Sleep Disturbance Preceding Completed Suicide in Adolescents

Genevie`ve Belleville and Charles M. Morin
E´
cole de Psychologie, Universite´ Laval, Centre de Recherche Universite´ Laval–Robert-Giffard
Objective: To compare individuals who were successful in discontinuing hypnotic medications against
those who were not on measures of insomnia severity, medication withdrawal symptoms, psychological
symptoms, perceived health, readiness to change and self-efficacy. Design: Secondary analyses of a
randomized clinical trial comparing a hypnotic taper intervention with or without self-help treatment for
insomnia. Main Outcome Measures: Self-report measures of insomnia severity, medication withdrawal
symptoms, depression and anxiety symptoms, physical and mental health, stages of change, readiness to
change, decisional balance, and general and situational self-efficacy. Results: There were no significant
differences at baseline between medication-free individuals and those still using sleep medication at the
end of a taper intervention. Group differences emerged midway through the 8-week withdrawal program
and were accentuated after the intervention; participants who remained medication-free during the next
six months had less severe insomnia and anxiety symptoms, a more positive perception of their health
and higher self-efficacy to refrain from hypnotic use in various situations. Contrary to expectations, there
were no differences between drug-free and nondrug-free participants on both readiness to change and
stages of change. Conclusions: Chronic users of hypnotic medications entered a taper intervention with
equal levels of psychological distress, health, self-efficacy, and readiness to change. Successful hypnotic
discontinuation was associated with overall improvement of insomnia, anxiety and distress symptoms,
perceived health and self-efficacy. More intensive and individualized therapeutic attention may be
warranted for individuals experiencing worsening of insomnia symptoms, more withdrawal symptoms
and psychological distress, and lower self-efficacy during medication discontinuation.
Keywords: hypnotic taper, insomnia, readiness to change, self-efficacy
Between 5% and 12% of the general population use a medication
to get relief from their sleep difficulties (Ohayon & Caulet,
1996). However, some people will use hypnotic medication for a
longer period of time than what was first planned. Prevalence of
long-term, continuous benzodiazepine (BZD) use is around 1% or
2% of all BZD users (Simon, VonKorff, Barlow, Pabiniak, &
Wagner, 1996), but a prevalence indicator of long-term BZD use
as high as 19.8% has been reported in a sample of communitydwelling
older adults (Egan, Moride, Wolfson, & Monette, 2000).
Among determinants of long-term hypnotic use, age, health and
psychological distress are the most often cited (Egan et al., 2000;
Simon et al., 1996).
In general, pharmacotherapy is an efficient treatment option for
transient insomnia (Nowell, 1997). However, prolonged use of BZD,
and to a lesser extent newer BZD-receptor agonists (e.g., zopiclone,
zolpidem), has been associated with cognitive and psychomotor impairment
(Glass, Lanctoˆt, Herrmann, Sproule, & Busto, 2005) and
increased risks of tolerance and dependence (Soldatos, Dikeos, &
Whitehead, 1999). It is recognized that behavioral approaches, alone
or combined with brief pharmacotherapy, should be preferred to
continuous long-term use of hypnotics to treat chronic insomnia
(National Institutes of Health, 2005).
Supervised hypnotic taper scheduled over an 8- to 10-week
period and psychological interventions, mainly within the
cognitive– behavioral approach, has been shown effective to facilitate
hypnotic discontinuation among chronic hypnotic users, with
50% to 67% achieving medication-free status (e.g., Morin et al.,
2004). However, around one third of chronic users are unable to
discontinue their sleep medication. Studies examining the reasons
why some chronic hypnotic users successfully reach a drug-free
status while others do not are scarce. Anxiety and psychological
distress have been associated with unsuccessful outcomes, while
increased self-efficacy (or the perceived ability to refrain from
using hypnotics) was observed only within participants who successfully
quit (O’Connor et al., 2004). Another study has reported
a positive association between self-efficacy and compliance to a
BZD taper (Be´langer, Morin, Bastien & Ladouceur, 2005). Pharmacological
factors, such as dosage, duration of treatment, and
half-life of BZD, have also been associated with discontinuation
outcome (Gorgels et al., 2006). Even among participants reaching
a drug-free status, relapse rates are relatively high, sometimes
exceeding 50% (Morin et al., 2004). In a survival analysis of
relapse after successful discontinuation of benzodiazepines for
insomnia (Morin, Be´langer, Bastien & Vallie`res, 2005), psychological
distress, insomnia severity, and treatment (taper alone,
cognitive-behavior therapy for insomnia or a combined approach)
were identified as significant predictors of relapse.