How should kind of clinicians interpret these different types of approaches and, you know, just give a little bit of more detail on, you know, what these recommendations actually show for clinicians themselves.

Yes, sure, happy to.

So there were really two focused, but I think highly clinically relevant recommendations that came out of these clinical practice guidelines.

The first was that we recommended that in adults with chronic insomnia disorder, that combination treatment with CBT-I plus medication be used over insomnia medication alone.

And, and we came to that recommendation for a couple of reasons.

First, we found that there were clinically meaningful improvement in cr- various critical outcomes that we defined, and the harms of combination therapy was not significantly different from the harms of pharmacotherapy alone.

Yeah, one of the, one of the considerations we had is, uh, that there are possible health equity concerns if, um, if CBT-I is unavailable to some patients and, uh, or, or unaffordable for that particular recommendation.

Was there anything that you and your colleagues, you know, had trouble actually writing recommendations for? Or, you know, were there things that may have been kind of left off that you guys didn't fully have a lot of answers to that kind of maybe didn't make it into these recommendations?

Okay.

We had to have a discussion as a committee about how we were gonna define combination therapy, 'cause you can define it in various ways.

And where we landed was that we defined it, it, for the purposes of this guideline, as the concurrent initiation, i.e. at the same time of a medicine and a behavioral psychological treatment.

And that was largely because most of the randomized controlled trials we wanted to use, you'd use to the extent possible the highest grade evidence, so randomized controlled trials generally followed that kind of, uh, of process where people would initiate concurrently the behavioral and the, um, and the medication treatment.

We recognize, though, that in practice, sequential treatment is often, as, as Dr. Buysse said off the top, often, uh, more commonly practiced.

But in the s- in the-- first of all, there are few sequential designs, randomized controlled trial studies.

And secondly, there are methodological issues often with those designs around lack of randomization or lack of information about baseline, um, symptom severity.

Let's talk about that