Study, Oct/19: Sleep-Related Disorders in Neurology and Psychiatry

https://www.ncbi.nlm.nih.gov/pubmed/31709972

 

Abstract

 

BACKGROUND:

 

Sleep-related disorders are a group of illnesses with marked effects on patients' quality of life and functional ability. Their diagnosis and treatment is a matter of common interest to multiple medical disciplines.

 

METHODS:

 

This review is based on relevant publications retrieved by a selective search in PubMed (Medline) and on the guide- lines of the German Society for Sleep Medicine, the German Neurological Society, and the German Association for Psychiatry, Psychotherapy and Psychosomatics.

 

RESULTS:

 

A pragmatic classification of sleep disorders by their three chief complaints-insomnia, daytime somnolence, and sleep-associated motor phenomena-enables tentative diagnoses that are often highly accurate. Some of these disorders can be treated by primary care physicians, while others call for referral to a neurologist or psychiatrist with special experience in sleep medicine. For patients suffering from insomnia as a primary sleep disorder, rather than a symptom of another disease, meta-analyses have shown the efficacy of cognitive behavioral therapy, with high average effect sizes. These patients, like those suffering from secondary sleep disorders, can also benefit from drug treatment for a limited time. Studies have shown marked improvement of sleep latency and sleep duration from short-term treatment with benzodiazepines and Z-drugs (non- benzodiazepine agonists such as zolpidem and zopiclone), but not without a risk of tolerance and dependence. For sleep disorders with the other two main manifestations, specific drug therapy has been found to be beneficial.

 

CONCLUSION:

 

Sleep disorders in neurology and psychiatry are a heterogeneous group of disorders with diverse manifestations. Their proper diagnosis and treatment can help prevent secondary diseases and the worsening of concomitant conditions. Care structures for the treatment of sleep disorders should be further developed.

I'm quite interested in this. " For patients suffering from insomnia as a primary sleep disorder, rather than a symptom of another disease, meta-analyses have shown the efficacy of cognitive behavioral therapy, with high average effect sizes." seems quite promising. I've found multiple webpages asserting that psychotherapy is at least equally effective as pharmacological treatments like benzos for certain disorders, but I'm having trouble locating the exact studies.

 

Psychotherapy is cheaper and more effective than medications for many of the problems that lead people to seek treatment. Estimates of psychotherapy's effectiveness, based on hundreds of empirical studies, are that it works approximately 75-80 percent of the time. That's a pretty impressive figure. And believe it or not, psychotherapy is cheaper than prescription medications particularly when you consider the impact on your ability to achieve your long-term life goals. (https://www.psychologytoday.com/us/blog/fulfillment-any-age/201108/13-qualities-look-in-effective-psychotherapist)

 

Unlike with the potential of some psychotropic medications, psychotherapy is not addictive. Furthermore, some studies have shown that Cognitive Behavioral Therapy can be more effective at relieving anxiety and depression than medication. (https://centerforanxietydisorders.com/choose-psychotherapy-medication/)

 

These drugs can, when taken correctly, help sufferers of anxiety disorders to feel better—but most experts agree that for long-term improvement, patients should combine use of pharmaceuticals with psychotherapy.https://psychcentral.com/anxiety/psychotherapy-for-anxiety-disorders/

 

A doctor named "Glen Spielmans" published a study in 2014 which implied that psychotherapy was more effective in the long-term than anti-depressants.

 

my research team conducted a meta-analysis examining only studies comparing psychotherapy, mostly CBT, to newer antidepressants. While these medications had a slight advantage over therapy at the end of treatment, when therapies provided by primary care physicians, nurses, or therapists with unclear training were removed from consideration, psychotherapy and newer antidepressants had equivalent outcomes in the short term across 14 comparisons (Spielmans GI et al, J Nerv Ment Dis 2011;199:142–149). At longer-term follow-up, psychotherapy by properly trained therapists outperformed newer antidepressants by a small, but statistically significant, margin.https://pro.psychcentral.com/cognitive-behavioral-therapy-versus-medications-for-depression-how-do-they-compare/

 

Benzodiazepines are not technically anti-depressants, though benzodiazepines are frequently prescribed for mixed anxiety and depression.

 

In this study, psychotherapy was found superior for preventing relapses of major depressive disorder, while the combination of psychotherapy with pharmacotherapy was better than pharmacotherapy alone at treating the condition initially.

 

In head-to-head studies, pharmacotherapy was significantly superior to psychotherapy for schizophrenia (psychodynamic) and dysthymia (cognitive behavioral therapy), and

psychotherapy was superior for major depressive disorder relapse prevention and bulimia. Adding pharmacotherapy to psychotherapy was significantly more effective than psychotherapy alone for major depressive disorder, social phobia, and bulimia. Conversely, adding psychotherapy to pharmacotherapy was superior to drug treatment for depressive disorder, schizophrenia, panic disorder, and bulimia. However, many of these results were based on small meta-analytic samples, leading to large CIs around the mean effect sizes.

Five studies met criteria for analysis. Low to moderate grade evidence suggests CBT-I has superior effectiveness to benzodiazepine and non-benzodiazepine drugs in the long term, while very low grade evidence suggests benzodiazepines are more effective in the short term. Very low grade evidence supports use of CBT-I to improve psychological outcomes.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481424/

 

At least one older study concluded that cognitive behavioral therapy was highly effective for tapering off benzodiazepines.

 

The rate of successful discontinuation of benzodiazepine treatment was significantly higher for pateitnts receiving the cognitive-behavioral program (13 of 17; 76%) than for patients receiving the slow taper program along (four of 16; 25%).https://www.researchgate.net/profile/Jerrold_Rosenbaum/publication/14818858_Discontinuation_of_benzodiazepine_treatment_efficacy_of_cognitive-[be...]/links/53d786fd0cf29265323ccbd5/Discontinuation-of-benzodiazepine-treatment-efficacy-of-cognitive-behavioral-therapy-for-patients-with-Panic-Disorder.pdf

 

That study was cited in this recent blog from a certain Dr. Jerrold Rosenbaum in the American Journal of Psychiatry:

 

Some benzodiazepine prescribing is straightforward, for example, as a brief intervention for acute distress or as-needed use for a phobic anxiety (e.g., airplanes) or transient insomnia. Some prescribing situations are, however, to be avoided if possible, like prescribing to manage persisting distress resulting from a personality disorder or for patients with known current or past substance use disorders. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20040376

 

Psychotheraphy is clearly the best option for tapering off benzos and preventing relapse of the conditions which respond to these drugs. My questions at this point are: how does one differentiate a competent therapist from an ineffective one without wasting money experimenting with the latter? Secondly: has anyone here had relevant experience with using psychotheraphy to get off (and stay off) benzos?

 

Psychotheraphy is clearly the best option for tapering off benzos and preventing relapse of the conditions which respond to these drugs. My questions at this point are: how does one differentiate a competent therapist from an ineffective one without wasting money experimenting with the latter? Secondly: has anyone here had relevant experience with using psychotheraphy to get off (and stay off) benzos?

 

 

I think you will receive more answers to these questions on one of the other boards.

 

I do not believe that psychotherapy can help someone withdrawal from benzos.  What is needed is a sensible taper plan, patience and acceptance that the process may be challenging. 

 

Benzos change the chemistry of the brain. No amount of therapy can reset these changes. The central nervous system has to find balance again, this can take time.

 

Therapy can help deal with issues that cause people to start taking benzos, I believe.  Finding ways to deal with issues like insomnia, anxiety and panic using non drug techniques is ideal.  I was put on benzos for a supposed medical condition. I did experience anxiety and panic, something I'd never experienced before, once I reached tolerance and during withdrawal.  Using CBT techniques did help me deal with this during withdrawal and recovery.

 

pianogirl

 

 

I see that I should clarify this: "Psychotheraphy is clearly the best option for tapering off benzos". I didn't intend to imply that therapy could be used instead of tapering. I am aware of what benzos do to GABA receptors. My intent was to say that therapy is the best option to use in combination with tapering because it addresses the anxiety and depression that often trigger the original prescription, which often result from dependency, and which tapering can trigger. This is the same point that Dr. Otto et al. reached in their study which I cited earlier. I think my underlying concern is that tapering by itself is not going to be sufficient to prevent relapses in the long term when the patient got on benzos originally because of underlying anxiety and depression that tapering alone does not address. There are, of course, people who get prescribed benzos for other reasons and who are not susceptible to relapse after tapering because the original problems which the benzos addressed were temporary.