Tai Chi as a Long-term Alternative to CBT-I for Chronic Insomnia in Older Adults: A Randomized Non-inferiority Trial

Introduction: The Growing Burden of Insomnia in an Aging Population

Chronic insomnia remains one of the most prevalent and debilitating health concerns among middle-aged and older adults. Characterized by persistent difficulty in falling asleep, staying asleep, or experiencing non-restorative sleep, the condition affects approximately 10% to 30% of the global population, with higher rates observed in geriatric cohorts. Beyond the immediate symptoms of fatigue and irritability, chronic insomnia is a significant risk factor for cardiovascular disease, metabolic syndrome, cognitive decline, and psychiatric disorders such as depression and anxiety.

Currently, Cognitive Behavioral Therapy for Insomnia (CBT-I) is recognized globally as the first-line treatment. CBT-I is a multicomponent intervention that addresses the behavioral, cognitive, and physiological factors that perpetuate sleep disturbances. However, despite its established efficacy, CBT-I faces several barriers to widespread implementation, including a shortage of trained therapists, high costs, and varying levels of patient adherence to its rigorous behavioral requirements. Consequently, there is an urgent clinical need to identify evidence-based, accessible, and sustainable alternative therapies for long-term insomnia management.

The Study: Tai Chi vs. CBT-I

A recent randomized, assessor-masked, non-inferiority trial published in the BMJ (Siu et al., 2025) investigated whether Tai Chi, a traditional Chinese mind-body exercise, could serve as a non-inferior alternative to CBT-I. The study focused on Chinese participants aged 50 and older who met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for chronic insomnia.

Tai Chi has long been hypothesized to improve sleep through its unique combination of physical movement, breath control, and meditative focus. Previous smaller studies have suggested its benefits, but this trial specifically aimed to measure its performance against the gold standard—CBT-I—over an extended 15-month period.

Trial Design and Methodology

The research was conducted at a single site in Hong Kong, recruiting 200 participants from the community between May 2020 and July 2022. Participants were randomized in a 1:1 ratio to either a Tai Chi group (n=100) or a CBT-I group (n=100).

Both interventions were delivered in a group format over a three-month period. Each group received two one-hour sessions per week, totaling 24 sessions. The CBT-I protocol included standard components such as stimulus control, sleep restriction, sleep hygiene education, and cognitive restructuring. The Tai Chi protocol focused on standardized movements emphasized in the 24-form Yang style, emphasizing the integration of mind and body.

The primary outcome measure was the change in the Insomnia Severity Index (ISI) score, a validated self-report tool ranging from 0 to 28, where higher scores indicate greater severity. Measurements were taken at baseline, immediately after the 3-month intervention, and at a 12-month follow-up (month 15). To establish non-inferiority, the researchers set a margin of 4 points on the ISI scale. If the upper limit of the 95% confidence interval (CI) for the difference between groups remained below 4, Tai Chi would be considered non-inferior to CBT-I.

Key Findings: Short-term Inferiority, Long-term Convergence

Immediate Post-Intervention Results (Month 3)

At the end of the 12-week intervention, both groups showed significant improvements in sleep. However, CBT-I demonstrated a more rapid and robust reduction in symptoms. The CBT-I group’s ISI scores decreased by an average of 11.19 points (95% CI: 10.06 to 12.32). In contrast, the Tai Chi group saw a reduction of 6.67 points (95% CI: 5.61 to 7.73).

The between-group difference at this stage was 4.52. Because the upper confidence limit exceeded the pre-defined 4-point non-inferiority margin, Tai Chi was statistically deemed inferior to CBT-I for immediate symptom relief. This suggests that for patients requiring rapid stabilization of severe insomnia, CBT-I remains the superior clinical choice.

Long-term Follow-up Results (Month 15)

The most compelling aspect of the study emerged during the 12-month follow-up period. By month 15, the gap between the two interventions narrowed significantly. The Tai Chi group continued to show improvement or sustained their gains, with a total reduction of 9.51 points (95% CI: 8.47 to 10.54) from baseline. The CBT-I group showed a total reduction of 10.18 points (95% CI: 8.97 to 11.40).

The between-group difference at 15 months was only 0.68. Critically, the upper confidence limit for this difference fell well within the 4-point non-inferiority margin. This led the researchers to conclude that Tai Chi is non-inferior to CBT-I for the long-term management of chronic insomnia.

Safety and Adherence

No adverse events were reported in either group throughout the study. This reinforces the safety profile of Tai Chi as a low-impact exercise suitable for aging populations who may have comorbid physical limitations.

Mechanistic Insights: Why Tai Chi Works Differently

The divergence in short-term and long-term results highlights the different mechanisms at play. CBT-I works by aggressively breaking the cycle of conditioned arousal. Techniques like sleep restriction and stimulus control provide an immediate, albeit sometimes difficult, correction of sleep-thwarting behaviors.

Tai Chi, conversely, likely operates through more gradual physiological and psychological pathways. It has been shown to modulate the hypothalamic-pituitary-adrenal (HPA) axis, reducing the levels of stress hormones like cortisol that contribute to hyperarousal. Additionally, the rhythmic movement and deep breathing of Tai Chi enhance parasympathetic nervous system activity, promoting a state of relaxation conducive to sleep. The physical activity component also helps regulate the homeostatic sleep drive, though more slowly than the direct behavioral interventions of CBT-I.

Expert Commentary and Clinical Implications

From a clinical perspective, these findings are highly significant. While CBT-I remains the preferred starting point for acute or severe cases, Tai Chi offers a valuable alternative for patients who cannot access CBT-I, those who find CBT-I protocols (like sleep restriction) too taxing, or those looking for a holistic approach to long-term health.

Health policy experts may also view these results as a call to integrate mind-body interventions into community-based care. Tai Chi is cost-effective, can be practiced in large groups, and requires minimal equipment, making it an ideal candidate for public health initiatives targeting the aging population.

However, some limitations should be noted. The study was conducted in a specific cultural context (Hong Kong) with Chinese participants, which may affect the generalizability of the findings to other populations. Additionally, while the 15-month follow-up is a strength, further research is needed to determine if these benefits persist beyond the one-year mark without continued instruction.

Conclusion

The trial (NCT04384822) confirms that while Tai Chi does not match the rapid efficacy of CBT-I, it is a formidable long-term strategy for managing chronic insomnia. For the millions of middle-aged and older adults struggling with sleep, Tai Chi represents a safe, effective, and sustainable path to better rest and improved quality of life.

Funding and Trial Registration

This study was supported by various research grants and the findings were published in the BMJ. Trial Registration: ClinicalTrials.gov NCT04384822.

References

Siu PM, Yu DJ, Yu AP, et al. Tai chi or cognitive behavioural therapy for treating insomnia in middle aged and older adults: randomised non-inferiority trial. BMJ. 2025;391:e084320. doi:10.1136/bmj-2025-084320.