Cognitive Behavioral Therapy for Insomnia (CBTi) is the most effective treatment for chronic insomnia and chronic insomnia is a major risk factor for developing chronic depression.
A colleague of ours, who is an expert in sleep, suggested, only somewhat in jest, that mood disorders should be considered a type of sleep disorder. Part of what he was talking about is new evidence that what drives mood instability for many people is disrupted sleep (and wakefulness) rhythms.
As we mentioned, the most effective treatment for insomnia is not medication at all, but rather cognitive behavioral therapy. Scroll to the bottom of the page to find information about a program that can be done using your computer and the internet that has helped many of our readers with long term significant improvements in the quality of their sleep.
The two approaches that seem to work are:
1. Sleep hygiene therapy. This focuses on trying to make sure that the room that you’re going to sleep in is cool, dark and quiet, and that you’re making an appropriate transition to sleep (not trying to go 1,000 miles an hour and then just hoping that your brain will shut off when you lie down).
2. Sleep restriction therapy. The focus of this treatment is trying to get people who may have developed anxiety about not sleeping (Oh my God I can’t get to sleep again, I am going to be a wreck tomorrow, I have to get asleep… etcetera) to re-associate their bed with relaxation and sleeping rather than with worrying. People are allowed to be in bed for a limited amount of time (short enough so that it will quickly guarantee that the person is sleeping almost all of the time they are in bed). Gradually that amount of time is increased until the person has a stable daily routine of sleep.
Causes of Insomnia:
One of the most frequent causes of insomnia is anxiety. Insomnia of this kind is caused by increased activation of the sympathetic nervous system at night. The body releases norepinephrine (the flight or fight hormone) at night when that system should be inactive.
You wake up and you feel “wide awake.”
There are several sleep hygiene techniques that can lead to a better night’s sleep. These include:
– Keep a regular sleep schedule – our bodies and brains cannot change the times we sleep suddenly, before electricity the time we went to sleep and the time we woke up never varied by more than a few minutes a day.
– Avoid forcing sleep
– Exercise regularly for at least 20 minutes a day 4-5 hours before bedtime
– Avoid smoking
– Do not go to bed hungry
– Adjust the bedroom environment – make sure that your room is cold and dark and quiet.
– Deal with your worries before bedtime – it may be helpful to write down your worries and plan some time in the future to review them.
– Do not watch TV, read, eat , or worry while in bed – your bed needs to be associated with sleep.
– Take an epsom salt bath
– Listen to relaxing CDs (can help regulate sleep waves)
– Read something spiritual or uplifting (not suspenseful)
– Make sure you are exercising regularly
Changing Your Sleep Cycle:
• Figure out in detail a plan for getting up earlier. Imagine as you are going to sleep what it is that you are going to do when the alarm goes off (“without thinking about it I will get out of bed and go take a shower, or I will go outside and get the newspaper, or I will go out in my PJ’s to Starbucks…”). The key parts of the plan are – to have a goal that is pretty easy to reach, to tell yourself you are not going to think about it, and to do some of the work the night before (set out your clothes… set multiple alarm clocks… tell your partner to pull off the covers).
• When you get up get some bright light exposure before you tell yourself that you can go back to bed (30 minutes at least of therapy light or sunlight exposure).
• Ideally add to that either some physical activity (walk) or a conversation with someone.
• Continue to do this for at least a week.
At the end of this, even if you have gone back to sleep for naps, you should find that you are going to sleep earlier, waking up earlier, your mood is better, you are more alert in the daytime and you sleep more deeply at night.
We offer two different online CBTi or CBT for insomnia treatment programs.
SHUTi has been shown in National Institute of Health studies to be effective in improving sleep, and it is very cost-effective. Here is a link to more information about the SHUTi program.
Sleepio recently partnered with Google and is now being offered as a health resource to all Google employees. This program is a newer option at Gateway psychiatric so we have a little less information about it. It’s shorter and that may make it appealing.
Additional Resources for Insomnia
- In person or virtual with local experts
- Britney Blair – this talented clinician and educator from Stanford’s sleep center offers individual and group at The Clinic, her group psychiatry practice. Ty Canning is a clinician with the group that most of my colleague’s clients actually work with – video or in-person, 6 sessions for most individuals – they accept insurance.
- Monique Thompson in Rockridge.
- Katherine Taylor works at the NCPTSD, and was a primary provider on the CBT-I Coach app. She has worked at Stanford with Rachel Manber on the CBT-I studies there, at the Veterans Administration CBT-I roll-out. She has a special interest in perinatal health, but will see all clients.
- UCSF’s Osher Center – Individual intake and wrap-up sessions; 5 group education sessions. Takes insurance, but is less individualized than individual therapy with the therapists above
- You may find other therapists at www.behavioralsleep.org
- Virtual solutions
- The Sleep Reset– designed with experts like Rachel Manber at Stanford, this solution pairs you with a sleep coach who has years of experience in sleep.
- Lullaby also pairs you with an expert-level coach for individualized CBTi treatment
- Crescent Health– an online solution for CBTi coaching and more. Want coaching on delayed sleep phase and circadian rhythm entrainment? Jet lag preparation? They will do it.
- Dreem Health also does virtual care for sleep difficulties. They can order a sleep study (but the person reading the study will not be a well-known specialist like Dr/’s Claman and Lu, who I refer to) and they can deliver CBTi over a virtual platform.
- Sleepspace– work with a coach to assess and adjust your own specific sleep challenges for the better, in an average of 6 sessions.
- CBT-i Coach is an app developed by the Veteran’s Affairs administration. It can be your companion through the process, it is not meant to be a stand-alone CBTi solution
- Insomnia Coach, developed for veterans, is helpful also –
- There is Sleepio, another CBTi app; this one is prescribed and is covered by insurance. It has a “virtual coach”, but you are ultimately left to do CBTi on your own with its lessons, which can be challenging.
- Somryst (formerly SHUTi) is also rx, also covered by insurance with many plans and employers. Also is a virtual program, without any personalized coaching.
- Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain – by New Harbinger Press
- Say Good Night to Insomnia: The Six-Week, Drug-Free Program Developed at Harvard Medical School By Gregg Jacobs PhD
- End the Insomnia Struggle by Colleen Ehrenstrom PhD
- The Depression and Bipolar Workbook: 30 Ways to Lift Your Mood & Strengthen the Brain by Chris Aiken MD has a full guide to CBT-I – along with 2 dozen other techniques to improve mood and energy.
- Monique Thompson’s book The Insomnia Workbook for Teens
- https://mysleepwell.ca/ for further CBTi options – lots of recommendations, books…
And this nice PDF file that compares sleeping pills with CBT-i!