In Brief

Forget counting sheep. Behavioral therapy and pharmacotherapy work better for treating persistent insomnia. Interestingly, both methods work equally as well, finds a meta-analysis by University of Rochester psychologists.

The research, led by Michael T. Smith, PhD, and Michael Perlis, PhD, reviewed 21 studies of a total of 470 participants and compared the short-term outcomes of people with insomnia who were treated with benzodiazepines or benzodiazepine-receptor agonists with those receiving behavioral sleep therapies, including stimulus control, which reduces the anxiety associated with falling asleep, and sleep restriction, which reduces the time spent in bed to increase sleep efficiency.

Overall, pharmacological treatment reduced the time it took participants to fall asleep by 30 percent, compared with a 43 percent reduction by behavioral interventions. Both treatments eliminated about one awakening each night. Wake time after sleep onset--how long a person is awake in the middle of the night--was reduced by 46 percent with pharmacotherapy and 56 percent with behavioral therapy. Both therapies increased the participants' total sleep time: pharmacotherapy by 12 percent and behavioral therapy by 6 percent. Sleep quality improved by 20 percent with pharmacotherapy and 28 percent with behavioral interventions.

"Under optimal conditions, in which patients choose their method of treatment, the behavioral and pharmacotherapeutic treatments yield equivalent outcomes," write the authors. "The question, then, is which treatment modality should be used?" Pharmacotherapy may be best for situations where immediately reducing a patient's insomnia symptoms is most important, say the researchers, while behavioral therapy may be more appropriate for a long-term fix or when there is the potential for drug interaction or a history of substance abuse.

Ultimately, they point out, the difference in treatment cost is likely to be a deciding factor: A 35-day trial of a sleep-inducing drug can cost about $166, while five weeks of behavioral treatment cost about $350, the authors write. On the other hand, the researchers caution that cost-benefit analyses must also consider that insomnia symptoms can return when pharmacological treatment is discontinued, while behavioral interventions have been proven effective up to two years later.

"The article chips away at that common myth that drug therapies are always more potent than behavioral treatments," says Smith. "It shows that behavior therapy for chronic insomnia should be a first-line treatment, which is currently not the case."

The paper, "Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia," appears in the January 2002 American Journal of Psychiatry.