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Chapter 5

Medication Considerations

Abstract
Despite the general efficacy of CBT for insomnia, this form of therapy

is generally not the first intervention chosen for the majority of treatment seeking

insomnia sufferers. Most are seen in primary care settings where they usually are

treated with some form of hypnotic medication. Many of those who eventually

present for a trial of CBT do so while continuing hypnotic medications prescribed

for their sleep difficulties. Additionally, many people with insomnia may con-

tinue using medications to manage their sleep problems for long periods of time

despite less than optimal benefits and their ongoing desires to become medication

free. Also, many insomnia sufferers use combinations of sedating anxiolytics and

prescription hypnotics in an effort to reduce their sleep-related anxiety and sleep

difficulties in general. These observations spawn a number of important questions

in regard to the use of CBT with such individuals. First, it is important to consider

whether these people derive similar benefits from CBT, as do those who enter

treatment medication free. It also seems useful to question if there is an optimal

treatment protocol for people who wish to combine CBT with pharmacotherapy

for insomnia. Finally, it seems useful to ascertain if CBT and other psychological

techniques are useful to those who exhibit hypnotic-dependence and ultimately

wish to discontinue their sleep medication use.

Will Cognitive Behavior Insomnia Therapy Work

with Those Who Use Sleep Medications?

Despite the general efficacy of CBT for insomnia, this form of therapy is generally

not the first intervention chosen for the majority of treatment seeking insomnia

sufferers. Most are seen in primary care settings where they usually are treated

with some form of hypnotic medication (Richardson, 2000; Walsh & Schweitzer,

1998). In fact, nearly 50% of those consulting for insomnia in medical practice are

prescribed a medication for sleep, and the majority of those will continue using

sleep medications almost nightly for periods of a year or longer (Ohayon, 1996;

Schramm et al., 1993). Moreover, experience indicates that a substantial propor-

tion of those who eventually present for a trial of CBT do so while continuing

C.E. Carney and J.D. Edinger,
Insomnia and Anxiety
, Series in Anxiety and Related Disorders,

63

DOI 10.1007/978-1-4419-1434-7_5, © Springer Science+Business Media, LLC 2010

64

5 Medication Considerations

hypnotic medications prescribed for their sleep difficulties. The following case

vignette exemplifies the common clinical features and treatment challenges pre-

sented by such patients:

Mr. P was a 52-year-old married man complaining of insomnia. He reported a history of

sleep difficulties dating back about 14 years to a time when he was having major medical

problems. At that time, he was experiencing considerable pain, immobility, and general

distress subsequent to undergoing surgery on one of his legs. Shortly after developing his

sleep problem, he obtained a prescription for clonazepam to treat his sleep difficulty and

general distress. He found this medication helpful and continued using that medication

almost nightly since that time. He also subsequently received a prescription for zolpi-

dem, 10 mg, to help his sleep. Thus, when he presented for CBT treatment, he was taking

10 mg of zolpidem along with 1 mg of clonazepam on a nightly basis to help his sleep.

Whereas he indicated a desire to discontinue these medications, he noted that he became

very anxious and unable to sleep without them. In fact, his previous efforts to stop these

medications resulted in experiencing elevated anxiety about sleep and pronounced wake-

fulness during the night. With his medications, he indicated that he was able to function

in the daytime without significant impairment. However, he did indicate that his sleep

still was not ideal and he experienced a significant level of fatigue many days each week

despite his nightly use medicinal sleep aids. A sleep diary, which he maintained prior to

his initial clinic visit, showed difficulty initiating sleep on two nights, and relatively poor

quality on several nights. This diary also showed he varied his sleep schedule signifi-

cantly from day-to-day reportedly in his efforts to compensate for intermittent poor

night’s sleep.

As suggested by this case, many people with insomnia may continue using

medications to manage their sleep problems for long periods of time despite less

than optimal benefits and their ongoing desires to become medication free. Also, as

shown by this case, many insomnia sufferers use combinations of sedating anxi-

olytics and prescription hypnotics in an effort to reduce their sleep-related anxiety

and sleep difficulties in general. These observations spawn a number of important

questions in regard to the use of CBT with such individuals. First, it is important to

consider whether these people derive similar benefits from CBT, as do those who