Staff Perspective: Helping Patients Off Hypnotic Medications Using CBT-I
It is very common for patients to be prescribed and use hypnotic medications for sleep related problems. The estimated rates are even higher for patients who are seeking cognitive behavioral treatment for insomnia (CBT-I), with studies indicating more than half of patients taking some type of medication for sleep (Simpson & Manber, 2022). Additionally, research has found that 20% of patients who take hypnotic medications for sleep problems will chronically use that medication for several years (Simpson & Manber, 2022).
Given that CBT-I focuses on cognitive and behavioral interventions to improve the quality of an individual’s sleep functioning, providers often have questions about what to do with patients who are already taking medication for their sleep problems. While some patients may express an interest in discontinuing sleep medications, others may have strong reservations despite the current quality of their sleep functioning. For example, patients can often be concerned that if their sleep is this bad with medication, they do not even want to imagine what it would be like without it. Some patients struggle or not successful in their attempts to get off sleep medication because they continue to experience sleep problems (Manber et al., 2023).
Research examining the effects of CBT-I on hypnotic medication use has found that it helped to reduce the percentage of patients taking the medications compared to control groups by about 50%. However, literature has presented mixed findings regarding how long patients might remain off of medications due to CBT-I. For example, results from different studies have ranged from less than 3 months to 12 months, and up to 3 years. While more research is needed in this area, it seems that the studies that had better results regarding medication use benefited from 1) providing patients with specific strategies on how to discontinue their medication use, and 2) to include eliminating hypnotic medication as part of the treatment goals for CBT-I (Manber et al., 2023; Simpson & Manber, 2022).
The American College of Physicians specifically notes in their Clinical Practice Guideline for Insomnia that the FDA approval for many medications for insomnia are only for short-term use (Qaseem et al., 2016). Patients may not be aware of this, or that CBT-I can include a specific plan to taper their medication and actually help increase their odds of success (Simpson & Manber, 2022). In particular, it can helpful to explain how certain psychological interventions will help target the same problem that the medication targets (e.g., building up a person’s sleep drive by using stimulus control and sleep restriction). Some providers may want to have a patient discontinue medications prior to starting treatment. This approach can help patients to realize: 1) that effects of withdrawal are short-lived; 2) discontinuing before therapy can help to prevent future setbacks; and 3) greater trust and confidence in the effectiveness of cognitive and behavioral interventions versus medication (Perlis et al., 2005).
Regardless of the timing, tapering of hypnotic sleep medication should include the following elements (Simpson & Manber, 2022):
- Agreement between prescribing and non-prescribing providers that hypnotic discontinuation is clinically indicated
- A clear understanding of each provider’s role
- Discussion of a flexible taper plan that is based on patient safety and success of discontinuation. A common reduction of hypnotic medication utilized in research protocols is a dose reduction of 25% in week 1-2, 50% reduction by week 4, and discontinuing medication by week 8.
- Continued communication as needed
However, if patients are reluctant to go off their medication prior to starting CBT-I, there are some ways that this issue can be addressed throughout the CBT-I treatment protocol.
Strategies on how to incorporate tapering into CBT-I (Simpson & Manber, 2022):
- Initial assessment or goal setting: Ask patients if they would like to reduce or eliminate their hypnotic medication as part of their CBT-I treatment goal.
- Pairing tapering with time in bed restrictions: It can be helpful to have patients build up a strong sleep drive which can support tapering hypnotic medication. The idea is to start tapering the medication once a patient’s sleep efficiency is 85% or higher and their sleep has been consolidated. It may be easier to taper medication at this point because sleep has started to improve as well as the patient’s confidence in applying CBT-I techniques has hopefully increased. This can make the tapering effort more successful. There may be a need to expand a patient’s time in bed if the patient is experiencing high levels of daytime sleepiness. It is generally recommended to have the daytime sleepiness to be within a safe level before initiating the tapering of medication. The earliest most patients will be ready to begin tapering is by appointment 3 in the CBT-I protocol.
- Pairing tapering with cognitive interventions: For patients who are ambivalent about medication reduction, or have more reservations about making changes may benefit from additional cognitive therapy or motivational enhancement prior to starting the tapering. While literature on CBT-I has noted that cognitive interventions can be integrated throughout the treatment protocol to enhance treatment adherence, cognitive skills are generally taught in later sessions of the CBT-I protocol (Manber et al., 2023).
CBT-I often helps to build self-efficacy around sleep which can help patients be more confident about tapering off hypnotic medications. Research indicates that combining a supportive tapering plan in conjunction with CBT-I is more effective at helping patients taper their medication than CBT-I alone, or by focusing tapering efforts by themselves (Simpson & Manber, 2022; Watson et al., 2023). This suggests that as providers encounter patients who are on hypnotic medications for insomnia, it is helpful to have a deliberate and thoughtful approach about how tapering can be more successfully incorporated into CBT-I. This approach can increase the chances of a patient being able to improve their sleep functioning, taper off medication, and maintain those gains in the future.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., serves as the Associate Director for Training and Education at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Rogers earned his Ph.D. in Counseling Psychology from the University of Akron.
References:
Manber, R., Simpson, N., & Gumport, N. B. (2023). Perspectives on increasing the impact and reach of CBT-I. Sleep, 46(12), 1-7. https://doi.org/10.1093/sleep/zsad168
Perlis, M.L., Jungquist, C., Smith, M.T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. Springer.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D., & Clinical Guidelines Committee of the American College of Physicians. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 165(2), 125-133. https://doi.org/10.7326/M15-2175
Simpson, N., & Manber, R. (2022). CBT-I in patients who wish to reduce use of hypnotic medication. In Adapting cognitive behavioral therapy for insomnia (pp. 437-456). Academic Press. Watson, N. F., Benca, R. M., Krystal, A. D., McCall, W. V., & Neubauer, D. N. (2023). Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. Journal of clinical medicine, 12(7), 2493. https://doi.org/10.3390/jcm12072493
It is very common for patients to be prescribed and use hypnotic medications for sleep related problems. The estimated rates are even higher for patients who are seeking cognitive behavioral treatment for insomnia (CBT-I), with studies indicating more than half of patients taking some type of medication for sleep (Simpson & Manber, 2022). Additionally, research has found that 20% of patients who take hypnotic medications for sleep problems will chronically use that medication for several years (Simpson & Manber, 2022).
Given that CBT-I focuses on cognitive and behavioral interventions to improve the quality of an individual’s sleep functioning, providers often have questions about what to do with patients who are already taking medication for their sleep problems. While some patients may express an interest in discontinuing sleep medications, others may have strong reservations despite the current quality of their sleep functioning. For example, patients can often be concerned that if their sleep is this bad with medication, they do not even want to imagine what it would be like without it. Some patients struggle or not successful in their attempts to get off sleep medication because they continue to experience sleep problems (Manber et al., 2023).
Research examining the effects of CBT-I on hypnotic medication use has found that it helped to reduce the percentage of patients taking the medications compared to control groups by about 50%. However, literature has presented mixed findings regarding how long patients might remain off of medications due to CBT-I. For example, results from different studies have ranged from less than 3 months to 12 months, and up to 3 years. While more research is needed in this area, it seems that the studies that had better results regarding medication use benefited from 1) providing patients with specific strategies on how to discontinue their medication use, and 2) to include eliminating hypnotic medication as part of the treatment goals for CBT-I (Manber et al., 2023; Simpson & Manber, 2022).
The American College of Physicians specifically notes in their Clinical Practice Guideline for Insomnia that the FDA approval for many medications for insomnia are only for short-term use (Qaseem et al., 2016). Patients may not be aware of this, or that CBT-I can include a specific plan to taper their medication and actually help increase their odds of success (Simpson & Manber, 2022). In particular, it can helpful to explain how certain psychological interventions will help target the same problem that the medication targets (e.g., building up a person’s sleep drive by using stimulus control and sleep restriction). Some providers may want to have a patient discontinue medications prior to starting treatment. This approach can help patients to realize: 1) that effects of withdrawal are short-lived; 2) discontinuing before therapy can help to prevent future setbacks; and 3) greater trust and confidence in the effectiveness of cognitive and behavioral interventions versus medication (Perlis et al., 2005).
Regardless of the timing, tapering of hypnotic sleep medication should include the following elements (Simpson & Manber, 2022):
- Agreement between prescribing and non-prescribing providers that hypnotic discontinuation is clinically indicated
- A clear understanding of each provider’s role
- Discussion of a flexible taper plan that is based on patient safety and success of discontinuation. A common reduction of hypnotic medication utilized in research protocols is a dose reduction of 25% in week 1-2, 50% reduction by week 4, and discontinuing medication by week 8.
- Continued communication as needed
However, if patients are reluctant to go off their medication prior to starting CBT-I, there are some ways that this issue can be addressed throughout the CBT-I treatment protocol.
Strategies on how to incorporate tapering into CBT-I (Simpson & Manber, 2022):
- Initial assessment or goal setting: Ask patients if they would like to reduce or eliminate their hypnotic medication as part of their CBT-I treatment goal.
- Pairing tapering with time in bed restrictions: It can be helpful to have patients build up a strong sleep drive which can support tapering hypnotic medication. The idea is to start tapering the medication once a patient’s sleep efficiency is 85% or higher and their sleep has been consolidated. It may be easier to taper medication at this point because sleep has started to improve as well as the patient’s confidence in applying CBT-I techniques has hopefully increased. This can make the tapering effort more successful. There may be a need to expand a patient’s time in bed if the patient is experiencing high levels of daytime sleepiness. It is generally recommended to have the daytime sleepiness to be within a safe level before initiating the tapering of medication. The earliest most patients will be ready to begin tapering is by appointment 3 in the CBT-I protocol.
- Pairing tapering with cognitive interventions: For patients who are ambivalent about medication reduction, or have more reservations about making changes may benefit from additional cognitive therapy or motivational enhancement prior to starting the tapering. While literature on CBT-I has noted that cognitive interventions can be integrated throughout the treatment protocol to enhance treatment adherence, cognitive skills are generally taught in later sessions of the CBT-I protocol (Manber et al., 2023).
CBT-I often helps to build self-efficacy around sleep which can help patients be more confident about tapering off hypnotic medications. Research indicates that combining a supportive tapering plan in conjunction with CBT-I is more effective at helping patients taper their medication than CBT-I alone, or by focusing tapering efforts by themselves (Simpson & Manber, 2022; Watson et al., 2023). This suggests that as providers encounter patients who are on hypnotic medications for insomnia, it is helpful to have a deliberate and thoughtful approach about how tapering can be more successfully incorporated into CBT-I. This approach can increase the chances of a patient being able to improve their sleep functioning, taper off medication, and maintain those gains in the future.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., serves as the Associate Director for Training and Education at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Rogers earned his Ph.D. in Counseling Psychology from the University of Akron.
References:
Manber, R., Simpson, N., & Gumport, N. B. (2023). Perspectives on increasing the impact and reach of CBT-I. Sleep, 46(12), 1-7. https://doi.org/10.1093/sleep/zsad168
Perlis, M.L., Jungquist, C., Smith, M.T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. Springer.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D., & Clinical Guidelines Committee of the American College of Physicians. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 165(2), 125-133. https://doi.org/10.7326/M15-2175
Simpson, N., & Manber, R. (2022). CBT-I in patients who wish to reduce use of hypnotic medication. In Adapting cognitive behavioral therapy for insomnia (pp. 437-456). Academic Press. Watson, N. F., Benca, R. M., Krystal, A. D., McCall, W. V., & Neubauer, D. N. (2023). Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. Journal of clinical medicine, 12(7), 2493. https://doi.org/10.3390/jcm12072493