Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial

Lucie Baillargeon, Philippe Landreville, René Verreault, Jean-Pierre Beauchemin, Jean-Pierre Grégoire, Charles M Morin, Lucie Baillargeon, Philippe Landreville, René Verreault, Jean-Pierre Beauchemin, Jean-Pierre Grégoire, Charles M Morin

Abstract

Background: Long-term use of hypnotics is not recommended because of risks of dependency and adverse effects on health. The usual clinical management of benzodiazepine dependency is gradual tapering, but when used alone this method is not highly effective in achieving long-term discontinuation. We compared the efficacy of tapering plus cognitive-behavioural therapy for insomnia with tapering alone in reducing the use of hypnotics by older adults with insomnia.

Methods: People with chronic insomnia who had been taking a benzodiazepine every night for more than 3 months were recruited through media advertisements or were referred by their family doctors. They were randomly assigned to undergo either cognitive-behavioural therapy plus gradual tapering of the drug (combined treatment) or gradual tapering only. The cognitive-behavioural therapy was provided by a psychologist in 8 weekly small-group sessions. The tapering was supervised by a physician, who met weekly with each participant over an 8-week period. The main outcome measure was benzodiazepine discontinuation, confirmed by blood screening performed at each of 3 measurement points (immediately after completion of treatment and at 3- and 12-month follow-ups).

Results: Of the 344 potential participants, 65 (mean age 67.4 years) met the inclusion criteria and entered the study. The 2 study groups (35 subjects in the combined treatment group and 30 in the tapering group) were similar in terms of demographic characteristics, duration of insomnia and hypnotic dosage. Immediately after completion of treatment, a greater proportion of patients in the combined treatment group had withdrawn from benzodiazepine use completely (77% [26/34] v. 38% [11/29]; odds ratio [OR] 5.3, 95% confidence interval [CI] 1.8-16.2; OR after adjustment for initial benzodiazepine daily dose 7.9, 95% CI 2.4-30.9). At the 12-month follow-up, the favourable outcome persisted (70% [23/33] v. 24% [7/29]; OR 7.2, 95% CI 2.4-23.7; adjusted OR 7.6, 95% CI 2.5-26.6); similar results were obtained at 3 months.

Interpretation: A combination of cognitive-behavioural therapy and benzodiazepine tapering was superior to tapering alone in the management of patients with insomnia and chronic benzodiazepine use. The beneficial effects were sustained for up to 1 year. Applying this multidisciplinary approach in the community could help reduce benzodiazepine use by older people.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/236226/bin/10FF1.jpg
Fig. 1: Flow of patients through a randomized trial of cognitive-behavioural therapy combined with tapering of benzodiazepine use. In the combined treatment group, one patient who completed the treatment was lost to follow-up by the time of the 3-month evaluation. For one additional patient in this group, information about benzodiazepine withdrawal was obtained at 12-month follow-up, but data for the variable “dosage reduction of 50% or more” was not available at that time. Of the 6 subjects who did not complete the tapering-alone treatment, 5 agreed to be contacted at the 3-month and 12-month follow-ups to report on benzodiazepine cessation.

References

    1. Mellinger GD, Balter MB, Uhlenhuth EH. Insomnia and its treatment. Arch Gen Psychiatry 1985;42:225-32.
    1. Hohagen F, Käppler C, Schramm E, Rink K, Weyerer S, Riemann D, et al. Prevalence of insomnia in elderly general practice attenders and the current treatment modalities. Acta Psychiatr Scand 1994;90:102-8.
    1. Morgan K, Clarke D. Longitudinal trends in late-life insomnia: implications for prescribing. Age Ageing 1997;26:179-84.
    1. Henderson S, Jorm AF, Scott R, Mackinnon AJ, Christensen H, Korten AE. Insomnia in the elderly: its prevalence and correlates in the general population. Med J Aust 1995;162:22-4.
    1. Ohayon MM, Caulet M. Psychotropic medication and insomnia complaints in two epidemiological studies. Can J Psychiatry 1996;41:457-64.
    1. Kupfer DJ, Reynolds CF. Management of insomnia. N Engl J Med 1997; 336: 341-6.
    1. Longo LP, Johnson B. Addiction: Part 1. Benzodiazepines: side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-8.
    1. Matalon A, Yinnon AM, Hurwitz A. Chronic uses of hypnotics in a family practice: patients' reluctance to stop treatment. Fam Pract 1990;7:258-60.
    1. Lader MH. Limitations on the use of benzodiazepines in anxiety and insomnia: Are they justified? Eur Neuropsychopharmacol 1999;9(Suppl 6):S399-S405.
    1. Sorock GS, Shimkin EE. Benzodiazepine sedatives and the risk of falling in a community-dwelling elderly cohort. Arch Intern Med 1988;148:2441-4.
    1. Ray WA, Griffin MR, Schaffner W, Bauth DK, Melton LJ. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987;316:363-9.
    1. Hemmelgarn B, Suissa S, Huang A, Boivin JF, Pinard G. Benzodiazepine use and the risk of motor vehicle crash in the elderly. JAMA 1997;278:27-31.
    1. Insomnia Consensus Conference. Drugs and insomnia. The use of medications to promote sleep. JAMA 1984;251:2410-4.
    1. Dunbar GC, Perera MH, Jenner FA. Patterns of benzodiazepine use in Great Britain as measured by a general population survey. Br J Psychiatry 1989; 155: 836-41.
    1. Schweizer E, Case WG, Rickels K. Benzodiazepine dependence and withdrawal in elderly patients. Am J Psychiatry 1989;146:529-31.
    1. Rickels K, Schweizer E, Case WG, Greenblatt DJ. Long-term therapeutic use of benzodiazepines. I. Effects of abrupt discontinuation. Arch Gen Psychiatry 1990;47:899-907.
    1. Friedman L, Bliwise DL, Yesavage JA, Salom SR. A preliminary study comparing sleep restriction and relaxation treatments for insomnia in older adults. J Gerontol 1991;46:P1-8.
    1. Morin CM, Azrin NH. Behavioral and cognitive treatments of geriatric insomnia. J Consult Clin Psychol 1988;56:748-53.
    1. Engle-Friedman M, Bootzin R, Hazlewood L, Tsao C. An evaluation of behavioral treatments for insomnia in the older adult. J Clin Psychol 1992;48:77-90.
    1. Anderson MW, Zendell SM, Rosa DP, Rubinstein ML, Herrera CO, Simons O, et al. Comparison of sleep restriction therapy and stimulus control in older insomniacs: an update [abstract]. Sleep Res 1988;17:144.
    1. Puder R, Lacks P, Bertelson AD, Storandt M. Short-term stimulus control treatment of insomnia in older adults. Behav Ther 1983;14:424-9.
    1. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999;281:991-9.
    1. Lichstein KL, Johnson RS. Relaxation for insomnia and hypnotic medication use in older women. Psychol Aging 1993;8:103-11.
    1. American Sleep Disorders Association. The international classification of sleep disorders. Lawrence (TX): Allen Press; 1990.
    1. Teng EL, Chui HC. The modified mini-mental state (3MS) examination. JClin Psychiatry 1987;48:314-7.
    1. Hébert R, Bravo G, Girouard D. Validation de l'adaptation française du modified mini-mental state (3MS). Rev Gériatr 1992;17:443-50.
    1. Spielberger CD. Manual for the State-Trait Anxiety Inventory(Form Y). Palo Alto (CA): Consulting Psychologist Press; 1983.
    1. Gauthier J, Bouchard S. Adaptation canadienne-française de la forme révisée du State-Trait Anxiety Inventory de Spielberger. Can J Behav Sci 1993;25: 559-78.
    1. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982-83;17(1):37-49.
    1. Bourque P, Blanchard L, Vézina J. Étude psychométrique de l'échelle de dépression gériatrique. Can J Aging 1990;9:348-55.
    1. Morin CM. Insomnia: psychological assessment and management. New York: Guilford Press; 1993.
    1. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep 1987;10:45-56.
    1. Bootzin RR, Epstein D, Wood JM. Stimulus control instructions. In: Hauri P, editor. Case studies in insomnia. New York: Plenum; 1991. p. 19-28.
    1. Glovinsky PB, Spielman AJ. Sleep restriction therapy. In: Hauri P, editor. Case studies in insomnia. New York: Plenum; 1991. p. 49-63.
    1. Jennings W. Analytical gas chromatography. San Diego: Academic Press; 1987.
    1. Greenblatt DJ, Franke K, Shader RI. Analysis of lorazepam and its glucuronide metabolite by electron-capture gas-liquid chromatography. J Chromatogr 1978;146:311-20.
    1. Riedel BW, Lichstein KL, Peterson BA, Epperson MT, Means MK, Aguillard RN. A comparison of the efficacy of stimulus control for medicated and non medicated insomniacs. Behav Modif 1998;22:3-28.
    1. Morin CM, Stone J, McDonald K, Jones S. Psychological management of insomnia: a clinical replication series with 100 patients. Behav Ther 1994; 25: 291-309.
    1. Morin CM, Colecchi CA, Ling WD, Sood RK. Cognitive behavior therapy to facilitate benzodiazepine discontinuation among hypnotic-dependent patients with insomnia. Behav Ther 1995;26:733-45.
    1. Onyett SR, Turpin G. Benzodiazepine withdrawal in primary care: a comparison of behavioral group training and individual sessions. Behav Psychother 1988; 16: 297-312.
    1. Murphy SM, Tyrer P. A double-blind comparison of the effects of gradual withdrawal of lorazepam, diazepam and bromazepam in benzodiazepine dependence. Br J Psychiatry 1991;158:511-6.
    1. Romach MK, Kaplan HL, Busto UE, Somer G, Sellers EM. A controlled trial of ondansetron, a 5-HT3 antagonist, in benzodiazepine discontinuation. J Clin Psychopharmacol 1998;18:121-31.
    1. Rickels K, Case WG, Schweizer E, Garcia-Espana F, Fridman R. Long-term benzodiazepine users 3 years after participation in a discontinuation program. Am J Psychiatry 1991;148:757-61.
    1. Shapiro CM, Sherman D, Peck DF. Withdrawal from benzodiazepines by initially switching to zopiclone. Eur Psychiatry 1995;10(Suppl 3):145s-151s.
    1. Coates TJ, Killen JD, George J, Marchini E, Silverman S, Toresen C. Estimating sleep parameters: a multitrait-multimethod analysis. J Consult Clin Psychol 1982;50:345-52.
    1. Hoch CC, Reynolds CF, Kupfer DJ, Berman SR, Houck PR, Stack JA. Empirical note: self-report versus recorded sleep in healthy seniors. Psychophysiology 1987;24:293-9.
    1. Spiegel R. Subjective sleep assessment and polygraphic criteria. In: Sleep and sleeplessness in advanced age. Vol. 5 of Advances in sleep research series (Weitzman ED, editor). New York: Spectrum; 1981. p. 169-88.
    1. Nüesch E, Spiegel R. Objective correlates of subjective sleep assessments in young and elderly subjects. In: Koela WP, Levin P, editors. Sleep 1976: 3rd European Congress on Sleep Research. New York and Basel: Karger; 1977. p. 281-5.
    1. Lacks P, Morin CM. Recent advances in the assessment and treatment of insomnia. J Consult Clin Psychol 1992;60:586-94.
    1. Morin CM, Kowatch RA, Barry T, Walton E. Cognitive-behavior therapy for late-life insomnia. J Consult Clin Psychol 1993;61:137-46.
    1. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized controlled trial. J Am Geriatr Soc 1999;47:850-3.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren