Psychological and pharmacological approaches to treating insomnia: Critical issues in assessing their separate and combined effects

This paper reviews the efficacy of psychological and pharmacological therapies, singly and combined, for treating insomnia. Their clinical usefulness are discussed in terms of short- and long-term outcomes, patientʹs acceptance and adherence to treatment, and cost-benefits/effectiveness. Psychological interventions, mostly cognitive-behavioral in content, produce reliable and durable improvements of sleep patterns in about 60–80% of patients with chronic and primary insomnia. Pharmacotherapy, especially benzodiazepine receptor agents, are effective for short-term usage, but there is little evidence of sustained benefits after drug tapering. Hypnotic medications are not recommended as the sole intervention. Combined approaches have yielded more favorable short-term outcomes relative to drug therapy alone, but not necessarily superior to behavioral treatment alone. Long-term outcomes of combined approaches have been mixed, with no clear advantage to adding sleep medication to behavioral interventions. Additional research is needed to evaluate the effectiveness of integrated biobehavioral approaches, particularly multifaceted, sequential methods that might be more cost-effective than any single approach alone. The high costs associated with insomnia, and its long-term consequences point to the benefits of early interventions, both in terms of maintaining quality of life and in reducing health care costs.