Association of a stellate ganglion block-based care pathway with hypnotic medication reduction in chronic insomnia with anxiety symptoms: a real-world retrospective cohort study.

BACKGROUND

Chronic insomnia with anxiety symptoms is frequently accompanied by sustained hypnotic or sedative medication use. Evidence regarding procedure-based adjuncts to structured medication reduction remains limited.

OBJECTIVE

To evaluate whether participation in a stellate ganglion block (SGB)-based care pathway, compared with contemporaneous routine care without SGB, was associated with hypnotic or sedative medication reduction at 1 month.

METHODS

This single-center retrospective cohort study screened 420 records from 1 January 2022 to 31 December 2025 and included 160 adults with chronic insomnia, anxiety symptoms, and baseline hypnotic or sedative use. Eighty patients received a standardized four-session SGB-based pathway and 80 routine-care controls were selected by outcome-blinded, 1:1 calendar-time risk-set sampling without replacement. The pragmatic 1 month composite outcome was achievement of at least one of the following: a ≥50% reduction in the exploratory operational medication-burden score, transition from combination therapy to monotherapy, or complete discontinuation maintained for ≥2 weeks. Components and class-specific benzodiazepine and Z-drug outcomes were analyzed separately. The primary adjusted model was restricted to age, sex, baseline operational burden, and baseline medication count. Robust Poisson, Firth logistic, marginal standardization, bootstrap, propensity-score matching, overlap weighting, and trimmed stabilized inverse probability weighting were used.

RESULTS

The composite outcome occurred in 32/80 patients (40.0%) in the SGB-based pathway group and 12/80 (15.0%) under routine care (crude risk difference, 25.0 percentage points; 95% CI, 11.7-38.3; crude RR, 2.67; 95% CI, 1.48-4.79). The core robust Poisson model yielded an adjusted RR of 2.43 (95% CI, 1.32-4.46), and marginal standardization yielded adjusted risks of 38.0% vs. 16.7% and an adjusted risk difference of 21.3 percentage points (95% CI, 8.9-32.3). The association was primarily driven by ≥50% operational-burden reduction (33.8% vs. 11.2%; adjusted RR, 2.77; 95% CI, 1.34-5.75). Transition to monotherapy and complete discontinuation were numerically more frequent but imprecisely estimated. Class-specific analyses supported an association with ≥50% benzodiazepine dose reduction; Z-drug analyses were directionally similar but less precise. Three month maintained response remained more frequent after conservative and censoring-weighted analyses. Fifteen of 80 SGB-treated patients had a recorded procedure-related event; no serious event was recorded.

CONCLUSION

Participation in an SGB-based care pathway was associated with a higher probability of short-term medication reduction, particularly substantial dose reduction, but evidence for complete discontinuation was inconclusive. Because treatment allocation and co-interventions were nonrandomized, the results do not establish an independent causal effect of SGB.