Insomnia poses significant challenges to individuals and society due to its 24-hour impact on nocturnal and daytime functioning. Recommended treatments include cognitive behavioral therapy (CBT) and medications, but data on the efficacy of medications for daytime functioning are limited. While CBT primarily targets sleep continuity, its impact on daytime symptoms remains modest. Comparative studies on the efficacy of CBT and medications for insomnia-related daytime symptoms yield mixed results. A randomized clinical trial with a sequential multiple assignment design, comparing four treatment sequences comprising psychological therapies (behavioral therapy and cognitive therapy) and medications (zolpidem and trazodone), explored optimal treatments for improving daytime functions in insomnia patients (Figure 1). Participants, totaling 211 adults with chronic insomnia, were randomly assigned to behavioral therapy (BT) or zolpidem for the first stage, followed by a second-stage treatment for non-remitters of cognitive therapy (CT) or trazodone. At baseline, 35% of participants had a comorbid psychiatric disorder (e.g., anxiety and depression) and 17% were using psychotropic medications. Outcome measures included mood disturbances, fatigue, functional impairments, and health-related quality of life. Results indicated that both BT and zolpidem are effective in reducing daytime symptoms, with no significant differences between groups after the first stage. The addition of second-stage therapy provide added value, particularly for sequences starting with zolpidem, which exhibit immediate effects. Sequences beginning with BT show delayed effects, especially at the 12-month follow-up (Figure 1). Limitations of this study include the absence of a control condition and underrepresentation of racial and ethnic minority groups in the study population which may limit the generalizability of the findings. Overall, the use of zolpidem or BT is effective for daytime symptoms of insomnia as a first therapy. Switching therapies for non-remitters may provide added immediate or delayed effects depending on the treatment strategy.
Morin CM et al. JAMA Netw Open 2023;6(12):e2349638. Abstract.