The Benefits and Limitations of Sedative-Hypnotics and Cognitive-Behavioral Therapy (CBT) for Insomnia

By Dr. Gregg D. Jacobs
January 19, 2005

With the release of a new sleeping pill called Lunesta to pharmacies around the United States in the near future, insomnia is receiving significant media attention. It will also receive increased attention through direct advertising to consumers by the companies that market Lunesta and its chief competitor, Ambien. As a result, it is essential that individuals with insomnia know the advantages and disadvantages of sleeping pills and the primary non-drug therapy for insomnia, called cognitive-behavioral therapy, or CBT for short. Like sleeping pills, CBT has received increased attention in the media recently due to the increasing recognition that it represents a viable alternative to sleeping pills. Exactly what are the relative benefits and limitations of these two approaches to treating insomnia?

Both CBT and sedative-hypnotic treatment have been shown to be effective for treating chronic insomnia. Both appear to be equally effective in the short-term (4-6 weeks) for treating sleep maintenance insomnia whereas CBT has been shown to be more effective for treating sleep onset insomnia over 4-6 weeks or longer. Sleeping pills appear to produce more immediate therapeutic effects whereas CBT produces better long term, durable effects.

Lunesta is the first sleeping pill that has been shown to be effective for up to 6 months of nightly use although the therapeutic effects after months are modest compared to placebo. Specifically, it only helps patients fall asleep 15-20 minutes faster than a placebo pill after 6 months of nightly use; and, patients still require 45-50 minutes to fall asleep after treatment and therefore still have significant insomnia.

Overall, newer generation non-benzodiazepine sleeping pills such as Ambien, Sonata, and Lunesta are safer than traditional benzodiazepines, which have many potential side effects with regular use that can outweigh benefits. For these reasons, non-benzodiazepine sleeping pills are the best choice for insomnia. It is important to note that intermittent, non-nightly use of hypnotics minimizes side effects and maintains efficacy over longer periods of time.

There appear to be several advantages of hypnotics over CBT, including the following:

1. Hypnotics are more appropriate and effective for transient or acute insomnia
2. Hypnotics work faster than CBT in improving sleep in the short-term
3. For chronic insomnia, hypnotics may be the preferred treatment for patients who do not respond to CBT or for whom CBT is not available
4. Hypnotics are more widely available and more cost effective in the short run
5. Hypnotics may prevent transient or acute insomnia form evolving into chronic insomnia

The drawbacks of hypnotics include the following:

1. They don't treat the causes of insomnia, which means that insomnia often returns upon discontinuation of hypnotic therapy
2. Long-term regular (nightly) use of hypnotics can lead to psychological dependency
3. Most patients don't need long-tern nightly use of a sleeping pill because they have mild to moderate insomnia; because they will respond as well to CBT; and, because a few nights per week of mild to moderate sleep loss will not significantly impair daytime functioning.
4. Most hypnotics lose effectiveness after 4-6 weeks of nightly use
5. Potential interactions of hypnotics with alcohol or other medications can be problematic
6. Little data exists on long-term side effects of hypnotics
7. Benzodiazepine side effects with regular use can outweigh benefits

The advantages of CBT over hypnotics include the following:

1. CBT is increasingly available via self-help books and the Internet
2. CBT treats the causes of insomnia and produces long-term improvements in sleep
3. CBT has no side effects
4. CBT is less expensive in the long run

The disadvantages of CBT compared to hypnotics include the following:

1. Few sleep clinics are trained in CBT
2. CBT receives low reimbursement rates by insurance companies
3. Many patients and health care professionals are not aware of CBT

When considering treatment options for chronic insomnia, the relative benefits and limitations of both sleeping pills and hypnotics must be considered by both the patient and the primary care physician. The good news is that, with increasing awareness of treatment options that are available for insomnia, more patients with insomnia will be diagnosed and treated effectively.

Read more in the Insomnia Corner.