Guest Blog Post: CBT-i or Medication for Insomnia?

This post is written by Máire Daugharty, MD, MS who is an anesthesiologist and counselor working with adult individuals and couples. She brings both medical and mental health perspectives to client work at Physician Vitality Services, offering both inperson and telehealth appointments. With a lifelong interest in mental health, she pursued a master’s degree in clinical mental health counseling and completed additional course work for licensure in marriage and family therapy and addiction counseling. Now she works as both physician and counselor to offer psychodynamic psychotherapy, EMDR, and medication management.

CBT-i or Medication for Insomnia? 

Insomnia is described by difficulty falling asleep, difficulty staying asleep, or poor  sleep overall. No matter what the specific problem, chronic inadequate sleep has  consequences over the long term for both physical and mental health. For those  who struggle with anxiety or depression, poor sleep can be part of a vicious cycle,  one exacerbating and worsening the other. For this reason, inquiries about quality  and duration of sleep become an important part of treating mental health. Chronic sleep deprivation contributes to daytime sleepiness and fatigue, but also negatively  impacts memory and mood over time.  

There are some medical problems associated with sleep including but not limited  to narcolepsy, obstructive sleep apnea, central sleep apnea, restless leg syndrome.  These need formal investigation and often require medical treatment to mitigate  long-term problems.  

For those who struggle to fall asleep without symptoms indicative of a medical  problem, cognitive behavioral therapy for insomnia (CBT-i) in conjunction with  assistance from a therapist can be very effective. Elegantly simple, CBT-i  highlights habits that if specifically addressed can lead to healthier long term sleep  patterns. In addition to working with a therapist especially trained to work with  insomnia and offer CBT-I, like Kasryn Kapp, LPC, there is an intuitive App to complement work and improve accountability. Some concepts addressed w CBT-i include sleep restriction and efficiency and there are specific instructions to  improve on these measures. Motivation to engage includes improved mood, memory, a sense of well being, and overall health, but it requires discipline in  altering habits. While duration of sleep is important, this is just one variable. 

Healthy sleep includes a light sleep phase, rapid eye movement (REM), and deep  sleep periods, and these alternate in a typical pattern throughout the night. Deep sleep predominates earlier in the sleep cycle, and REM sleep increases throughout  periods later in the night. Each contributes to health, a sense of well being, memory, and mood, and the overall architecture is important. Although people drink alcohol feeling that it helps with initial sleepiness, it interferes with sleep  architecture, and other signs of health such as heart rate and heart rate variability.  For this reason, sleep medication is a better choice, especially if a combination of  therapy and CBT-i are not enough. There are effective, non-addictive medications which don’t interfere with sleep architecture, don’t contribute to poor memory, and  don’t lead to a tired feeling the next day. Sometimes medication can help  temporarily, particularly in extreme or acute circumstances leading to  overwhelming anxiety.  

In summary, it is important to understand the specific benefits of regular, adequate  sleep, and how best to approach differing etiologies of interference. Sleep medicine  can diagnose medical problems and provide appropriate treatment. Because quality  of sleep has a ubiquitous impact on the mood problems presenting for therapy,  therapists are equipped to help navigate this with you. Suggested readings are  included below, if you’d like to learn more.  

Suggested reading: 

Cartwright, R. (2010). The twenty-four hour mind. Oxford University Press. 

Walker, M. (2017). Why We Sleep: Unlocking the power of sleep and dreams. Scribner. 

Randall, D. (2012). Dreamland: Adventures in the strange science of sleep. W.W.  Norton & Company, Inc. 

Rubin Naiman, R. (2014). Hush: A book of bedtime contemplations. Rubin Naiman  PhD.