Cognitive behavioral therapy for insomnia–assisted discontinuation or reduction of benzodiazepine receptor agonists and Z-drugs in chronic insomnia: A systematic review and meta-analysis
- 1Department of Nursing, The Affiliated Traditional Chinese Medicine Hospital, Guangzhou Medical University, China
- 2Department of Medicine, Meizhou Second Chinese Medicine Hospital, China
- 3College of Medicine, Jiaying University, China
Abstract
Background: Long term use of benzodiazepine receptor agonists and Z-drugs for chronic insomnia is associated with challenges, including dependence, withdrawal, rebound insomnia, cognitive impairment, and falls. Cognitive behavioral therapy for insomnia (CBT-I) may support hypnotic deprescribing; however, the certainty of evidence supporting this approach remains unclear.
Methods: This systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered in PROSPERO (CRD420261399947). Randomized controlled trials evaluating CBT-I, CBT-I–informed, digital, blended, or behavioral-component interventions delivered in the context of benzodiazepine receptor agonist/Z-drug discontinuation or dose reduction were included. Risk of bias was assessed using the risk of bias 2 tool, and the certainty of evidence was rated using Grading of Recommendations Assessment, Development and Evaluation. PubMed was rerun on 2 July 2026 without the randomized-trial search block as a targeted sensitivity search.
Results: Thirteen randomized controlled trials were included. After assigning Gardner et al. 2024 only to the longest-follow-up analysis, 6 trials involving 298 participants contributed to early complete discontinuation. The pooled estimate favored CBT-I–assisted interventions, although the evidence remained uncertain (risk ratio = 1.35, 95% confidence interval: 0.87 to 2.11; I2 = 59.8%). Evidence for complete discontinuation at the longest available follow-up was highly uncertain (4 trials; 543 participants; risk ratio = 1.64, 95% confidence interval: 0.45 to 5.89; I2 = 84.3%). Dose-reduction outcomes were not pooled as confirmatory endpoints because thresholds and time points differed, and repeated time points from the same trial could not be treated as independent observations. No clear difference was found in dropout or intervention noncompletion (10 trials; 885 participants; risk ratio = 0.93, 95% confidence interval: 0.40 to 2.16; I2 = 58.6%). Post-treatment Insomnia Severity Index scores were lower with CBT-I–assisted interventions (3 trials; 126 analyzed participants; mean difference = −4.73, 95% confidence interval: −8.46 to −0.99; I2 = 0%); however, the evidence remained uncertain because the synthesis was based on three small trials.
Conclusions: This review does not provide high-certainty evidence that CBT-I–assisted interventions reliably improve complete discontinuation of benzodiazepine receptor agonists or Z-drugs. CBT-I may nevertheless have clinical value as a behavioral component of individualized deprescribing programs by supporting dose reduction and insomnia-related coping during gradual tapering. Larger trials with standardized outcomes, long-term follow-up, and complete safety reporting are needed.
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BibTeX
@article{zhang2026cognitive,
title = {{Cognitive behavioral therapy for insomnia–assisted discontinuation or reduction of benzodiazepine receptor agonists and Z-drugs in chronic insomnia: A systematic review and meta-analysis}},
author = {Chuanji Zhang and Lei Yang and Jiapeng Zhang},
journal = {The Journal of International Medical Research},
year = {2026},
month = sep,
doi = {10.1177/03000605261487272},
url = {https://doi.org/10.1177/03000605261487272},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Cognitive behavioral therapy for insomnia–assisted discontinuation or reduction of benzodiazepine receptor agonists and Z-drugs in chronic insomnia: A systematic review and meta-analysis
AU - Chuanji Zhang
AU - Lei Yang
AU - Jiapeng Zhang
PY - 2026
DA - 2026/09/17
JO - The Journal of International Medical Research
DO - 10.1177/03000605261487272
UR - https://doi.org/10.1177/03000605261487272
AB - Background: Long term use of benzodiazepine receptor agonists and Z-drugs for chronic insomnia is associated with challenges, including dependence, withdrawal, rebound insomnia, cognitive impairment, and falls. Cognitive behavioral therapy for insomnia (CBT-I) may support hypnotic deprescribing; however, the certainty of evidence supporting this approach remains unclear. Methods: This systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered in PROSPERO (CRD420261399947). Randomized controlled trials evaluating CBT-I, CBT-I–informed, digital, blended, or behavioral-component interventions delivered in the context of benzodiazepine receptor agonist/Z-drug discontinuation or dose reduction were included. Risk of bias was assessed using the risk of bias 2 tool, and the certainty of evidence was rated using Grading of Recommendations Assessment, Development and Evaluation. PubMed was rerun on 2 July 2026 without the randomized-trial search block as a targeted sensitivity search. Results: Thirteen randomized controlled trials were included. After assigning Gardner et al. 2024 only to the longest-follow-up analysis, 6 trials involving 298 participants contributed to early complete discontinuation. The pooled estimate favored CBT-I–assisted interventions, although the evidence remained uncertain (risk ratio = 1.35, 95% confidence interval: 0.87 to 2.11; I2 = 59.8%). Evidence for complete discontinuation at the longest available follow-up was highly uncertain (4 trials; 543 participants; risk ratio = 1.64, 95% confidence interval: 0.45 to 5.89; I2 = 84.3%). Dose-reduction outcomes were not pooled as confirmatory endpoints because thresholds and time points differed, and repeated time points from the same trial could not be treated as independent observations. No clear difference was found in dropout or intervention noncompletion (10 trials; 885 participants; risk ratio = 0.93, 95% confidence interval: 0.40 to 2.16; I2 = 58.6%). Post-treatment Insomnia Severity Index scores were lower with CBT-I–assisted interventions (3 trials; 126 analyzed participants; mean difference = −4.73, 95% confidence interval: −8.46 to −0.99; I2 = 0%); however, the evidence remained uncertain because the synthesis was based on three small trials. Conclusions: This review does not provide high-certainty evidence that CBT-I–assisted interventions reliably improve complete discontinuation of benzodiazepine receptor agonists or Z-drugs. CBT-I may nevertheless have clinical value as a behavioral component of individualized deprescribing programs by supporting dose reduction and insomnia-related coping during gradual tapering. Larger trials with standardized outcomes, long-term follow-up, and complete safety reporting are needed.
SN - 0300-0605
SN - 1473-2300
ER -