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December 24, 1997, Vol 278, No. 24 >
ARTICLE | December 24, 1997

Benzodiazepines and Zolpidem for Chronic Insomnia: Title and subTitle BreakA Meta-analysis of Treatment Efficacy FREE

Peter D. Nowell, MD; Sati Mazumdar, PhD; Daniel J. Buysse, MD; Mary Amanda Dew, PhD; Charles F. Reynolds, III, MD; David J. Kupfer, MD
[+] Author Affiliations

Presented at the 10th annual meeting of the Association of Professional Sleep Societies, Washington, DC, June 1, 1996.

Reprints: Peter D. Nowell, MD, Western Psychiatric Institute and Clinic, 3811 O'Hara St, Pittsburgh, PA 15215.


JAMA. 1997;278(24):2170-2177. doi:10.1001/jama.1997.03550240060035
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References

Objective.  —To evaluate the efficacy of benzodiazepines and zolpidem tartrate in chronic insomnia based on a quantitative review of literature.

Data Sources.  —Articles from 1966 to 1996 were identified using MEDLINE, by a manual review of relevant journals, and from bibliographies of identified articles.

Study Selection.  —Studies using randomized, double-blind, placebo-controlled, parallel or crossover designs with benzodiazepines or zolpidem in adults younger than 65 years with chronic insomnia (modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for primary insomnia) were selected for review. Self-report and polysomnographic measures of sleep-onset latency, total sleep time, number of awakenings, and sleep quality were selected as outcomes.

Data Extraction.  —Twenty-two studies met the selection criteria. A combined test of P values was performed, pooling broadly from the 22 studies to determine whether medication was superior to placebo. A combined test of effect sizes was performed on the subset of studies that reported effect size information to determine the magnitude of medication effect.

Data Synthesis.  —A homogeneous sample of studies summarized 1894 patients treated for a median duration of 7 days. The combined test of P values demonstrated that medication was superior to placebo in all 4 outcome measures. Treatment response was moderate in magnitude by the combined test of effect sizes.

Conclusions.  —Benzodiazepines and zolpidem produced reliable improvements in commonly measured parameters of sleep in patients with chronic insomnia. Relative to the chronic and recurring course of insomnia, both the limited duration of treatments studied and the lack of follow-up data from controlled trials represent challenges for developing evidence-based guidelines for the use of hypnotics in the management of chronic insomnia.

REFERENCES

1 +
Mellinger GD, Balter MB, Uhlenhuth EH.  Insomnia and its treatment: prevalence and correlates . Arch Gen Psychiatry . 1985;;42:225-232.
2 +
Baiter MB, Uhlenhuth EH.  New epidemiologic findings about insomnia and its treatment . J Clin Psychiatry . 1992;;53( (suppl) ):34-39.
3 +
Stoller MK.  Economic effects of insomnia . Clin Ther . 1994;;16:873-97. Review Discussion 854.
4 +
Walsh JK, Engelhardt CL, Hartman PG.  The direct economic cost of insomnia . In: Hypnotics and Anxiolytics: Bailliere's Clinical Psychiatry . London, England: Bailliere Tindall; 1995;.
5 +
Kales A, Caldwell AB, Soldatos CR, Bixler EO, Kales JD.  Biopsychobehavioral correlates of insomnia, II: pattern specificity and consistency with the Minnesota Multiphasic personality inventory . Psychosom Med . 1983;;45:341-356.
6 +
Tan TL, Kales JD, Kales A, Soldatos CR, Bixler EO.  Biopsychobehavioral correlates of insomnia, IV: diagnosis based on DSM-III . Am J Psychiatry . 1984;;141:357-362.
7 +
Schramm E, Hohagen F, Kappler C, Grasshoff U, Berger M.  Mental comorbidity of chronic insomnia in general practice attenders using DSM-III-R . Acta Psychiatr Scand . 1995;;91:10-17.
8 +
Gislason T, Almqvist M.  Somatic diseases and sleep complaints: an epidemiological study of 3201 Swedish men . Acta Med Scand . 1987;;221:475-481.
9 +
Vollrath M, Wicki W, Angst J.  The Zurich Study, VIII, insomnia: association with depression, anxiety, somatic syndromes, and course of insomnia . Eur Arch Psychiatry Clin Neurosci . 1989;;239:113-124.
10 +
Whorwell PJ, McCallum M, Creed FH.  Noncolonic features of irritable bowel syndrome . Gut . 1986;;27:37-40.
11 +
Johnson LC, Spinweber CL.  Good and poor sleepers differ in Navy performance . Mil Med . 1983;;148:727-731.
12 +
Mendelson WB, Garnett D, Linnoila M.  Do insomniacs have impaired daytime functioning? Biol Psychiatry . 1984;;19:1261-1264.
13 +
Mendelson WB, Garnett D, Gillin JC, Weingartner H.  The experience of insomnia and daytime and nighttime functioning . Psychiatry Res .1984;;12:235-250.
14 +
Sugarman JS, Stern JA, Walsh JK.  Daytime alertness in subjective and objective insomnia: some preliminary findings . Biol Psychiatry . 1985;;20:741-750.
15 +
Ford DE, Kamerow DB.  Epidemiologic study of sleep disturbances and psychiatric disorders . JAMA . 1989;;262:1479-1484.
16 +
Angst J, Vollrath M, Koch R, Dobler-Mikola A.  The Zurich Study, VII: insomnia: symptoms, classification and prevalence . Eur Arch Psychiatry Clin Neurosci . 1989;;238:285-293.
17 +
Ganguli M, Reynolds CF, Gilby JE.  Prevalence and persistence of sleep complaints in a rural older community sample: the movies project . J Am Geriatr Soc . 1996;;44:778-784.
18 +
Mendelson WB.  Long-term follow-up of chronic insomnia . Sleep . 1995;;18:698-701.
19 +
Bootzin RR, Perlis ML.  Nonpharmacologic treatments of insomnia . J Clin Psychiatry . 1992;;53 ( (suppl) ):37-41.
20 +
Hauri P.  Treating psychophysiologic insomnia with biofeedback . Arch Gen Psychiatry . 1981;;38:752-758.
21 +
Hauri P, Fisher J.  Persistent psychophysiologic (learned) insomnia . Sleep . 1986;;9:38-53.
22 +
Morin CM, Colecchi CA, Stone J, Sood RK, Brink D.  Cognitive-behavior therapy and pharmacotherapy for insomnia: update of a placebo-controlled clinical trial . Sleep Res . 1995;;24:303.
23 +
Kupfer DJ, Reynolds CF.  Management of insomnia . N Engl J Med . 1997;;336:341-346.
24 +
Bliwise DL.  Treating insomnia: pharmacological and nonpharmacological approaches . J Psychoactive Drugs . 1991;;23:335-341.
25 +
Woods JH, Winger G.  Current benzodiazepine issues . Psychopharmacology . 1995;;118:107-15. Review Discussion 118.
26 +
Linsen SM, Zitman FG, Breteler MH.  Defining benzodiazepine dependence: the confusion persists . European Psychiatry . 1995;;10:306-311.
27 +
Walsh JK, Engelhardt CL.  Trends in the pharmacologic treatment of insomnia . J Clin Psychiatry . 1992;;53( (suppl) ):10-7. Discussion 18.
28 +
Ware JC.  Tricyclic antidepressants in the treatment of insomnia . J Clin Psychiatry . 1983;;44:25-28.
29 +
Lilie JK, Lahmeyer H.  Psychiatric management of sleep disorders . Psychiatric Medicine . 1991;;9:245-260.
30 +
Pearce PL.  Trends in pharmacologic treatment of insomnia . J Clin Psychiatry . 1994;;55:163-164.
31 +
Staedt J, Stoppe G, Hajak G, Mullerstruck A, Ruther E.  Chronic insomnia: what should be done if minor tranzuilizers are no longer helpful? Fortschr Neurol Psychiatr . 1995;;63:368-372.
32 +
National Institute of Mental Health.  Consensus conference report: drugs and insomnia—the use of medication to promote sleep . JAMA . 1984;;251:2410-2414.
33 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;:551-607.
34 +
Diagnostic Classification Steering Committee T. International Classification of Sleep Disorders: Diagnostic and Coding Manual . Rochester, Minn: American Sleep Disorders Association; 1990;:27-38.
35 +
World Health Organization. Mental Disorders: Glossary and Guide to Their Classification in Accordance With the 9th Revision of the International Classification of Diseases . Geneva, Switzerland: World Health Organization; 1978;.
36 +
Kripke DF, Hauri P, Ancoli-Israel S, Roth T.  Sleep evaluation in chronic insomniacs during 14day use of flurazepam and midazolam . J Clin Psychopharmacol . 1990;;10( (suppl) ):32S-43S.
37 +
Hajak G, Clarenbach P, Fischer W, Haase W, Ruther E.  Zopiclone improves sleep quality and daytime well-being in insomniac patients: comparison with triazolam, flunitrazepam and placebo . Int Clin Psychopharmacol . 1994;;9:251-261.
38 +
Akerstedt T, Hume K, Minors D, Waterhouse J.  The subjective meaning of good sleep, an intraindividual approach using the Karolinska Sleep Diary . Percept Mot Skills . 1994;;79:287-296.
39 +
Carskadon M, Dement W, Mitler M, Guilleminault C, Zarcone V, Spiegel R.  Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia . Am J Psychiatry . 1976;;133:1382-1388.
40 +
Hunter JE, Schmidt FL, Jackson GB. Metaanalysis: Cumulating Research Findings Across Studies . Beverly Hills, Calif: Sage; 1982;:12-34.
41 +
Rosenthal R. Meta-analytic Procedure for Social Research . Beverly Hills, Calif: Sage; 1984;:93-216.
42 +
Morin CM, Culbert JP, Schwartz SM.  Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy . Am J Psychiatry . 1994;;151:1172-1180.
43 +
Murtagh DRR, Greenwood KM.  Identifying effective psychologicaltreatments for insomnia: a metaanalysis . J Consult Clin Psychol . 1995;;63:79-89.
44 +
Buysse DJ, Reynolds CF, Kupfer DJ, et al.  Clinical diagnoses in 216 insomnia patients using ICSD, and proposed DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV field trials . Sleep . 1994;;17:630-637.
45 +
Buysse DJ, Reynolds CF, Kupfer DJ, Mesiano D.  Does diagnosis affect treatment recommendations in insomnia patients? Sleep Res . 1993;;22:178.
46 +
Roth T, Roehrs T, Vogel G.  Zolpidem in the treatment of transient insomnia: a double-blind, randomized comparison with placebo . Sleep . 1995;;18:246-251.
47 +
Frankel BL, Coursey RD, Buchbinder R, Snyder F.  Recorded and reported sleep in chronic primary insomnia . Arch Gen Psychiatry . 1976;;33:615-623.
48 +
Roehrs T, Vogel G, Vogel F, et al.  Eligibility requirements in hypnotic trials . Sleep . 1985;;8:34-39.
49 +
Steinmark SW, Borkovec TD.  Active and placebo treatment effects on moderate insomnia under counterdemand and positive demand instructions . J Abnorm Psychol . 1974;;83:157-163.
50 +
Carr-Kaffashan L, Woolfolk RL.  Active and placebo effects in treatment of moderate and severe insomnia . J Consult Clin Psychol . 1979;;47:1072-1080.
51 +
Borkovec TD.  Insomnia . J Consult Clin Psychol . 1982;;50:890-895.
52 +
Reynolds CF, Nowell PD, Hoch CC, Neylan TC, Buysse DJ, Kupfer DJ. Diagnosis and treatment of insomnia in the elderly. In: Salzman C, ed. Clinical Geriatric Psychopharmacology. Baltimore, Md: Williams & Wilkins. In press.
53 +
Hoch CC, Dew MA, Reynolds CF, et al.  Longitudinal changes in diary- and laboratory-based sleep measures in health 'old old' and 'young old' subjects: a 3-year follow-up . Sleep . 1997;;20:192-202.
54 +
Greenblatt DJ.  Pharmacology of benzodiazepine hypnotics . J Clin Psychiatry . 1992;;53( (suppl) ):7-13.
55 +
Bangert-Drowns RL.  Review of developments in meta-analytic method . Psychol Bull . 1986;;99:388-399.
56 +
Rosenthal R, Rubin DB.  Meta-analytic procedures for combining studies with multiple effect sizes . Psychol Bull . 1986;;99:400-406.
57 +
Cohen J. Statistical Power Analysis for the Behavioral Sciences . New York, NY: Academic Press; 1977;.
58 +
Hedges LV, Olkin I. Statistical Methods for Meta-analysis . Orlando, Fla: Academic Press; 1985;.
59 +
Petitti DB. Meta-analysis, Decision Analysis, and Cost-effectiveness Analysis: Methods for Quantitative Synthesis in Medicine . New York, NY: Oxford University Press; 1994;:119-123.
60 +
Aden GC, Thatcher C.  Quazepam in the short-term treatment of insomnia in outpatients . J Clin Psychiatry . 1983;;44:454-456.
61 +
Cohn JB, Wilcox CS, Bremner J, Ettinger M.  Hypnotic efficacy of estazolam compared with flurazepam in outpatients with insomnia . J Clin Pharmacol . 1991;;31:747-750.
62 +
Cohn JB.  Double-blind crossover comparison of triazolam and lorazepam in the posthypnotic state . J Clin Psychiatry . 1984;;45:104-107.
63 +
Cuanang JR, Limos L.  Treatment of insomnia with temazepam: double-blind, placebo-controlled evaluation . Clin Ther . 1982;;4:402-412.
64 +
Declerck AC, Ruwe F, O'Hanlon JF, Vermeeren A, Wauquier A.  Effects of zolpidem and flunitrazepam on nocturnal sleep of women subjectively complaining of insomnia . Psychopharmacology . 1992;;106:497-501.
65 +
 Correction : Psychopharmacology . 1992;;109:254.
66 +
Melo de Paula AJ.  Comparative study of lormetazepam and flurazepam in the treatment of insomnia . Clin Ther . 1984;;6:500-508.
67 +
Dominguez RA, Goldstein BJ, Jacobson AF, Steinbook RM.  Comparative efficacy of estazolam, flurazepam, and placebo in outpatients with insomnia . J Clin Psychiatry . 1986;;47:362-365.
68 +
Elie R, Lavoie G, Bourgouin J, Le Morvan P.  Zopiclone versus flurazepam in insomnia: prolonged administration and withdrawal . Int Clin Psychopharmacol . 1990;;5:279-286.
69 +
Fabre LF Jr, Brachfeld J, Meyer LR, Slowe IA, Calvo R, Metzler C.  Multi-clinic double-blind comparison of triazolam (Halcion) and placebo administered for 14 consecutive nights in outpatients with insomnia . J Clin Psychiatry . 1978;;39:679-682.
70 +
Fillingim JM.  Double-blind evaluation of the efficacy and safety of temazepam in outpatients with insomnia . Br J Clin Pharmacol . 1979;;8( (suppl) ):73S-77S.
71 +
Herrmann WM, Kubicki ST, Boden S, Eich FX, Attali P, Coquelin JP.  Pilot controlled double-blind study of the hypnotic effects of zolpidem in patients with chronic learned insomnia: psychometric and polysomnographic evaluation . J Int Med Res . 1993;;21:306-322.
72 +
Hernandez-Lara R, Del Rosal PL, Ponce MC.  Short-term study of quazepam 15 milligrams in the treatment of insomnia . J Int Med Res . 1983;;11:162-166.
73 +
Linnoila M, Viukari M, Lamminsivu U, Auvinen J.  Efficacy and side effects of lorazepam, oxazepam, and temazepam as sleeping aids in psychogeriatric inpatients . Int Pharmacopsychiatry . 1980;;15:129-135.
74 +
Mendels J, Stern S.  Evaluation of the short-term treatment of insomnia in out-patients with 15 milligrams of quazepam . J Int Med Res . 1983;;11:155-161.
75 +
Monti JM, Attali P, Monti D, Zipfel A, de la Giclais B, Morselli PL.  Zolpidem and rebound insomnia—a double-blind, controlled polysomnographic study in chronic insomniac patients . Pharmacopsychiatry .1994;;27:166-175.
76 +
Nair NP, Schwartz G, Dimitri R, Le Morvan P, Thavundayil JX.  A dose range finding study of zopiclone in insomniac patients . Int Clin Psychopharmacol . 1990;;52( (suppl) ):1-10.
77 +
Ponciano E, Freitas F, Camara J, Faria M, Barreto M, Hindmarch I.  A comparison of the efficacy, tolerance and residual effects of zopiclone, flurazepam and placebo in insomniac outpatients . Int Clin Psychopharmacol . 1990;;52( (suppl) ):69-77.
78 +
Scharf MB, Roth PB, Dominguez RA, Ware JC.  Estazolam and flurazepam: a multicenter, placebo-controlled comparative study in outpatients with insomnia . J Clin Pharmacol . 1990;;30:461-467.
79 +
Scharf MB, Roth T, Vogel GW, Walsh JK.  A multicenter, placebo-controlled study evaluating zolpidem in the treatment of chronic insomnia . J Clin Psychiatry . 1994;;55:192-199.
80 +
Walsh JK, Targum SD, Pegram V, et al.  A multicenter clinical investigation of estazolam: short-term efficacy . Curr Ther Res . 1984;;36:866-874.
81 +
Kales A,Bixler EO, Vela-Bueno A, Soldatos CR, Manfredi RL.  Alprazolam: effects on sleep and withdrawal phenomena . J Clin Pharmacol . 1987;;27:508-515.
82 +
Kales A, Soldatos CR, Bixler EO, Kales JD, Vela-Bueno A.  Diazepam: effects on sleep and withdrawal phenomena . J Clin Psychopharmacol . 1988;; 8:340-346.
83 +
Mitler MM, Seidel WF, Van Den Hoed J, Green-blatt DJ, Dement WC.  Comparative hypnotic effects of flurazepam, triazolam, and placebo: a long-term simultaneous nighttime and daytime study . J Clin Psychopharmacol . 1984;;4:2-13.
84 +
Hauri PJ.  Sleep hygiene, relaxation therapy, and cognitive interventions . In: Hauri PJ, ed. Case Studies in Insomnia . New York, NY: Plenum Publishing Corp; 1991;:65-84.
85 +
Hauri PJ. The Sleep Disorders . Kalamazoo, Mich: The Upjohn Co; 1982;:1-32.
86 +
Morin CM, Colecchi C, Brink D, Astruc M, Mercer J, Remsberg S.  How 'blind' are double-blind placebo-controlled trials of benzodiazepine hypnotics? Sleep . 1995;;18:240-245.
87 +
Orwin P.  A fail-safe n for effect size in meta-analysis . J Educ Stat . 1983;;8:157-159.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Mellinger GD, Balter MB, Uhlenhuth EH.  Insomnia and its treatment: prevalence and correlates . Arch Gen Psychiatry . 1985;;42:225-232.
2 +
Baiter MB, Uhlenhuth EH.  New epidemiologic findings about insomnia and its treatment . J Clin Psychiatry . 1992;;53( (suppl) ):34-39.
3 +
Stoller MK.  Economic effects of insomnia . Clin Ther . 1994;;16:873-97. Review Discussion 854.
4 +
Walsh JK, Engelhardt CL, Hartman PG.  The direct economic cost of insomnia . In: Hypnotics and Anxiolytics: Bailliere's Clinical Psychiatry . London, England: Bailliere Tindall; 1995;.
5 +
Kales A, Caldwell AB, Soldatos CR, Bixler EO, Kales JD.  Biopsychobehavioral correlates of insomnia, II: pattern specificity and consistency with the Minnesota Multiphasic personality inventory . Psychosom Med . 1983;;45:341-356.
6 +
Tan TL, Kales JD, Kales A, Soldatos CR, Bixler EO.  Biopsychobehavioral correlates of insomnia, IV: diagnosis based on DSM-III . Am J Psychiatry . 1984;;141:357-362.
7 +
Schramm E, Hohagen F, Kappler C, Grasshoff U, Berger M.  Mental comorbidity of chronic insomnia in general practice attenders using DSM-III-R . Acta Psychiatr Scand . 1995;;91:10-17.
8 +
Gislason T, Almqvist M.  Somatic diseases and sleep complaints: an epidemiological study of 3201 Swedish men . Acta Med Scand . 1987;;221:475-481.
9 +
Vollrath M, Wicki W, Angst J.  The Zurich Study, VIII, insomnia: association with depression, anxiety, somatic syndromes, and course of insomnia . Eur Arch Psychiatry Clin Neurosci . 1989;;239:113-124.
10 +
Whorwell PJ, McCallum M, Creed FH.  Noncolonic features of irritable bowel syndrome . Gut . 1986;;27:37-40.
11 +
Johnson LC, Spinweber CL.  Good and poor sleepers differ in Navy performance . Mil Med . 1983;;148:727-731.
12 +
Mendelson WB, Garnett D, Linnoila M.  Do insomniacs have impaired daytime functioning? Biol Psychiatry . 1984;;19:1261-1264.
13 +
Mendelson WB, Garnett D, Gillin JC, Weingartner H.  The experience of insomnia and daytime and nighttime functioning . Psychiatry Res .1984;;12:235-250.
14 +
Sugarman JS, Stern JA, Walsh JK.  Daytime alertness in subjective and objective insomnia: some preliminary findings . Biol Psychiatry . 1985;;20:741-750.
15 +
Ford DE, Kamerow DB.  Epidemiologic study of sleep disturbances and psychiatric disorders . JAMA . 1989;;262:1479-1484.
16 +
Angst J, Vollrath M, Koch R, Dobler-Mikola A.  The Zurich Study, VII: insomnia: symptoms, classification and prevalence . Eur Arch Psychiatry Clin Neurosci . 1989;;238:285-293.
17 +
Ganguli M, Reynolds CF, Gilby JE.  Prevalence and persistence of sleep complaints in a rural older community sample: the movies project . J Am Geriatr Soc . 1996;;44:778-784.
18 +
Mendelson WB.  Long-term follow-up of chronic insomnia . Sleep . 1995;;18:698-701.
19 +
Bootzin RR, Perlis ML.  Nonpharmacologic treatments of insomnia . J Clin Psychiatry . 1992;;53 ( (suppl) ):37-41.
20 +
Hauri P.  Treating psychophysiologic insomnia with biofeedback . Arch Gen Psychiatry . 1981;;38:752-758.
21 +
Hauri P, Fisher J.  Persistent psychophysiologic (learned) insomnia . Sleep . 1986;;9:38-53.
22 +
Morin CM, Colecchi CA, Stone J, Sood RK, Brink D.  Cognitive-behavior therapy and pharmacotherapy for insomnia: update of a placebo-controlled clinical trial . Sleep Res . 1995;;24:303.
23 +
Kupfer DJ, Reynolds CF.  Management of insomnia . N Engl J Med . 1997;;336:341-346.
24 +
Bliwise DL.  Treating insomnia: pharmacological and nonpharmacological approaches . J Psychoactive Drugs . 1991;;23:335-341.
25 +
Woods JH, Winger G.  Current benzodiazepine issues . Psychopharmacology . 1995;;118:107-15. Review Discussion 118.
26 +
Linsen SM, Zitman FG, Breteler MH.  Defining benzodiazepine dependence: the confusion persists . European Psychiatry . 1995;;10:306-311.
27 +
Walsh JK, Engelhardt CL.  Trends in the pharmacologic treatment of insomnia . J Clin Psychiatry . 1992;;53( (suppl) ):10-7. Discussion 18.
28 +
Ware JC.  Tricyclic antidepressants in the treatment of insomnia . J Clin Psychiatry . 1983;;44:25-28.
29 +
Lilie JK, Lahmeyer H.  Psychiatric management of sleep disorders . Psychiatric Medicine . 1991;;9:245-260.
30 +
Pearce PL.  Trends in pharmacologic treatment of insomnia . J Clin Psychiatry . 1994;;55:163-164.
31 +
Staedt J, Stoppe G, Hajak G, Mullerstruck A, Ruther E.  Chronic insomnia: what should be done if minor tranzuilizers are no longer helpful? Fortschr Neurol Psychiatr . 1995;;63:368-372.
32 +
National Institute of Mental Health.  Consensus conference report: drugs and insomnia—the use of medication to promote sleep . JAMA . 1984;;251:2410-2414.
33 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;:551-607.
34 +
Diagnostic Classification Steering Committee T. International Classification of Sleep Disorders: Diagnostic and Coding Manual . Rochester, Minn: American Sleep Disorders Association; 1990;:27-38.
35 +
World Health Organization. Mental Disorders: Glossary and Guide to Their Classification in Accordance With the 9th Revision of the International Classification of Diseases . Geneva, Switzerland: World Health Organization; 1978;.
36 +
Kripke DF, Hauri P, Ancoli-Israel S, Roth T.  Sleep evaluation in chronic insomniacs during 14day use of flurazepam and midazolam . J Clin Psychopharmacol . 1990;;10( (suppl) ):32S-43S.
37 +
Hajak G, Clarenbach P, Fischer W, Haase W, Ruther E.  Zopiclone improves sleep quality and daytime well-being in insomniac patients: comparison with triazolam, flunitrazepam and placebo . Int Clin Psychopharmacol . 1994;;9:251-261.
38 +
Akerstedt T, Hume K, Minors D, Waterhouse J.  The subjective meaning of good sleep, an intraindividual approach using the Karolinska Sleep Diary . Percept Mot Skills . 1994;;79:287-296.
39 +
Carskadon M, Dement W, Mitler M, Guilleminault C, Zarcone V, Spiegel R.  Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia . Am J Psychiatry . 1976;;133:1382-1388.
40 +
Hunter JE, Schmidt FL, Jackson GB. Metaanalysis: Cumulating Research Findings Across Studies . Beverly Hills, Calif: Sage; 1982;:12-34.
41 +
Rosenthal R. Meta-analytic Procedure for Social Research . Beverly Hills, Calif: Sage; 1984;:93-216.
42 +
Morin CM, Culbert JP, Schwartz SM.  Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy . Am J Psychiatry . 1994;;151:1172-1180.
43 +
Murtagh DRR, Greenwood KM.  Identifying effective psychologicaltreatments for insomnia: a metaanalysis . J Consult Clin Psychol . 1995;;63:79-89.
44 +
Buysse DJ, Reynolds CF, Kupfer DJ, et al.  Clinical diagnoses in 216 insomnia patients using ICSD, and proposed DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV field trials . Sleep . 1994;;17:630-637.
45 +
Buysse DJ, Reynolds CF, Kupfer DJ, Mesiano D.  Does diagnosis affect treatment recommendations in insomnia patients? Sleep Res . 1993;;22:178.
46 +
Roth T, Roehrs T, Vogel G.  Zolpidem in the treatment of transient insomnia: a double-blind, randomized comparison with placebo . Sleep . 1995;;18:246-251.
47 +
Frankel BL, Coursey RD, Buchbinder R, Snyder F.  Recorded and reported sleep in chronic primary insomnia . Arch Gen Psychiatry . 1976;;33:615-623.
48 +
Roehrs T, Vogel G, Vogel F, et al.  Eligibility requirements in hypnotic trials . Sleep . 1985;;8:34-39.
49 +
Steinmark SW, Borkovec TD.  Active and placebo treatment effects on moderate insomnia under counterdemand and positive demand instructions . J Abnorm Psychol . 1974;;83:157-163.
50 +
Carr-Kaffashan L, Woolfolk RL.  Active and placebo effects in treatment of moderate and severe insomnia . J Consult Clin Psychol . 1979;;47:1072-1080.
51 +
Borkovec TD.  Insomnia . J Consult Clin Psychol . 1982;;50:890-895.
52 +
Reynolds CF, Nowell PD, Hoch CC, Neylan TC, Buysse DJ, Kupfer DJ. Diagnosis and treatment of insomnia in the elderly. In: Salzman C, ed. Clinical Geriatric Psychopharmacology. Baltimore, Md: Williams & Wilkins. In press.
53 +
Hoch CC, Dew MA, Reynolds CF, et al.  Longitudinal changes in diary- and laboratory-based sleep measures in health 'old old' and 'young old' subjects: a 3-year follow-up . Sleep . 1997;;20:192-202.
54 +
Greenblatt DJ.  Pharmacology of benzodiazepine hypnotics . J Clin Psychiatry . 1992;;53( (suppl) ):7-13.
55 +
Bangert-Drowns RL.  Review of developments in meta-analytic method . Psychol Bull . 1986;;99:388-399.
56 +
Rosenthal R, Rubin DB.  Meta-analytic procedures for combining studies with multiple effect sizes . Psychol Bull . 1986;;99:400-406.
57 +
Cohen J. Statistical Power Analysis for the Behavioral Sciences . New York, NY: Academic Press; 1977;.
58 +
Hedges LV, Olkin I. Statistical Methods for Meta-analysis . Orlando, Fla: Academic Press; 1985;.
59 +
Petitti DB. Meta-analysis, Decision Analysis, and Cost-effectiveness Analysis: Methods for Quantitative Synthesis in Medicine . New York, NY: Oxford University Press; 1994;:119-123.
60 +
Aden GC, Thatcher C.  Quazepam in the short-term treatment of insomnia in outpatients . J Clin Psychiatry . 1983;;44:454-456.
61 +
Cohn JB, Wilcox CS, Bremner J, Ettinger M.  Hypnotic efficacy of estazolam compared with flurazepam in outpatients with insomnia . J Clin Pharmacol . 1991;;31:747-750.
62 +
Cohn JB.  Double-blind crossover comparison of triazolam and lorazepam in the posthypnotic state . J Clin Psychiatry . 1984;;45:104-107.
63 +
Cuanang JR, Limos L.  Treatment of insomnia with temazepam: double-blind, placebo-controlled evaluation . Clin Ther . 1982;;4:402-412.
64 +
Declerck AC, Ruwe F, O'Hanlon JF, Vermeeren A, Wauquier A.  Effects of zolpidem and flunitrazepam on nocturnal sleep of women subjectively complaining of insomnia . Psychopharmacology . 1992;;106:497-501.
65 +
 Correction : Psychopharmacology . 1992;;109:254.
66 +
Melo de Paula AJ.  Comparative study of lormetazepam and flurazepam in the treatment of insomnia . Clin Ther . 1984;;6:500-508.
67 +
Dominguez RA, Goldstein BJ, Jacobson AF, Steinbook RM.  Comparative efficacy of estazolam, flurazepam, and placebo in outpatients with insomnia . J Clin Psychiatry . 1986;;47:362-365.
68 +
Elie R, Lavoie G, Bourgouin J, Le Morvan P.  Zopiclone versus flurazepam in insomnia: prolonged administration and withdrawal . Int Clin Psychopharmacol . 1990;;5:279-286.
69 +
Fabre LF Jr, Brachfeld J, Meyer LR, Slowe IA, Calvo R, Metzler C.  Multi-clinic double-blind comparison of triazolam (Halcion) and placebo administered for 14 consecutive nights in outpatients with insomnia . J Clin Psychiatry . 1978;;39:679-682.
70 +
Fillingim JM.  Double-blind evaluation of the efficacy and safety of temazepam in outpatients with insomnia . Br J Clin Pharmacol . 1979;;8( (suppl) ):73S-77S.
71 +
Herrmann WM, Kubicki ST, Boden S, Eich FX, Attali P, Coquelin JP.  Pilot controlled double-blind study of the hypnotic effects of zolpidem in patients with chronic learned insomnia: psychometric and polysomnographic evaluation . J Int Med Res . 1993;;21:306-322.
72 +
Hernandez-Lara R, Del Rosal PL, Ponce MC.  Short-term study of quazepam 15 milligrams in the treatment of insomnia . J Int Med Res . 1983;;11:162-166.
73 +
Linnoila M, Viukari M, Lamminsivu U, Auvinen J.  Efficacy and side effects of lorazepam, oxazepam, and temazepam as sleeping aids in psychogeriatric inpatients . Int Pharmacopsychiatry . 1980;;15:129-135.
74 +
Mendels J, Stern S.  Evaluation of the short-term treatment of insomnia in out-patients with 15 milligrams of quazepam . J Int Med Res . 1983;;11:155-161.
75 +
Monti JM, Attali P, Monti D, Zipfel A, de la Giclais B, Morselli PL.  Zolpidem and rebound insomnia—a double-blind, controlled polysomnographic study in chronic insomniac patients . Pharmacopsychiatry .1994;;27:166-175.
76 +
Nair NP, Schwartz G, Dimitri R, Le Morvan P, Thavundayil JX.  A dose range finding study of zopiclone in insomniac patients . Int Clin Psychopharmacol . 1990;;52( (suppl) ):1-10.
77 +
Ponciano E, Freitas F, Camara J, Faria M, Barreto M, Hindmarch I.  A comparison of the efficacy, tolerance and residual effects of zopiclone, flurazepam and placebo in insomniac outpatients . Int Clin Psychopharmacol . 1990;;52( (suppl) ):69-77.
78 +
Scharf MB, Roth PB, Dominguez RA, Ware JC.  Estazolam and flurazepam: a multicenter, placebo-controlled comparative study in outpatients with insomnia . J Clin Pharmacol . 1990;;30:461-467.
79 +
Scharf MB, Roth T, Vogel GW, Walsh JK.  A multicenter, placebo-controlled study evaluating zolpidem in the treatment of chronic insomnia . J Clin Psychiatry . 1994;;55:192-199.
80 +
Walsh JK, Targum SD, Pegram V, et al.  A multicenter clinical investigation of estazolam: short-term efficacy . Curr Ther Res . 1984;;36:866-874.
81 +
Kales A,Bixler EO, Vela-Bueno A, Soldatos CR, Manfredi RL.  Alprazolam: effects on sleep and withdrawal phenomena . J Clin Pharmacol . 1987;;27:508-515.
82 +
Kales A, Soldatos CR, Bixler EO, Kales JD, Vela-Bueno A.  Diazepam: effects on sleep and withdrawal phenomena . J Clin Psychopharmacol . 1988;; 8:340-346.
83 +
Mitler MM, Seidel WF, Van Den Hoed J, Green-blatt DJ, Dement WC.  Comparative hypnotic effects of flurazepam, triazolam, and placebo: a long-term simultaneous nighttime and daytime study . J Clin Psychopharmacol . 1984;;4:2-13.
84 +
Hauri PJ.  Sleep hygiene, relaxation therapy, and cognitive interventions . In: Hauri PJ, ed. Case Studies in Insomnia . New York, NY: Plenum Publishing Corp; 1991;:65-84.
85 +
Hauri PJ. The Sleep Disorders . Kalamazoo, Mich: The Upjohn Co; 1982;:1-32.
86 +
Morin CM, Colecchi C, Brink D, Astruc M, Mercer J, Remsberg S.  How 'blind' are double-blind placebo-controlled trials of benzodiazepine hypnotics? Sleep . 1995;;18:240-245.
87 +
Orwin P.  A fail-safe n for effect size in meta-analysis . J Educ Stat . 1983;;8:157-159.

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