Combining pharmacologic and nonpharmacologic therapies for insomnia

Although both clinical experience and formal studies confirm the efficacy of cognitive-behavioral therapy (CBT) and hypnotic medications as treatments for insomnia, the interaction of the 2 treatments when combined has not been fully clarified. In principle, they could potentiate each other, not interact at all (in which case the benefits would be the sum of the 2 treatments alone), or inhibit each other. In this review, I suggest that the weight of available evidence indicates that the 2 treatments have a beneficial interaction, but that the paucity of data should prevent excessive generalization. It would be desirable for future studies to employ newer hypnotics with a range of doses in both nightly and p.r.n. administration and to examine comorbid as well as primary insomnias. The manner in which the medication is presented to the patient and the caregiver's conviction regarding the effectiveness of therapy need to be carefully controlled. Studies that consider these issues will need to be performed before firmer conclusions can be reached.