The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review

Alexander Sweetman; Stacey Putland; Leon Lack; R Doug McEvoy; Robert Adams; Ron Grunstein; Nigel Stocks; Billingsley Kaambwa; Emer Van Ryswyk; Christopher Gordon; Andrew Vakulin; Nicole Lovato

doi:10.1016/j.smrv.2020.101404

The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review

Sleep Med Rev. 2021 Apr:56:101404. doi: 10.1016/j.smrv.2020.101404. Epub 2020 Dec 9.

Authors

Affiliations

¹ The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia. Electronic address: alexander.sweetman@flinders.edu.au.
² College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
³ The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁴ The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; The Health Observatory, Discipline of Medicine, The Queen Elizabeth Hospital Campus, University of Adelaide, Woodville, South Australia, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁵ Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁶ Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁷ Health Economics, College of Medicine and Public Health, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
⁸ Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.

PMID: 33370637
DOI: 10.1016/j.smrv.2020.101404

Abstract

Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.

Keywords: Benzodiazepine; Cognitive behavioural therapy for insomnia; General practice; Insomnia; Medication withdrawal; Pharmacotherapy; Primary care; Sedative-hypnotic; Sleeping aid; Sleeping pill.

Publication types

Research Support, Non-U.S. Gov't
Review

MeSH terms

Aged
Cognitive Behavioral Therapy*
Humans
Hypnotics and Sedatives
Primary Health Care
Sleep Initiation and Maintenance Disorders* / drug therapy
Treatment Outcome

Substances

Hypnotics and Sedatives