March 1, 2004 -- The combination of cognitive behavioral therapy with supervised taper was better for some outcomes than either modality alone in facilitating benzodiazepine discontinuation in older adults with chronic insomnia, according to the results of a randomized clinical trial published in the February issue of the American Journal of Psychiatry.

"Discontinuation of hypnotic medications, particularly benzodiazepines, can pose a significant challenge after prolonged use, even when they have been used at low therapeutic doses," write Charles M. Morin, PhD, from the Université Laval in Sainte-Foy, Québec, Canada, and colleagues. "Although benzodiazepine discontinuation studies have yielded promising short-term results, relapse rates often exceed 50% at follow-up."

In a three-way randomization, 76 older adult outpatients with chronic insomnia and prolonged use of benzodiazepine medication for sleep received a 10-week intervention consisting of a supervised benzodiazepine withdrawal program, cognitive behavior therapy for insomnia, or both treatments. There were 38 women and 38 men; mean age was 62.5 years, and mean duration of benzodiazepine use was 19.3 years. Subjects were reevaluated at three and at 12 months.

Within an average of seven weeks, all three interventions produced significant reductions in both the quantity (90% reduction) and frequency (80% reduction) of benzodiazepine use. The proportion of patients who were benzodiazepine-free was 63% overall, 85% in the group treated with medication taper plus cognitive behavior therapy, 48% in the group that received medication taper alone, and 54% in the group that received only cognitive behavior therapy.

Subjective sleep improvements were greater in the two groups that received cognitive behavior therapy than in the group that received medication taper alone. From baseline to posttreatment, all three groups had an increase in stages 3 and 4 sleep and REM sleep and a decrease in total sleep time, based on polysomnographic data.

At 12-month follow-up, initial benzodiazepine reductions were well-maintained, and sleep improvements became more noticeable, without significant withdrawal symptoms or adverse events.

The authors warn that these findings are not generalizable to older patients with chronic medical or mental health problems, or to chronic benzodiazepine users poorly motivated to discontinue or reduce their medication.

"A structured, time-limited intervention is effective in assisting chronic users of benzodiazepine medication to discontinue or reduce their use of medication," the authors write, while recommending additional placebo-controlled and longitudinal studies to identify predictors of relapse or successful discontinuation. "The addition of cognitive behavior therapy alleviates insomnia, but sleep improvements may become noticeable only after several months of benzodiazepine abstinence."

The National Institutes of Mental Health supported this study.

Am J Psychiatry. 2004;161:332-342