How CBT for insomnia can unlock other mental health challenges

Our pediatrician sat reviewing answers from an intake form and looked up at my wife Lyssa to deliver a request that was equal parts jarring and practical.  
“You need to talk to someone.”  
The visit was ostensibly for our then 6-month-old son, Ezra, but the questionnaire was about postpartum anxiety and depression. It was also the first time Lyssa stepped back and really considered speaking to a professional about how she had felt since she was a teenager, herself.  
Our early days as parents were dotted with uncertainty. After we brought our son home in February 2020, a global pandemic unfurled and extended our private bubble of parental leave into a longer-term period of isolation. What began as forced loneliness also made us more reflective on how we felt and approached being new parents, and now, more mindful of how our decisions could impact our child.  
“If it wasn’t for our pediatrician, I would have kept being anxious at home and not had any treatment,” Lyssa said.  
“Treatment” came in a few forms: talk therapy, peer support groups—both virtual. However, when she first began treatment, our lifestyle at the time made it easy to rely on alcohol as a self-medicating outlet, too. Like many as the COVID-19 pandemic crept along, our weekly family Zoom happy hours gave way to almost nightly drinks as a way to process…everything.  
In summer of 2023, after her therapist moved to a new practice, Lyssa found the Time Efficient, Accessible, Multidisciplinary (TEAM) clinic at Penn. The clinic model uses a collaborative approach (medication management and psychotherapy) to mental health treatment, typically working with patients for up to four months before referring them for additional treatment, as a means to expand treatment options for more patients.  
After completing her intake assessment, Lyssa was paired with a medication manager and therapist.  
“I was self-medicating with alcohol, and thought it was helping me sleep at night,” Lyssa said, noting that tackling alcohol use was at the top of the list since alcohol is a stimulant that significantly impacts sleep quality.  
Lyssa and her clinical team worked through a harm reduction plan for alcohol use using cognitive behavioral therapy (CBT), a treatment originally developed by the late Penn psychiatrist Aaron Beck, MD. The structured, goal-oriented talk therapy is based in part on recognizing unhelpful ways of thinking and learned behavioral patterns.   
While we both worked in earnest on more productive coping mechanisms, Lyssa’s alcohol use waned, but sleep remained an issue. Falling asleep and staying asleep took, as Lyssa remembers, hours. In this, she was not alone: Recent estimates have stated that as many as 12 percent of Americans reported being diagnosed with chronic insomnia.  
Voluminous studies have shown the ripple effects of quality sleep. It impacts our mood and focus as well as helps to maintain healthy weight; improve heart health; and lower risk of chronic conditions like diabetes, stroke, and high blood pressure. In this case, we were also hoping it was key to resolving her anxiety and depression.  
“It’s so important to screen for insomnia—it’s transdiagnostic,” said Katelyn Kennedy, LCSW, a psychotherapist who worked with Lyssa. “We originally focused on anxiety and other issues, but sleep remained this sort of bugaboo. Because the TEAM model is time efficient, trying CBT for insomnia made sense because it typically can take about 12 sessions.”  
In theory, CBT for insomnia (CBT-I) is akin to hitting what is known as a hard reset for your computer—holding the power button until your system shuts down and slowly rebooting yourself. In this case, it reboots how you sleep. In this case, Lyssa had already developed a working relationship with Kennedy, enabling the therapist to be an advocate to guide Lyssa through the early stages.  
“The relationship helped in that it was a motivator for me,” Lyssa said. “The messenger was as important as the message, because she had helped others with this therapy before and she was working with me on other issues.”  
“It’s not easy,” Kennedy said. “I tell patients, it’s short-term pain for long-term gain, in that we have to consolidate their sleep.”  
In Lyssa’s case, this meant restricting her sleep to five hours per night to start before adding back 15-minute increments each week.   
As Kennedy describes, those in a CBT-I program can add back 15 minutes if patients have sleep efficiencies of 90 percent or more, tracked in a mobile application. That number is calculated by how much time in bed is actually spent asleep.  
“Folks with insomnia typically have a pretty large ‘mismatch’ between time asleep versus time in bed,” explained Kennedy, “hence why we engage in sleep restriction at first to match up with what patients’ sleep ability is pre-treatment (how much time they’re actually sleeping).” 
“My first week, I didn’t get to add any time back. I remember crying a lot about that,” Lyssa said, before reminding me that I was there for that. I was—including when we drove aimlessly through Fairmount Park with the windows down, so she wouldn’t accidentally fall asleep at home.  
Our son thought we were on an adventure, but we were really trying to keep Mom awake.  
The approach that Lyssa’s care team took came as a result of an evolution of recommendations about insomnia treatment over the past decade—from thinking of insomnia as a single symptom, to a lynchpin, and in embracing the power of CBT. 
In 2016, momentum for CBT-I as a first-line treatment began to build, following guidance from the American College of Physicians. For researchers like Michael Perlis, PhD, associate professor of Psychiatry and director of the Behavioral Sleep Medicine Program at Penn, this also cemented what he and colleagues had been working towards for decades through clinical trials and meta-analyses, the publication of practice standards papers, and the formation of professional credentialing bodies and support organizations.  
“There is no population where I’ve tried CBT-I for which it fails,” Perlis said. “It works as well, if not better, than medication.” Perlis also pointed to pandemic-era rule changes that allowed therapists to conduct telehealth visits in jurisdictions outside of their original license, which widened the availability of CBT-I providers—though he noted a need remains as there are only about 1,000 registered CBT-I providers worldwide, according to his estimates.  
There is a growing number of digital CBT-I options, such as mobile apps and digital platforms, that largely rely on a patient to self-direct their care with light digital assistance. But Perlis says this misses a fundamental human touch: the therapist relationship.  
“This is a hard therapy to do to yourself, and that’s the power of having an advocate in the form of a clinician or a therapist: They can brainstorm with you,” Perlis said. “Not only can they explain what you have to do, they can help you do it. Sleep rescheduling and sleep reconditioning require behavior change and when implementing such stuff, it helps to have someone looking over your shoulder.” 
Identifying insomnia is, according to Perlis, an opportunity to untangle a host of conditions, rather than counting it as a mere symptom. 
In the context of related comorbid disorders, “insomnia is often the first to come and the last to leave, if it leaves at all,” Perlis said. “No matter how well-managed your anxiety, your depression, your trauma, may be, if not subjected to targeted treatment, chronic insomnia is unlikely to resolve.”  
As Perlis described, if you treat the insomnia first, you are likely to get a treatment response—70 percent or more of the time—and such success will increase the patient’s confidence about other forms of cognitive and behavioral therapy and empower patients to be successful with other CBT therapies. “Empowerment occurs with the reduced sleepiness and fatigue and improved mood and cognitive function that come with improved sleep,” he said.  
Empowerment, for Lyssa, has meant completing her CBT-I sessions with tools to manage things on her own. If she catches herself sinking back into bad sleep habits, like bringing her phone to bed or lying awake at night thinking anxious thoughts, she can do things like add sleep restrictions or schedule specific ‘worry time’ for herself to keep intrusive thoughts at bay.  
In that way, CBT has allowed her to approach her broader spectrum of care as a result of those ‘halo’ effects Perlis alluded to and take control.  
“I feel good. I don’t feel perfect. I’m a parent, and so things happen to my sleep regularly, but I know how to fix the problem now. It’s tough work, but it’s worthwhile work,” Lyssa said. “Because the sleep I started getting after CBT-I was much more restful than before.”