Sleep study touts therapy over pills
A handful of therapy sessions does more to help chronic insomniacs get to sleep than the top-selling sleeping pill, according to a new Harvard Medical School study, suggesting that doctors are relying too heavily on medications to treat Americans' increasingly restless nights.
A quarter of adults take sleeping pills at some point during the year, according to a National Sleep Foundation survey, reflecting the difficulty that more than half of Americans have sleeping at least a few nights a week. But the Harvard study found that among people who chronically struggle with insomnia, advice from a therapist is more likely to produce a normal night's rest than Ambien, the top-selling sleep aid, with sales of $1.5 billion for 2003.
"The first line of treatment should be cognitive behavior therapy, not drugs, and in 75 percent of patients, that is going to be more effective," said Gregg Jacobs of the Sleep Disorders Center at Beth Israel Deaconess Medical Center, lead author of the study.
Jacobs said sleeping pills should be prescribed mainly for people whose insomnia is caused by an event or illness, such as jet lag from a long trip or the side effects of chemotherapy. Other insomniacs, he said, are staying awake in part because of bad sleep habits that a behavior therapist can best help to change.
Therapists' advice typically includes such basics as going to bed only when drowsy and getting up at the same time every day, even after a poor night's sleep. The objective is to get insomniacs to unlearn bad habits such as paying bills in bed, worrying instead of sleeping, and keeping themselves awake at night with coffee and strenuous exercise.
Dr. Carl Hunt, director of the National Center on Sleep Disorders Research, said the new study, one of the first to directly compare the benefits of talk therapy and medication, expands on recent research suggesting that therapy should play a larger role in the battle for a better night's sleep. The most popular prescription medications, Ambien and Sonata, have federal approval only for short-term use, he said, making therapy the preferred treatment for long-term insomnia.
But a sleep specialist for one of the drugmakers said the Harvard study has limited application for doctors who treat sleeplessness, noting that patients in the research had all suffered insomnia for at least six months.
"The vast majority of people have insomnia that is far more short-lived than that," said Dr. Steven James, neuropsychiatry consultant to
National Sleep Foundation surveys indicate that Americans are sleeping less -- and more fitfully -- today than 20 years ago, which sleep specialists say is probably driven by the rise of late-night distractions such as cable television and the Internet, as well as long and irregular workweeks. Nearly a third of adults say they have no set sleeping schedule, for instance, which sleep specialists say makes sleeplessness more likely.
Despite the medical understanding that lifestyle factors contribute heavily to insomnia, Jacobs said doctors still overwhelmingly prescribe medication to treat sleeplessness. And although Sanofi-Aventis, maker of Ambien, emphasizes that the drug should be taken for no more than a month, doctors commonly prescribe it for long-term use, he said.
"It is very disconcerting to see the number of patients who come in for treatment to my office who are not only taking sleeping pills long-term -- meaning years -- but they are on multiple sleeping pills," said Jacobs, author of "Say Goodnight to Insomnia," a book critical of the effectiveness of sleeping pills.
In the new study, published in today's edition of the Archives of Internal Medicine, Jacobs and his colleagues divided 63 chronic insomniacs into four groups receiving either Ambien, five therapy sessions, a combination of the two, or a placebo. The patients kept a sleep diary for eight weeks, recording such factors as how long it took to fall asleep and how long they were awake during the night. Researchers acknowledge that such diaries are subjective, but as long as the patient is consistent, they are useful for comparison purposes.
The researchers found that therapy was most effective for shortening the time it took patients to fall asleep, from 67.9 minutes a night on average to a near-normal 34.1 minutes after eight weeks. The Ambien patients, by contrast, reduced sleep onset time only from 71.5 minutes to 58.7 minutes. Likewise, after therapy patients awoke much less frequently in the night, sleeping 83.5 percent of the time they were in bed compared with 67.2 percent for those taking Ambien.
Sanofi-Aventis issued a statement saying patients should try lifestyle changes before obtaining a prescription.
"We recommend that patients talk to their physician about their sleeping habits and keep a sleep diary to determine if lifestyle or behavioral changes might work for them," the statement said.
Stacia Sailer, codirector of the sleep disorders clinic at UMass Memorial Medical Center in Worcester, said the Harvard research confirms what she and others already champion. She said therapists recommend simple changes such as getting out of bed rather than tossing and turning, or treating the bed as a place only for sleep and sex.
Scott Allen can be reached via e-mail at allen@globe.com
