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Behavioral and Pharmacological Therapies for Late-Life Insomnia: A Randomized Controlled Trial

Morin, Charles M., Colecchi, Cheryl, Stone, Jackie, Sood, Rakesh, Brink, Douglas·1999·JAMA
DOI 10.1001/jama.281.11.991
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Abstract

CONTEXT: Insomnia is a prevalent health complaint in older adults. Behavioral and pharmacological treatments have their benefits and limitations, but no placebo-controlled study has compared their separate and combined effects for late-life insomnia. OBJECTIVE: To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for late-life insomnia. DESIGN AND SETTING: Randomized, placebo-controlled clinical trial, at a single academic medical center. Outpatient treatment lasted 8 weeks with follow-ups conducted at 3, 12, and 24 months. SUBJECTS: Seventy-eight adults (50 women, 28 men; mean age, 65 years) with chronic and primary insomnia. INTERVENTIONS: Cognitive-behavior therapy (stimulus control, sleep restriction, sleep hygiene, and cognitive therapy) (n = 18), pharmacotherapy (temazepam) (n = 20), or both (n = 20) compared with placebo (n = 20). MAIN OUTCOME MEASURES: Time awake after sleep onset and sleep efficiency as measured by sleep diaries and polysomnography; clinical ratings from subjects, significant others, and clinicians. RESULTS: The 3 active treatments were more effective than placebo at posttreatment assessment; there was a trend for the combined approach to improve sleep more than either of its 2 single components (shorter time awake after sleep onset by sleep diary and polysomnography). For example, the percentage reductions of time awake after sleep onset was highest for the combined condition (63.5%), followed by cognitive-behavior therapy (55%), pharmacotherapy (46.5%), and placebo (16.9%). Subjects treated with behavior therapy sustained their clinical gains at follow-up, whereas those treated with drug therapy alone did not. Long-term outcome of the combined intervention was more variable. Behavioral treatment, singly or combined, was rated by subjects, significant others, and clinicians as more effective than drug therapy alone. Subjects were also more satisfied with the behavioral approach. CONCLUSIONS: Behavioral and pharmacological approaches are effective for the short-term management of insomnia in late life; sleep improvements are better sustained over time with behavioral treatment.

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  • Short-term pharmacological treatments alone are effective during the course of treatment for chronic insomnia.

    “short-term pharmacological treatments alone are effective during the course of treatment for chronic insomnia”

    From Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008) · cites this paper as [66]

  • Taken as a whole, these investigations do not demonstrate a clear advantage for combined treatment over cognitive behavioral treatment alone.

    “Taken as a whole, these investigations do not demonstrate a clear advantage for combined treatment over cognitive behavioral treatment alone. 65,66,68-70”

    From Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008) · cites this paper as [66]

  • Short-term pharmacological treatments alone do not provide sustained improvement following discontinuation.

    “but do not provide sustained improvement following discontinuation, 65,66”

    From Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008) · cites this paper as [66]

  • Cognitive Behavioral Therapy for Insomnia does not carry the risks of prescription hypnotic medications and is therefore preferable for reasons beyond demonstrated efficacy, efficacy relative to medications, and effectiveness.

    “The recommended first-line treatment, Cognitive Behavioral Therapy for Insomnia (CBTI) does not carry these risks and is therefore preferable for reasons beyond demonstrated efficacy(244-248), efficacy relative to medications(249-253), and effectiveness(254).”

    From Sleep: important considerations for the prevention of cardiovascular disease (2016) · cites this paper as [252]

  • The trials compared CBT-I to zopiclone, zolpidem, temazepam, and triazolam.

    “The trials compared CBT-I to zopiclone [29], zolpidem [30], temazepam [31,32], and triazolam [33].”

    From Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review (2012) · cites this paper as [31]

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Authors
Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D.
Affiliations
Université Laval (CA)
ORCID
Morin, Charles M.
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
1999-03-17
Volume
281
Issue
11
Pages
991
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.281.11.991
OpenAlex
W2079808059
Cited by
1,095
References
31
Citations by year
2026: 19 · 2025: 20 · 2024: 19 · 2023: 26 · 2022: 29 · 2021: 33 · 2020: 36 · 2019: 39 · 2018: 34 · 2017: 40 · 2016: 41 · 2015: 48 · 2014: 51 · 2013: 43 · 2012: 53
FWCI
57.16
Type
journal article
Language
en
Open access
closed
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health (5r29mh047020-05)
  • National Institute of Mental Health (MH47020)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
  • Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Circadian rhythm and melatonin
Keywords
cognitive behavioral therapy for insomnia, temazepam, sleep restriction, stimulus control, sleep hygiene, cognitive therapy, sleep efficiency, older adults, long-term treatment outcomes, patient satisfaction
MeSH terms
Aged, Analysis of Variance, Behavior Therapy, Chronic Disease, Combined Modality Therapy, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Temazepam, Anti-Anxiety Agents, Cognitive Behavioral Therapy, Polysomnography

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