It will surprise nobody to hear that poor quality sleep is one of our country’s biggest health problems. A full 10 percent of adults suffer from insomnia (meaning they’re not getting a complete night’s sleep at least three nights a week) and its associated behaviours (including anxiety, irritability, and difficulty learning and remembering), says Jennifer Felder, Ph.D., a postdoctoral fellow in health psychology at UCSF. In recent studies, Cognitive Behavioural Therapy (CBT) has emerged as a drug-free, therapy-based solution that’s effective for the majority of sufferers—and it’s accessible to everyone via web-based programs.
Insomnia is more prevalent in women than men, and according to Felder, it may be particularly problematic during pregnancy—her current work is focused on the effects of CBT on insomnia in pregnant women, and whether it might unlock some relief for postpartum depression. (Incidentally, if you’re pregnant, consider signing up for her REST study, which uses digital CBT and requires no in-person visits, so it’s open to women across the country.) Below, Felder’s suggestions for a better night’s sleep—pregnant or not.
A Q&A with Jennifer Felder, Ph.D.
Q
What are the most commonly used solutions for insomnia?
A
Insomnia is defined as experiencing difficulty falling or staying asleep, or waking earlier than intended, accompanied by significant distress or impairment. According to the diagnostic criteria, symptoms must be present for at least three nights per week for a minimum of three months. If you are in the 10 percent of adults who experience insomnia, take heart—there are effective treatment options. Natural or homeopathic products and prescribed and over-the-counter medications are the most common treatments for insomnia. But, the American College of Physicians recommends Cognitive Behaviour Therapy (CBT) as the first line of treatment because it is effective and associated with few side effects.
Q
Can you explain CBT—why is it effective?
A
CBT is an evidence-based therapy that is effective for a variety of mental health concerns. A CBT therapist helps clients identify and change the thoughts and behaviours that contribute to depression or anxiety, for example. CBT for insomnia is typically offered by a therapist over the course of six in-person sessions. There are five components to treatment, in which patients learn and implement several strategies to combat insomnia, including:Stimulus Control
The below strategies teach the mind and body to associate the bed with sleep, instead of with lying awake anxiously pining for sleep to come.- Use your bed only for sleep (and sex); keep all other activities out of the bedroom (watching TV, reading, talking on the phone).
- The bed should be the only place where sleep occurs; try to avoid dozing on the couch.
- Keep regular sleep and wake times—including on the weekend.
- If you find yourself lying in bed awake for 20 minutes or longer, get out of bed to do something relaxing. Once you feel sleepy, get back in bed. At first, you may need to do this several times per night. Plan in advance what relaxing activity you will do (e.g., listen to soothing music, try a meditation practice—but no TV, computer, or phone!); these strategies take discipline and consistency.
Sleep Restriction
This is an incredibly powerful technique to have deeper, more consolidated sleep. People with insomnia often spend much more time in bed than they do sleeping. A person who spends ten hours lying in bed, but only six hours sleeping, has a sleep efficiency score of 60 percent. Sleep restriction aims to get sleep efficiency up to 90 percent. During sleep restriction, a therapist will help the client determine their “time in bed prescription.” Reducing the time in bed causes sleep deprivation in the short-term, thereby increasing the drive for sleep, leading to deeper, higher quality sleep. It may seem counterintuitive to reduce the amount of time you spend in bed, and it’s often miserable for the first few weeks, but those who stick with it will likely experience profound improvements in sleep. As sleep efficiency improves, a therapist increases the amount of time allowed in bed.
CBT takes longer to work than medication, but it produces long-lasting effects. It’s effective because clients learn skills that directly address the behaviours and thoughts that perpetuate insomnia, rather than masking its symptoms.
That said, digital CBT gives the client increased flexibility and convenience, since sessions can be completed whenever and wherever. For those who don’t have a schedule that allows for in-person CBT, digital CBT is an excellent option.
It’s important to note that CBT does not work for everyone—approximately 40 percent of clients do not respond to this treatment. In light of this, another approach I’m excited about is mindfulness-based therapy for insomnia.
Cognitive Therapy
Patients learn to identify maladaptive beliefs about sleep, such as, “I must get eight hours of sleep to function at work the next day.” A therapist helps challenge such beliefs, for example, by reviewing times when the client functioned just fine at work after getting less than eight hours of sleep. For those who are kept awake by worries, a therapist might suggest a constructive worrying technique. For a free example, see Dr. Colleen Carney’s worksheets.Relaxation Techniques
To promote relaxation, therapists teach patients progressive muscle relaxation or mindfulness practices. In progressive muscle relaxation, the patient alternates tensing (5-10 seconds) and relaxing (10-20 seconds) muscle groups throughout the body.Sleep Hygiene
Changing daytime behaviours can promote better sleep. A therapist may recommend limiting the consumption of caffeine, especially in the afternoon or evening, or alcohol, which can cause drowsiness, but also causes sleep to be more broken and disturbed. A therapist may also recommend regular, moderate exercise, but not immediately before bedtime. Minor modifications to the bedroom can also make a big difference. Noise and even dim light can disrupt sleep, so ear plugs and blackout shades (or an eye mask) may help. The temperature should be cool; ideally below 75 degrees.CBT takes longer to work than medication, but it produces long-lasting effects. It’s effective because clients learn skills that directly address the behaviours and thoughts that perpetuate insomnia, rather than masking its symptoms.
Q
What makes CBT well-suited to online therapy, and are there some products that are better than others?
A
There is a shortage of clinicians who are trained to provide CBT for insomnia, so in order to increase access to this effective therapy, researchers developed digital versions. There are several options on the market: Sleepio and SHUTi have undergone rigorous investigation and have been shown to outperform control conditions. In fact, clients using these programs show improvements in sleep that are comparable to standard, in-person CBT (though these digital CBT programs have not been directly tested against in-person CBT).
Q
Are there risks of doing CBT online vs. with a therapist in-person?
A
Although many digital CBT programs tailor feedback based on client progress, it’s not the same level of personalization that you get from in-person therapy. And—as is the case for all digital therapy programs—many people find that there is less accountability than meeting with a real person.That said, digital CBT gives the client increased flexibility and convenience, since sessions can be completed whenever and wherever. For those who don’t have a schedule that allows for in-person CBT, digital CBT is an excellent option.
Q
What is the state of research on CBT?
A
There is a large and growing body of evidence to suggest that CBT is effective for insomnia. To me, a crucial next step is figuring out how to get CBT into the hands of the people who need it—whether through self-help books, digital programs, integrating CBT within primary care, or training more clinicians.It’s important to note that CBT does not work for everyone—approximately 40 percent of clients do not respond to this treatment. In light of this, another approach I’m excited about is mindfulness-based therapy for insomnia.
Q
What are the potential implications of CBT for pregnant women?
A
This is an area I am especially excited about. Insomnia is highly prevalent during pregnancy. Estimates vary depending on how insomnia is measured, with some as high as 50 percent. Research suggests that poor sleep quality during pregnancy is associated with depressive symptoms, suicidal thoughts, gestational diabetes, and preterm birth, so it is important to intervene when a pregnant woman is experiencing insomnia.
However, there are a few important obstacles to overcome. First, I believe that insomnia is often dismissed during pregnancy. I’ve heard doctors say, “All pregnant women sleep poorly, there’s nothing you can do!” Second, we need more research on how to best treat insomnia during pregnancy. Not surprisingly, pregnant women prefer non-medication treatments (like CBT) for insomnia. Preliminary data from a small trial of CBT were promising, and larger-scale investigations are currently underway, including at my lab at the University of California, San Francisco.
However, there are a few important obstacles to overcome. First, I believe that insomnia is often dismissed during pregnancy. I’ve heard doctors say, “All pregnant women sleep poorly, there’s nothing you can do!” Second, we need more research on how to best treat insomnia during pregnancy. Not surprisingly, pregnant women prefer non-medication treatments (like CBT) for insomnia. Preliminary data from a small trial of CBT were promising, and larger-scale investigations are currently underway, including at my lab at the University of California, San Francisco.
Q
Does CBT have implications for postpartum depression, or depression more generally?
A
There is ample evidence that CBT for depression is effective for pregnant and postpartum women. It’s too soon to know whether CBT for insomnia will also help depression during pregnancy and postpartum, but my hypothesis is that it will. Research in non-pregnant patients suggests that CBT for insomnia is associated with improvement in depressive symptoms and suicidal ideation, but more research is needed.
Q
What tips do you have for people (pregnant or otherwise) who have trouble sleeping, but aren’t ready to commit to the full therapy?
A
I’d recommend a “stepped” approach. You might start by trying the recommendations described above, plus the following additional pregnancy-specific suggestions (if applicable):- Drink plenty of water during the day, but cut back a couple hours before bedtime to reduce frequent trips to the bathroom.
- Use supportive pillows to improve comfort and relieve pressure.
- Avoid foods that may cause heartburn or reflux (citrus, rich/fatty foods).
You might also try using a self-help CBT workbook (there are many great ones, but I’m partial to this one). If those don’t work, or you need a bit more structure, try a digital program.
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