Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep: The YAWNS NB Randomized Clinical Trial
Open accessAbstract
Importance: Direct-to-patient interventions enabling transitions from long-term benzodiazepine receptor agonist (BZRA) use to cognitive behavioral therapy for insomnia (CBTI) by older adults has the potential to reduce BZRA use and related harms while improving sleep outcomes without requiring prearranged clinician involvement. Objective: To compare 2 direct-to-patient behavior change interventions with treatment as usual (TAU) on BZRA use, sleep, and other health outcomes, and uptake of CBTI techniques. Design, Setting, and Participants: The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study was a 3-arm, pragmatic, open-label, minimum-contact, randomized clinical trial. The study began November 2020 and ended June 2022. Participants were randomly allocated to 1 of 3 groups, including 2 different mailed behavior change interventions or no intervention (TAU). Participants were from communities across the province of New Brunswick, Canada, and included adults 65 years and older living independently with long-term use of BZRAs and current or past insomnia. Interventions: The Sleepwell package (YAWNS-1) consisted of a cover letter and 2 booklets (“How to Stop Sleeping Pills” and “How to Get Your Sleep Back”). The other package (YAWNS-2) included updated versions of the 2 booklets (“You May Be at Risk” and “How to Get a Good Night’s Sleep Without Medication”) used in the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) study. Main Outcomes and Measures: BZRA use at 6 months was the primary measure. Secondary measures included CBTI use, sleep, insomnia, daytime sleepiness, safety, anxiety, frailty, and quality of life. Results: A total of 1295 individuals expressed interest in the study, and 565 (43.6%) completed a baseline assessment. Participants had a mean (SD) age of 72.1 (5.7) years, a mean (SD) BZRA use duration of 11.4 (9.1) years, and 362 (64.1%) were female. Discontinuations and dose reductions of 25% or greater were highest with YAWNS-1 (50 of 191 [26.2%]; 39 of 191 [20.4%]; total, 46.6%) compared with YAWNS-2 (38 of 187 [20.3%]; 27 of 187 [14.4%]; total, 34.8%, P = .02) and TAU (14 of 187 [7.5%]; 24 of 187 [12.8%]; total, 20.3%, P < .001). YAWNS-1 also demonstrated better uptake of CBTI techniques and sleep outcomes compared with YAWNS-2 (new CBTI techniques: 3.1 vs 2.4; P =.03; sleep efficiency change: 4.1% vs −1.7%; P =.001) and reduced insomnia severity and daytime sleepiness compared with TAU (insomnia severity index change: −2.0 vs 0.3; P <.001; Epworth Sleepiness Scale change: −0.8 vs 0.3; P =.001). Conclusions and Relevance: Results of the YAWNS NB randomized clinical trial show that, as a simple, scalable, direct-to-patient intervention, YAWNS-1 substantially reduced BZRA use and improved sleep outcomes. It could be implemented to transform insomnia care for older adults at the population level. Trial Registration: ClinicalTrials.gov Identifier: NCT04406103
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Three studies reported that outcome assessors were unblinded.
“Three studies reported that outcome assessors were unblinded (reasons were open-label trial [41], differences in the data collected between arms [34] and outcome assessors part of the clinical team [70]).”
From Blinding outcome assessors in randomised controlled trials of psychological interventions: how is it done? A narrative review (2026) · cites this paper as [41]
Findings regarding self-guided CBT-I are inconsistent; some studies demonstrated a significant reduction in Z-drug use among intervention groups compared to controls, while another study reported no significant effect on hypnotic discontinuation.
“Findings regarding self-guided CBT-I are inconsistent. While some studies 78 79 have demonstrated a significant reduction in Z-drug use among individuals in the intervention groups compared to the controls, another study 77 reported no significant effect on hypnotic discontinuation.”
From Z-drug abuse and dependence: Clinical guideline of the Brazilian Academy of Neurology for diagnosis and management (2025) · cites this paper as [79]
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- Authors
- Gardner, D. M., Turner, J. P., Magalhaes, S., Rajda, M., & Murphy, A. L.
- Affiliations
- Dalhousie University (CA)
- Monash University (AU)
- University of New Brunswick (CA)
- Corresponding author
- Gardner, David M.
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2024-12-01
- Volume
- 81
- Issue
- 12
- Pages
- 1187
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC11411453
- OpenAlex
- W4402599281
- Cited by
- 19
- References
- 64
- Citations by year
- 2026: 9 · 2025: 10
- FWCI
- 7.77
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- benzodiazepine receptor agonists, benzodiazepine discontinuation, cognitive behavioral therapy for insomnia, older adults, insomnia, sleep quality, daytime sleepiness, drug safety, patient self-management, frailty, quality of life, anxiety
- MeSH terms
- Aged, Aged, 80 and over, Female, Humans, Hypnotics and Sedatives, Sleep Initiation and Maintenance Disorders, Male, New Brunswick, Cognitive Behavioral Therapy
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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