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Daily Medical Update
Insomnia (CBT-I, pharmacotherapy safety)
Sunday, March 08, 2026
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🔬 Practice‑Changing Findings
Evidence from RCTs and meta‑analyses published in the last 12 months.
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JMIR Mental Health (2025) - Randomized Controlled Trial
Key Findings
- In 336 adults with DSM-5 insomnia, SleepioRx improved insomnia severity versus sleep hygiene at 10 weeks (Cohen d=0.60, P<.001), with sustained effect at 24 weeks (d=0.77, P<.001).
- Digital CBT-I increased odds of clinical response (OR 2.52) and remission (OR 5.78) at week 10 versus control (both P<.001).
📋 Practice Implication: Make prescription digital CBT-I a default first-line option when local therapist-delivered CBT-I access is delayed or unavailable.
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Sleep Medicine (2026) - Randomized Controlled Trial
Key Findings
- In adults with insomnia and mood symptoms, dCBT-I achieved greater hypnotic medication reduction than digital sleep hygiene at weeks 4, 8, and 12.
- Participants in the dCBT-I arm maintained superior taper trajectory while also improving insomnia severity over follow-up.
📋 Practice Implication: When patients request chronic refill continuation, offer dCBT-I plus a documented week-by-week taper protocol instead of dose maintenance.
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Sleep Medicine (2026) - Systematic Review/Meta-analysis
Key Findings
- Across 77 placebo-controlled trials (16,416 participants), DORAs increased subjective total sleep time by 18.91 minutes.
- DORAs increased treatment-emergent somnolence risk (RR 2.91), while insomnia adverse-event rates were not different from placebo (RR 0.97).
📋 Practice Implication: If nonpharmacologic therapy is inadequate, prefer DORAs over benzodiazepine-receptor agonists in higher-risk adults while proactively monitoring daytime sedation.
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Sleep Medicine (2026) - Randomized Controlled Trial
Key Findings
- In a taper-plus-behavioral trial, 58.6% achieved benzodiazepine/Z-drug abstinence and 29.9% reduced dose by >50% at 12 months.
- There was no significant difference between single-session CBT-I support and full ACT-I on abstinence outcomes when both were paired with tapering.
📋 Practice Implication: Adopt a low-resource deprescribing model (brief CBT-I session + scheduled taper calls) for long-term hypnotic users in primary care panels.
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BMJ (2025) - Randomized Non-inferiority Trial
Key Findings
- Tai chi was inferior to CBT-I at 3 months for ISI reduction but met non-inferiority at 15 months in adults aged 50 years or older.
- No intervention-related adverse events were reported during the trial period.
📋 Practice Implication: For older adults declining psychotherapy or sedatives, prescribe structured tai chi as a safer long-horizon insomnia management pathway.
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Recent high-level evidence reinforces CBT-I (including digital formats) as first-line care for chronic insomnia, with measurable gains in remission and sustained benefit. For patients needing medication, dual orexin receptor antagonists and newer agents improve sleep continuity but require explicit next-day sedation counseling. The most practice-changing development for primary care is pairing behavioral treatment with structured hypnotic deprescribing pathways.
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