June 2007

rTMS: Inferior to ECT?
Repetitive transcranial magnetic stimulation (rTMS) is not as efficacious as electroconvulsive therapy (ECT) in patients referred for ECT.

Psychotropics and Fracture Risk
Patients (especially elderly ones) taking psychiatric medications are at increased risk for fractures.

Riluzole Augmentation for Depression
Preliminary evidence suggests riluzole (Rilutek) may be helpful in treating mood and anxiety disorders.

CBT Beats Zopiclone for Insomnia in Elderly
Cognitive behavioral therapy (CBT) was superior to zopiclone (Ambien) for chronic primary insomnia.

Alternative Medicines Are Commonly Used
Surveys show alternative medicines used by more than half of US population.

Hyponatremia with Antidepressants
Hyponatremia reported in patients treated with escitalopram (Lexapro) or duloxetine (Cymbalta).

In Brief
Dosing Strategies for Risperidone Long-Acting Injection; Deaths Associated with Methadone Treatment for Pain

Prolactin Levels and Associated Side Effects with Risperidone
Initial elevation of prolactin levels with risperidone (Risperdal) returns to normal with long-term treatment.

Mifepristone for Psychotic Depression?
Treatment with mifepristone (Mifeprex) improves psychosis but not depression in patients with psychotic depression.

An NSAID for Schizophrenia?
Adjunctive celecoxib (Celebrex) may be beneficial for treating schizophrenia.

CBT Beats Zopiclone for Insomnia in Elderly

June 2007

Complaints about poor sleep occur in 9% to 25% of people 55 years and older.1 Insomnia has been associated with reduced quality of life and increased health services utilization. Many sufferers turn to over-the-counter medications or alcohol. Primary care physicians tend to prescribe hypnotic drugs or sedating antidepressants (BTP 2005;28:48-50). These medications are limited in efficacy and raise safety issues, particularly for elderly people (BTP 2005;28:33). An increase in the use of zolpidem (Ambien) in the United States was associated with next-day sleepiness and traffic accidents.2 A National Institutes of Health consensus panel concluded that antidepressants are overprescribed for insomnia while psychosocial approaches, such as cognitive behavioral therapy (CBT), should be prescribed more often.3

Sivertsen and coworkers in Norway compared CBT and the hypnotic zopiclone* to treat chronic primary insomnia in older adults.1 Subjects were 22 women and 24 men at least 55 years old (mean age, 60.8 ± 5.4 years). The mean duration of primary insomnia was 14.1 ± 11.3 years. In double-blind fashion, subjects were randomly assigned to either CBT; zopiclone, 7.5 mg nightly; or placebo. Treatment lasted for 6 weeks, and patients who took one of the two active treatments were followed up at 6 months.

Patients receiving CBT spent significantly less time awake (P < .001) than those who took zopiclone after 6 weeks of treatment. The total wake time was reduced by 52% in the CBT group versus 4% with zopiclone. CBT showed a trend for superiority in sleep efficiency as well, and patients receiving CBT had significantly more slow wave sleep (stages 3 and 4) (P = .002) than those who took zopiclone. At 6 months follow-up, total sleep time had increased significantly in the CBT group (P = 0.5), with no change in the zopiclone group.

Data from this and earlier studies suggest that CBT for chronic primary insomnia should become more widely available. It seems to be safe and effective and to have long-term benefits, in contrast with hypnotic medications. As we have noted previously, the quantitative benefits of hypnotic medications tend to be modest, and they carry adverse effects, especially in the elderly. Whenever possible, then, a nonpharmacologic approach, such as CBT, should be offered first for patients with chronic primary insomnia, with "sleeping pills" reserved as a second-line option.

*Racemic zopiclone is not available in the United States. However, the stereoisoform, eszopiclone, is now available as Lunesta.

1Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, Nielsen GH, Nordhus IH: Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. JAMA 2006;295:2851-2858.

2Stuever H: Snooze alarm: The pill that drove us to sleep. Washington Post May 6, 2006:C01.

3Lamberg L: Physicians underprescribe best insomnia treatments. Psychiatr News 2005;40:30.