A sequential multiple-assignment randomized trial concluded that behavioral therapy (BT) and zolpidem medication produced equivalent response and remission rates for insomnia. Adding a second treatment produced an added value for those whose insomnia failed to remit with initial therapies. The study included 211 adults (132 women; mean age, 45.6 years) with a chronic insomnia disorder in Canada and the US, including 74 patients with a comorbid anxiety or mood disorder. First-stage therapy with BT or zolpidem produced equivalent weighted percentages of responders (BT, 45.5%; zolpidem, 49.7%) and remitters (BT, 38.03%; zolpidem, 30.3%). Second-stage therapy produced significant increases in responders for the 2 conditions, starting with BT (BT to zolpidem, 40.6% to 62.7%; BT to cognitive therapy [CT], 50.1% to 68.2%) but no significant change following zolpidem treatment. Significant increase in percentage of remitters was observed in 2 of 4 therapy sequences (BT to zolpidem, 38.1% to 55.9%; zolpidem to trazodone, 31.4% to 49.4%). Although response/remission rates were lower among patients with psychiatric comorbidity, treatment sequences that involved BT followed by CT or zolpidem followed by trazodone yielded better outcomes for patients with comorbid insomnia. Response and remission rates were well sustained through the 12-month follow-up. However, no significant differences were observed in analyses comparing the cumulative response rates of all four treatment options. While BT aims to change sleep habits, CT focuses more on a patient’s beliefs and attitudes towards sleep. The findings are consistent with previous studies — non-medication therapy works at least as well as medication as a first-line therapy, without all of the risks involved. Source: https://jamanetwork.com/
