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Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial

From the Department of Family Medicine (Baillargeon), the School of Psychology (Landreville), the Department of Social and Preventive Medicine (Verreault), the Department of Family Medicine – Geriatrics (Beauchemin), the Faculty of Pharmacy (Grégoire) and the School of Psychology (Morin), Laval University, Sainte-Foy, Que.

Correspondence to: Dr. Lucie Baillargeon, Family Medicine Unit, Centre hospitalier universitaire de Québec (CHUL), 2705, boul. Laurier, Sainte-Foy QC G1V 4G2; fax 418 654-2138; lucie.baillargeon{at}crchul.ulaval.ca

Background: Long-term use of hypnotics is not recommended because of risks of dependency and adverse effects on health. The usual clinical management of benzodiazepine dependency is gradual tapering, but when used alone this method is not highly effective in achieving long-term discontinuation. We compared the efficacy of tapering plus cognitive-behavioural therapy for insomnia with tapering alone in reducing the use of hypnotics by older adults with insomnia.

Methods: People with chronic insomnia who had been taking a benzodiazepine every night for more than 3 months were recruited through media advertisements or were referred by their family doctors. They were randomly assigned to undergo either cognitive-behavioural therapy plus gradual tapering of the drug (combined treatment) or gradual tapering only. The cognitive-behavioural therapy was provided by a psychologist in 8 weekly small-group sessions. The tapering was supervised by a physician, who met weekly with each participant over an 8-week period. The main outcome measure was benzodiazepine discontinuation, confirmed by blood screening performed at each of 3 measurement points (immediately after completion of treatment and at 3- and 12-month follow-ups).

Results: Of the 344 potential participants, 65 (mean age 67.4 years) met the inclusion criteria and entered the study. The 2 study groups (35 subjects in the combined treatment group and 30 in the tapering group) were similar in terms of demographic characteristics, duration of insomnia and hypnotic dosage. Immediately after completion of treatment, a greater proportion of patients in the combined treatment group had withdrawn from benzodiazepine use completely (77% [26/34] v. 38% [11/29]; odds ratio [OR] 5.3, 95% confidence interval [CI] 1.8–16.2; OR after adjustment for initial benzodiazepine daily dose 7.9, 95% CI 2.4–30.9). At the 12-month follow-up, the favourable outcome persisted (70% [23/33] v. 24% [7/29]; OR 7.2, 95% CI 2.4–23.7; adjusted OR 7.6, 95% CI 2.5–26.6); similar results were obtained at 3 months.

Interpretation: A combination of cognitive-behavioural therapy and benzodiazepine tapering was superior to tapering alone in the management of patients with insomnia and chronic benzodiazepine use. The beneficial effects were sustained for up to 1 year. Applying this multidisciplinary approach in the community could help reduce benzodiazepine use by older people.

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