Sleep Med 2006 May 13; (Read article online)

Lichstein KL

BACKGROUND AND PURPOSE: Patients with hypnotic-dependent insomnia and those with secondary (comorbid) insomnia have previously been regarded as being unsuitable for inclusion in studies of cognitive behavioral therapy (CBT). This paper reviews CBT clinical trials that have mainly been published in the past 15 years with these two disorders. PATIENTS AND METHODS: CBT studies that targeted patients taking sleep medication and exhibiting current insomnia qualified for hypnotic-dependent insomnia and patients with comorbid conditions that presented a high risk of producing insomnia such as depression and chronic pain were included as secondary insomnia. RESULTS: In recent years, studies in patients with hypnotic-dependent insomnia have shown that supervised hypnotic gradual withdrawal programs can reduce patients' use of hypnotic medications and, when combined with CBT, can also significantly improve parameters such as sleep-onset latency and sleep efficiency. Secondary, or comorbid, insomnia accounts for 60% of all cases of insomnia. A number of reports now show that CBT can lead to improvements in sleep efficiency, latency and quality in a wide range of medical and psychiatric conditions, with similar improvements being seen regardless of the primary disorder. Indeed, it is now believed that insomnia should not be considered as 'secondary' to other causes, pariticularly in patients with chronic illness. In these individuals, the secondary component of insomnia is likely to be greatly reduced, particularly by the time they are referred to a sleep specialist. CONCLUSIONS: Previous theory-based beliefs that hypnotic-dependent insomnia and secondary insomnia were unresponsive to CBT intervention have been shown to be unfounded. Data support the psychological treatment of both these conditions.