Commentary

Although other studies have explored the effects of CBTT in benzodiazepine withdrawal¹, the study by Baillargeon et al is important because it is one of few studies that have targeted patients with chronic insomnia.

The findings support the conclusion that CBTT is superior to standard TA for discontinuation of benzodiazepines in older patients with chronic insomnia and that this benefit is sustained over time. The sample is representative of the chronicity of hypnotic use seen in clinical settings. The unblinded design is not ideal, but this weakness is somewhat offset by the large effect observed, statistical adjustment for baseline differences, audiotape monitoring of consultations, and blood screening to confirm self reported benzodiazepine use. Despite the collection of sleep diaries, the effect of treatment on sleep was not reported even though this is an important factor in the assessment of the effectiveness of hypnotic withdrawal regimens. The study findings are relevant to nurses working with older patients with chronic insomnia who take benzodiazepines, although they are not generalisable to poorly motivated and mentally or physically impaired older adults.

Although promising, it is premature to recommend widespread adoption of intensive CBTT for hypnotic withdrawal without first comparing it with less costly strategies or a placebo control condition. For example, in a study of general practice patients, 21% reported stopping chronic benzodiazepine use after receiving only a letter advising its discontinuation.¹ Furthermore, regimens that first replace benzodiazepines with non-benzodiazepine hypnotics (eg, zopiclone) have received some attention, although research support is scant. These new hypnotics are easily substituted and have few withdrawal and tolerance effects.² The most cost-effective of these withdrawal regimens still needs to be determined.