***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This study asks whether insomniacs undergoing behavioral training  need to do so while totally free of hypnotics . Twenty-six insomniacs participated in the study , which included extensive monitoring of sleep both in the laboratory and at home . All subjects received six sessions of training in sleep hygiene and relaxation . About half the subjects were also given a hypnotic for occasional use ; the others were asked to abstain from all hypnotics . Follow-up was performed immediately after treatment and again 10 months later . When compared with a waiting list , 6 hours of behavioral therapy improved insomniacs ' sleep latency and sleep efficiency immediately after treatment , whether or not hypnotics were given concomitantly . Immediately following the 6 hours of therapy , those who had combined pharmacotherapy and behavior therapy improved about the same as those who had received behavior therapy alone . However , on the 10-month follow-up , those who had learned sleep hygiene and relaxation without the help of occasional hypnotics had more sleep and a better sleep efficiency than those who had been allowed an occasional hypnotic . We conclude that when teaching sleep hygiene and behavioral therapy to insomniacs , it might be advantageous to disallow the concomitant use of hypnotics as needed Dysfunctional beliefs and attitudes about sleep are presumed to play an important mediating role in perpetuating insomnia . The present study evaluated the impact of cognitive-behavioral and pharmacological treatments for insomnia on sleep-related beliefs and attitudes and the relationship between those changes and sleep improvements . The participants were older adults with chronic and primary insomnia . They received cognitive-behavior therapy ( CBT ) , pharmacotherapy ( PCT ) , combined CBT+PCT ( COMB ) , or a medication placebo ( PLA ) . In addition to daily sleep diaries and sleep laboratory measures , the participants completed the dysfunctional beliefs and attitudes about sleep scale ( DBAS ) at baseline and posttreatment , and at 3- , 12- and 24-month follow-up assessment s. The results showed that CBT and COMB treatments produced greater improvements of beliefs and attitudes about sleep at posttreatment than PCT and PLA . Reductions of DBAS scores were significantly correlated with improvements of sleep efficiency as measured by daily sleep diaries and by polysomnography . In addition , more adaptive beliefs and attitudes about sleep at posttreatment were associated with better maintenance of sleep improvements at follow-ups . These findings highlight the importance of targeting sleep-related beliefs and attitudes in the treatment of insomnia A sample of 21 medicated and 20 nonmedicated insomniacs participated in a sleep medication withdrawal program  that provided education about sleep medication and a , gradual medication withdrawal schedule . Ten medicated participants received stimulus control treatment and the withdrawal program , and 11 medicated participants served as a control grouip that received only the withdrawal program . Half of the nonmedicated participants received stimulus control , and the remaining nommedicated participants served as a wait-list control condition . Medicated participants significantly reduced sleep medication use without significant deterioration on sleep , anxiety , or depression measures from baseline to 8-week follow-up . Stimulus control participants , unlike control group participants , showed significant improvement at follow-up for total sleep time , sleep efficiency , and sleep quality . Stimulus control participants also reported less daytime sleepiness than control participants after treatment . Nonmedicated participants exhibited a more positive response to stimulus control than medicated participants CONTEXT Use of nonpharmacological behavioral therapy has been suggested for treatment of chronic primary insomnia , but well-blinded , placebo-controlled trials demonstrating effective behavioral therapy for sleep-maintenance insomnia are lacking . OBJECTIVE To test the efficacy of a hybrid cognitive behavioral therapy ( CBT ) compared with both a first-generation behavioral treatment and a placebo therapy for treating primary sleep-maintenance insomnia . DESIGN AND SETTING R and omized , double-blind , placebo-controlled clinical trial conducted at a single academic medical center , with recruitment from January 1995 to July 1997 . PATIENTS Seventy-five adults ( n = 35 women ; mean age , 55.3 years ) with chronic primary sleep-maintenance insomnia ( mean duration of symptoms , 13.6 years ) . INTERVENTIONS Patients were r and omly assigned to receive CBT ( sleep education , stimulus control , and time-in-bed restrictions ; n = 25 ) , progressive muscle relaxation training ( RT ; n = 25 ) , or a quasi-desensitization ( placebo ) treatment ( n = 25 ) . Outpatient treatment lasted 6 weeks , with follow-up conducted at 6 months . MAIN OUTCOME MEASURES Objective ( polysomnography ) and subjective ( sleep log ) measures of total sleep time , middle and terminal wake time after sleep onset ( WASO ) , and sleep efficiency ; question naire measures of global insomnia symptoms , sleep-related self-efficacy , and mood . RESULTS Cognitive behavioral therapy produced larger improvements across the majority of outcome measures than did RT or placebo treatment . For example , sleep logs showed that CBT-treated patients achieved an average 54 % reduction in their WASO whereas RT-treated and placebo-treated patients , respectively , achieved only 16 % and 12 % reductions in this measure . Recipients of CBT also showed a greater normalization of sleep and subjective symptoms than did the other groups with an average sleep time of more than 6 hours , middle WASO of 26.6 minutes , and sleep efficiency of 85.1 % . In contrast , RT-treated patients continued to report a middle WASO of 43.3 minutes and sleep efficiency of 78.8 % . CONCLUSIONS Our results suggest that CBT represents a viable intervention for primary sleep-maintenance insomnia . This treatment leads to clinical ly significant sleep improvements within 6 weeks and these improvements appear to endure through 6 months of follow-up Discontinuous , nonnightly hypnotic therapy in the treatment of chronic insomnia is likely to offer benefits such as maintained efficacy while preventing unnecessary long-term nightly use associated with the risk of tolerance and dependence . Based on the favorable results seen in four zolpidem studies using increasing degrees of flexibility in drug intake schedule , we developed the concept further and investigated “ as needed ” zolpidem pharmacotherapy amended by the optional use of stimulus control in conditions close to the “ real life ” practice . In a prospect i ve , observational open study in 550 primary care setting s throughout Germany , 2690 patients with chronic insomnia ( mean age 59 years , 66 % female , 50 % with pharmacotherapy pretreatment ) were treated with zolpidem according to an “ as-needed ” ( pro re nata ) administration treatment schedule ( up to five tablets per week , intake nights chosen by the patient ) , amended by the optional use of behavioral therapy ( stimulus control ) during drug-free nights . After the three weeks ' treatment period , in two thirds of patients ( 63 % ) the weekly number of tablets used was reduced in contrast to baseline . The average zolpidem tablet number taken decreased by 28 % ( from 3.7 to 2.6 per week ; p < 0.00001 ) without any significant impact on the treatment efficacy assessed through the CGI . The subjective latency to sleep onset was reduced from a mean of 74 27 min ( p < 0.00001 ) and total sleep time increased from 5.0 to 6.8 h ( p < 0.00001 ) . Efficacy of treatment was rated as very good or good in 93 % by the investigators . Adverse events were observed only in 1.2 % of patients and were generally of mild nature . No serious adverse event occurred . These results underline the validity of the zolpidem “ as needed ” treatment concept . It is feasible in a safe and effective manner also in a primary care setting and can be amended by stimulus control . Further research is warranted on the contributions of both treatment components to effectiveness and on the efficacy and safety issues of long-term use OBJECTIVES This study was conducted to test the effectiveness of an abbreviated cognitive-behavioral insomnia therapy ( ACBT ) with primary DESIGN A single-blind , r and omized group design was used in which study patients were r and omized to either a brief , 2-session ACBT or a similarly brief intervention ( SHC ) that included only generic sleep hygiene recommendations . SETTING A university-affiliated Department of Veterans Affairs medical center . PARTICIPANTS Twenty ( 2 women ) veteran patients ( M(age ) = 51.0 yrs . , SD = 13.7 years ) who met criteria for chronic primary insomnia . MEASUREMENTS AND RESULTS Participants completed sleep logs for 2 weeks and question naires to measures insomnia symptoms , sleep-related self-efficacy , and dysfunctional beliefs about sleep before treatment , during a 2-week posttreatment assessment , and again at a 3-month posttreatment follow-up . Statistical analyses showed that ACBT produced significantly larger improvements across a majority of outcome measures than did SHC . Case-by-case analyses showed that only the ACBT produced consistent positive effects across study patients , and a sizeable proportion of these patients receiving this treatment achieved clinical ly significant improvements by their study endpoints . Approximately 52 % of those receiving the ACBT reported at least a 50 % reduction in their wake time after sleep onset , and 55.6 % of ACBT-treated patients who entered the study with pathologic scores on an Insomnia Symptom Question naire ( ISQ ) , achieved normal ISQ scores by their final outcome assessment . CONCLUSIONS ACBT is effective for reducing subjective sleep disturbance and insomnia symptoms in primary care patients Fifty-four adults with primary insomnia were r and omly assigned to a self-help treatment ( cognitive-behavioral bibliotherapy [ BT ] ) , BT with weekly phone consultations , or a waiting-list control ( WL ) group . Treated participants were mailed 6 treatment booklets at the rate of 1 booklet per week ; 1/2 of them also received minimal professional guidance through a 15-min weekly phone consultation . The WL group members continued to monitor their sleep during this period . Participants in both treatment conditions improved significantly on the main outcome variables ( total wake time and sleep efficiency ) at posttreatment , whereas WL participants remained unchanged . The addition of weekly phone calls slightly enhanced improvements at posttreatment . However , both treatment conditions were comparable at follow-up . These results suggest that BT , with or without minimal professional guidance , is an effective approach for treating primary insomnia Chronic insomnia is a very common clinical condition which may respond well to non-pharmacological treatment . Indeed , the literature supports the efficacy of cognitive behaviour therapy ( CBT ) . However , there has been no substantial study of clinical effectiveness . Since insomniacs typically present in general medical practice this is a crucial gap in the outcome research . This study , therefore , specifically investigated the clinical effectiveness of CBT delivered by Health Visitors ( primary care nurses ) trained as therapists . One hundred and thirty-nine insomniacs ( mean age 51 yr ) were r and omised to CBT or Self-Monitoring Control ( SMC ) in a controlled trial . CBT comprised six group sessions ( n=4 to 6 patients ) . After the controlled phase , SMC patients entered deferred treatment ( CBT-DEF ) , allowing both treatment replication and long-term outcome to be investigated for a sizeable , treated sample . Repeated measures ANOVAs demonstrated superiority of CBT over SMC in substantially reducing sleep latency and wakefulness during the night . CBT-DEF replicated similar effects and maintained improvement was observed in both groups one year later . Furthermore , total sleep increased significantly during follow-up and 84 % of patients initially using hypnotics remained drug-free . Results suggest that CBT administered by Health Visitors offers a clinical ly effective treatment for insomnia 
    Output:
    
Among beneficial outcomes , improvement of sleep efficacy , sleep onset latency and wake after sleep onset were the most frequently reported .
In addition , participants significantly reduced sleep medication use .
Some studies gave follow-up data which indicated that the CBT produced durable clinical changes in total sleep time and night-time wakefulness .
CONCLUSIONS These r and omized controlled trial studies demonstrated that CBT was superior to any single-component treatment such as stimulus control , relaxation training , educational programmes , or other control conditions .