Discussion
depressive, insomnia, depressive symptoms
The current study showed that first-stage treatment with BT or zolpidem was effective in reducing daytime symptoms of insomnia, with no significant differences between groups. The addition of a second-stage therapy resulted in an added value in enhancing daytime functions. In particular, immediate effects of second-stage therapies were observed for sequences that used zolpidem as the initial treatment, while delayed effects were made with sequences starting with BT at 12-month follow-up. Overall, these findings provide further support for the efficacy of CBT and sleep-promoting medication for improving daytime functions among patients with insomnia.Although some studies have previously reported benefits of CBT on daytime outcomes,At the end of second-stage therapy, although patients in the 2 groups starting with zolpidem showed further improvements for most daytime outcomes, only patients who switched from pharmacotherapy to psychological treatment (from zolpidem to BT) reported greater reductions in depressive severity. This finding aligned with our hypothesis that switching treatment modalities would lead to greater treatment benefits, although it needs to be interpreted cautiously given the smaller sample size for the treatment sequence involving 2 medications and the mild range of depressive symptoms. In the treatment sequences starting with BT, patients who received 2 treatments within the same modality (from BT to CT) had slightly better outcomes than those who switched modality (from BT to zolpidem) at 12-month follow-up, which may be partially attributed to the broader action of CT by targeting psychological and mood symptoms compared with zolpidem.