To the Editor: In their randomized controlled trial, Dr Morin and colleagues1 demonstrated the superiority of cognitive behavioral therapy (CBT) alone over CBT combined with intermittent, as-needed use of zolpidem for extended treatment of insomnia. These results should not be surprising.
Cognitive behavioral therapy for insomnia involves cognitive restructuring (whereby maladaptive thoughts are analyzed and replaced by more adaptive thoughts) and exposure response prevention (whereby patients learn not to respond maladaptively to feared situations). For instance, a maladaptive thought such as “If I don't sleep well tonight, tomorrow will be a disaster” may be replaced with the more adaptive “If I don't sleep well tonight, I would likely not be at my best tomorrow morning, but I have a lot of experience functioning with little sleep, so I will be okay.” Similarly, a therapist may review sleep physiology with patients so they will appreciate that a poor night's sleep is usually followed by better sleep on the next night and they do not have to take sleeping medication for occasional poor sleep. In the management of insomnia, use of an intermittent, as-needed hypnotic such as zolpidem can undo the exposure response prevention learned as part of CBT. The effectiveness of CBT is improved when patients have confidence in what they learn during CBT.