Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders
Abstract
:1. Introduction
2. Benzodiazepine Use and Abuse
2.1. Prevalence of BZD Use
2.1.1. Statistics on BZD Consumption
2.1.2. Consumption Trends
2.2. Low Benefit-to-Risk Ratio
2.2.1. Side Effects
2.2.2. Withdrawal Syndrome
2.2.3. Ecological Impact
2.3. Recommendations for Use
2.3.1. Reduce Access to BZDs
2.3.2. Increase the Cost of BZDs
2.3.3. Deprescribing
3. Cognitive Behavioral Therapy (CBT) for Discontinuing Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders
3.1. Methods
3.2. Effectiveness of CBT on the Causes of BZD Use
3.3. Benefits of CBT for Optimising Adherence and Compliance with the Withdrawal Program
3.4. Effectiveness of Adding CBT to Taper Programs
4. Acceptance and Commitment Therapy for Discontinuing Long-Term Benzodiazepine Use
4.1. Differences between CBT and ACT
4.2. Effectiveness of ACT on the Causes of Benzodiazepine Use
4.3. Effectiveness of ACT for Substance Use Disorders
4.4. Effectiveness of Adding ACT to Taper Programs
4.5. The Benefits of ACT for Adherence and Compliance with Withdrawal Programs
5. Discussion
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations
ACT | Acceptance and Commitment Therapy |
BZD | Benzodiazepines and Z-drugs |
CBT | Cognitive Behavioral Therapy |
TAU | Treatment As Usual |
SRD | Substance-related disorder |
WL | Waiting List |
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Study | Condition | Population | Benzodiazepine Use | Design | Withdrawal Schedule | Main Outcomes |
---|---|---|---|---|---|---|
Otto et al., 1993 [118] | Panic disorder | n = 33, 22 women | Alprazolam or clonazepam use >6 months | Slow taper alone (5 to 7 weeks) (n = 16) vs. slow taper + 10 weekly sessions (60–90 min) of group CBT (n = 17) | Alprazolam: Reduction of 0.25 mg or 0.125 mg every 2 days (depending on the initial dose) Clonazepam: reduction of 0.25 mg every 4 or 8 days (depending on the initial dose) | Successful discontinuation (=completion of the taper and no use of BZD beyond “minimal p.r.n use” during the 2 post-discontinuation weeks) in 76% with CBT vs. 25% without CBT (p < 0.01) At 3 months: persistent effect of CBT |
Spiegel et al., 1994 [120] | Panic disorder | n = 21, 17 women | Alprazolam use, 1 to 10 mg/j | Supportive drug maintenance and slow flexible taper (n = 10) vs. same taper + 12 weekly sessions of individual CBT (n = 11) | Reduction of 0.125 mg to 0.5 mg/1–2 week, mean duration 6.5 weeks | Successful discontinuation (=completion of the taper and no use of BZD through the follow-up) 2 weeks after treatment: 90% with CBT vs. 80% without CBT (ns) At 6 months: 90% with CBT vs. 40% without CBT (p < 0.05) |
Baillargeon et al., 2003 [122] | Chronic insomnia in older adults | n = 65, >50 years, 38 women | Daily use of BZD >3 months (Molecules not specified) | Slow taper alone (n = 30) vs. slow taper + 8 weekly sessions (90 min) of group CBT (n = 35) | 25% reduction of dosage every 1–2 weeks | Successful discontinuation (= BZD cessation confirmed by blood screening) in 77% with CBT vs. 38% without CBT after treatment completion (p = 0.002), and results maintained at 3 and 12 months |
Voshaar et al., 2003 [121] | Not mentioned | n = 180, 128 women | BZD use >3 months BZDs were switched for an equivalent dose of diazepam | Usual care (letter with advice to stop) (n = 34) vs. taper (n = 73) vs. taper + 5 weekly sessions (120 min) of group CBT (n = 73) | 25% reduction of dosage every week | Successful discontinuation (=no self-reported BZD use at 3 months follow-up) in 58% with CBT vs. 62% tapering off without CBT (no additional benefice of CBT) vs. 21% with usual care |
Morin et al., 2004 [33] | Chronic insomnia in older adults | n = 76, >55 years, 38 women | BZD use >50% of nights >3 months (different molecules: lorazepam, alprazolam, bromazepam, oxazepam, temazepam, clonazepam, flurazepam, triazolam) | Supervised withdrawal program (n = 25) vs. CBT for insomnia (weekly 90 min sessions) (n = 24) vs. supervised withdrawal program + CBT (n = 27) For all groups: program duration 10 weeks | 25% reduction of dosage every 2 weeks and introduction of an increasing number of drug-free nights | Drug-free patients (confirmed by blood and urine samples): 85% taper + CBT vs. 48% taper alone vs. 54% CBT alone at post-treatment (p < 0.002) and results maintained at 3 and 12 months Reduction of weekly quantity of BZD use (dosage_overall 90% reduction_and number of nights_overall 80% reduction) in the 3 groups with lower frequency of medicated night in the CBT + taper vs. taper alone group |
Gosselin et al., 2006 [112] | Generalized Anxiety Disorders (GAD) | n = 61, 36 women | BZD use >4 days/week for >12 months (different molecules: clonazepam, lorazepam, alprazolam, bromazepam, oxazepam, temazepam, diazepam, clorazepate) | Non-specific psychological treatment (NST) + taper (n = 30) vs. CBT + taper (n = 31), 12 weekly 90 min sessions | 25% reduction of dosage every 2–3 weeks | Drug-free patients at post-treatment: 74% CBT + taper vs. 37% NST + taper group, p < 0.001. Results maintained at 3, 6 and 12 months. Greater proportion of patients no longer with GAD criteria in the CBT group |
Otto et al., 2010 [119] | Panic Disorders | n = 47, 31 women | Alprazolam or clonazepam use >6 months | Taper alone (5 to 9 weeks) (n = 15) vs. taper + CBT (8 weekly 60–90 min sessions followed by 3 booster sessions separated by 2 weeks) (n = 16) vs. taper + relaxation (same number/duration of session as CBT sessions) (n = 16) | Alprazolam: Reduction of 0.25 mg or 0.125 mg every 2 days (depending on the initial dose) Clonazepam: reduction of 0.25 mg every 4 or 8 days (depending on the initial dose) | Successful discontinuation (=completion of the taper and no use of BZD beyond “minimal p.r.n use” during the month post-discontinuation) in 56% CBT vs. 31% relaxation vs. 40% taper alone (ns), and maintained at 3 (44% vs. 13% vs. 27%, ns) and 6 months (63% vs. 13% vs. 27%, p < 0.01) |
Lichstein et al., 2013 [123] | Chronic insomnia in older adults | n = 70, >50 years, women | Hypnotic dependance (BZD, non-BZD receptor agonists, sedating antidepressants) | Withdrawal only (4–8 biweekly 30 min sessions) vs. withdrawal (n = 23) + placebo biofeedback vs. withdrawal (8 weekly 45 min sessions) (n = 23) + CBT (8 weekly 45 min sessions) (n = 24) | Conversion of the dose of hypnotics in a number of “lowest recommended dosages” (LRD): gradual reduction to nightly dose at 1 LRD then gradual elimination of nightly dose | Drug-free patients at post-treatment: 67% CBT vs. 61% placebo feedback vs. 52% withdrawal only (ns) At follow-up (1 year): 50% vs. 35% vs. 43% (ns) |
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Chapoutot, M.; Peter-Derex, L.; Bastuji, H.; Leslie, W.; Schoendorff, B.; Heinzer, R.; Siclari, F.; Nicolas, A.; Lemoine, P.; Higgins, S.; et al. Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. Int. J. Environ. Res. Public Health 2021, 18, 10222. https://doi.org/10.3390/ijerph181910222
Chapoutot M, Peter-Derex L, Bastuji H, Leslie W, Schoendorff B, Heinzer R, Siclari F, Nicolas A, Lemoine P, Higgins S, et al. Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. International Journal of Environmental Research and Public Health. 2021; 18(19):10222. https://doi.org/10.3390/ijerph181910222
Chicago/Turabian StyleChapoutot, Mélinée, Laure Peter-Derex, Hélène Bastuji, Wendy Leslie, Benjamin Schoendorff, Raphael Heinzer, Francesca Siclari, Alain Nicolas, Patrick Lemoine, Susan Higgins, and et al. 2021. "Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders" International Journal of Environmental Research and Public Health 18, no. 19: 10222. https://doi.org/10.3390/ijerph181910222
APA StyleChapoutot, M., Peter-Derex, L., Bastuji, H., Leslie, W., Schoendorff, B., Heinzer, R., Siclari, F., Nicolas, A., Lemoine, P., Higgins, S., Bourgeois, A., Vallet, G. T., Anders, R., Ounnoughene, M., Spencer, J., Meloni, F., & Putois, B. (2021). Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. International Journal of Environmental Research and Public Health, 18(19), 10222. https://doi.org/10.3390/ijerph181910222