duced; and (e) nights with and without hypnotics were planned in advance (i.e.,

noncontingently).

Previous tests of these approaches have yielded positive results with each.

Lichstein et al. (1999) noted that their approach led to an 80% in sleep medication

use by the end of the treatment. Patients who underwent this tapering method cou-

pled with relaxation therapy also achieved notable improvements in sleep efficiency

and sleep quality as well. In studies by Morin’s group (Belleville et al., 2007; Morin

et al., 2004), those who received a combined treatment of CBT and the medication-

tapering approach described, achieved greater sleep and medication reduction out-

comes considered collectively than did comparison groups who received CBT alone

or the medication tapering instructions alone. The use of the types of structured

medication tapering approaches, described along with a psychological insomnia

therapy, appears to be an optimal method for addressing the sleep problems and

medication reduction goal of those who are dependent on hypnotic medications.

References

Agostini, J. V., Leo-Summers, L. S., & Inouye, S. K. (2001). Cognitive and other adverse effects

of diphenhydramine use in hospitalized older patients.
Archives of Internal Medicine, 161
(17),

2091–2097.

Ancoli-Israel, S., & Roth, T. (1999). Characteristics of insomnia in the United States: Results of

the 1991 National Sleep Foundation Survey I.
Sleep, 2
(Suppl.), S347–353.

Backhaus, J., Hohagen, F., Voderholzer, U., & Riemann, D. (2001). Long-term effectiveness of a

short-term cognitive-behavioral group treatment for primary insomnia.
European Archives of

Psychiatry and Clinical Neuroscience, 251
, 35–41.

Belleville, G., Guay, C., Guay, B., & Morin, C. M. (2007). Hypnotic taper with or without self-

help treatment of insomnia: A randomized clinical trial.
Journal of Consulting and Clinical

Psychology, 75
(2), 325–335.

Brower, K. J., Aldrich, M., Robinson, E. A. R., Zucker, R. A., & Greden, J. F. (2001). Insomnia,

self-medication, and relapse to alcoholism.
The American Journal of Psychiatry, 158
, 399–404.

Buscemi, N., Vandermeer, B., Pandya, R., Hooton, N., Tjosvold, L., Hartling, L., et al. (2004).

Melatonin for treatment of sleep disorders.
Evidence Report/Technology Assessment, 108
, 1–7.

Buysse, D. J., Germain, A., Moul, D., & Nofzinger, E. A. (2005). Insomnia. In D. J. Buysse (Ed.),

Sleep disorders and psychiatry
(pp. 29–75). Washington, DC: American Psychiatric Publishing.

Carney, C. E., Edinger, J. D., Manber, R., Garson, C. S., & Segal, Z. V. (2007). Beliefs about sleep

in disorders characterized by sleep and mood disturbance.
Journal of Psychosomatic Research,

62
(2), 179–188.

Dawson, A., Lehr, P., Bigby, B. G., & Mitler, M. M. (1993). Effect of bedtime ethanol on total

inspiratory resistance and respiratory drive in normal nonsnoring men.
Alcoholism, Clinical

and Experimental Research, 17
(2), 256–262.

76

5 Medication Considerations

Donath, F., Quispe, S., & Diefenbach, K. (2000). Critical evaluation of valerian extract on sleep

structure and sleep quality.
Pharmacopsychiatry, 33
(2), 47–53.

Edinger, J. D., & Carney, C. E. (2008).
Overcoming insomnia: A cognitive behavior therapy

approach therapist guide
. New York: Oxford University Press.

Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive