Patient education and side effects

In many instances in clinical practice, education about the adverse effects of long-term hypnotic use has motivated a patient to discontinue medication. The adverse effects of benzodiazepine-like receptor agonists, including impaired psychomotor functioning,14as well as potential tolerance, rebound effects, dependence, and withdrawal, and other unknown long-term side effects10should be emphasized as part of a behavioral strategy to limit hypnotic use.

Patients should also be aware that the efficacy of hypnotics is limited, as those who report chronic hypnotic use still often report poor quality of sleep and frequent sleep disturbances.15Many patients report improved sleep quality when discontinuing long-term use of hypnotics.16

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Behavioral therapy

Although hypnotics are effective in the short term, cognitive behavioral therapy for insomnia (CBT-I) is not only safer but also more effective as a long-term treatment for patients with insomnia, compared with nonbenzodiazepines and benzodiazepines,17,18,19and is therefore recommended as a first-line therapy.17Patients with insomnia who report chronic hypnotic use still often report poor quality of sleep and frequent sleep disturbances.15Although the effects of hypnotics are limited due to tolerance, cognitive behavioral therapy produces more sustainable effects for maintenance after hypnotics are discontinued.18,20

Cognitive behavioral therapy for insomnia is designed to incorporate behavioral changes in the long-term treatment of insomnia. These strategies include teaching patients improved sleeping habits, discouraging dysfunctional thoughts about sleeping, and encouraging mindfulness.17,19Other behavioral-based therapies, including stimulus control therapy, relaxation strategies, sleep restriction, and sleep hygiene (including setting a regular bedtime and wake-up time and other lifestyle advice)19have also been shown to help the discontinuation of chronic hypnotic use.2

Implementing CBT in primary care

The feasibility of implementing cognitive behavioral therapy, rather than its efficacy, is the greatest challenge with insomnia management in primary care.21Several studies have demonstrated that cognitive behavioral therapy is effectively performed in the primary care setting using brief interventions.2,19,22One randomized controlled trial demonstrated that trained nurses were able to deliver cognitive behavioral therapy to patients with insomnia in general practice with post-treatment improvements in sleep latency.19

Another study demonstrated that behavioral health consultants, including clinical psychologists and social workers, effectively delivered brief CBT-I interventions in the primary care setting to reduce insomnia symptoms.22

In a randomized controlled trial in general practice settings, cognitive behavioral therapy was effective in reducing chronic insomnia in patients with repeated chronic use of hypnotics.15These symptomatic improvements, including an improved quality of life and reduced or no use of hypnotic medications, were sustained for at least one year following the intervention.15