#512 Sleep Optimization and CBT for Insomnia with Ashley E. Mason, PhD

January 19, 2026 | By Matthew Watto, MD

Audio

Video

Transcript available via YouTube

What Dreams May Come

Breeze through your next visit for insomnia. Learn how to comfortably approach insomnia and optimize sleep. We touch on specifics such as cognitive behavioral therapy for insomnia or the effects of various sleep-related drugs/supplements, and how to taper down from them. We are joined by Ashley E. Mason, PhD (UCSF).

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Show Segments

• Intro
• Case
• Understanding patient’s goals
• Cognitive behavioral therapy for insomnia
• Stimulus control
• Sleep Hygiene
• Time-in-bed restriction
• Impact of different medications/substances on sleep
• Tapering off medications
• Outro

Disclosures

Dr. Mason has disclosed the following:

Financial Relationships: Evolve Global, consulting fee and stock options; Oura Health, consulting fee.

The Curbsiders report no relevant financial disclosures.

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Sleep Optimization and CBT-I Pearls

1. The amount of sleep one gets is not as important as the quality and regularity of sleep.
2. Having a consistent wake time is the first step toward establishing a regular sleep schedule.
3. The two non-negotiable elements of CBT for insomnia are stimulus control and time-in-bed restriction.
4. Stimulus control means reserving your bed only for sleep and sex, and getting out of bed if you aren’t doing either.
5. Scheduling worry time to occur during the day is an effective cognitive tool for patients who have thoughts that keep them up at night.
6. Many medications and substances can cause you to fall asleep (become unconscious) quicker, but can negatively impact sleep architecture.
7. Supplements are not effective treatments for insomnia, and they can be tapered off in incremental amounts.

Sleep Optimization and CBT for Insomnia – Show Notes

Establishing Goals

It is helpful to gauge what a patient’s goals are for sleep. Is it to fall asleep faster, stay asleep longer, feel less tired during the day, or something else entirely? It is normal to feel groggy 30-60 minutes after waking, which is known as sleep inertia. It is also helpful to determine whether the goal is realistic; if someone has had insomnia for a long time, there likely isn’t a quick fix and it may take some time. Determine whether a person just needs tips for sleep, or is actually struggling with an insomnia disorder. 

Insomnia Disorder

According to the DSM-5 and International Classification of Sleep Disorders Text Revision (ICSD-3-TR), insomnia disorder is confirmed when all four of the following criteria are met:

1. The patient reports difficulty initiating or maintaining sleep, or if the final waking is earlier than desired.
2. The sleep difficulties occur despite adequate opportunity and circumstances for sleep.
3. There are daytime impairments due to the sleep difficulties.
4. The sleeping difficulties are not better explained by any other medical/mental disorder, or medication/substance use.

Chronic insomnia occurs when the above criteria are met and it occurs for at least 3 nights per week for at least 3 months. 

Insomnia can also be further classified as: 

• Early/initial/sleep-onset insomnia: difficulty falling asleep at the start of the night
• Middle/maintenance insomnia: waking up in the middle of the night and having difficulty falling back asleep for a while
• Late/terminal insomnia: waking up early in the morning and never getting back to sleep.

How much sleep should the patient get?

There isn’t quite a set number, and as we age the amount of sleep decreases as well as the hours of deep sleep. The quality and regularity of sleep should be focused on more than the quantity.

Sleep regularity, which is heavily influenced by a consistent wake up time, has been found to have a lower association with major adverse cardiovascular events (MACE) when compared to irregular sleep even when the recommended duration of sleep has been met (Chaput et al. 2025).

Chronotypes

Naturally, likely through evolution, people have different sleep chronotypes. This is the body’s natural genetically influenced preference for when someone might feel the most alert or sleepy, aligning with their internal circadian rhythm. E.g. Some can be considered “night owls” who sleep late and wake late, while “larks” sleep early and wake early. Ultimately, it can be hard to significantly change a person’s chronotype, and modern society caters to the early/morning chronotypes.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

The 5 buckets of CBT-I include: sleep hygiene, stimulus control, time-in-bed restriction, cognitive tools, and relaxation tools. CBT-I is effective for all types of insomnia: early, middle or late insomnia.

Note: The 2 non-negotiable buckets are stimulus control and time-in-bed restriction!

Sleep Hygiene

There are many components within sleep hygiene, these include:

• Temperature Regulation: Your body is warm during the day and cool at night. Ditch any duvets or quilts, and switch to cotton sheets and blankets. Ideal temperature is 65-68 degrees Fahrenheit.
• Light Regulation: Dim the lights at night. For early awakenings, sleep masks or sleep hats that you can pull down over the eyes can be helpful! Please see the links below for some recommended products. Once awake in the morning, getting morning light outside is great for regulating circadian rhythm.
• Digestion: The last meal should be at least 2-3 hours before bed.
• Exercise: Exercising is important but should not be done late in the day or close to bedtime as it can increase body temperature which is not conducive to sleep.
• Caffeine: The half-life of caffeine is around 4-6 hours, and affects sleep architecture negatively. Dr. Mason tells her patients that 11 am is the cutoff for caffeine, or at least 10 hours before bedtime..
• Naps: Naps can be problematic for some people. Avoid napping if you can, but if you have to nap, limit it to a 25 minute “napportunity”. This avoids any deep sleep. Napping any longer than this can take away from sleep pressure.

Stimulus Control

Reserve your bed only for sleep and sex! We want to associate the bed with sleep (think of Pavlov’s dogs and classical conditioning).

If you have the thought 3 times that you cannot sleep or are in bed for 20 mins without sleep, get out of bed. Have a “reset” before getting back into bed to try and sleep again. Any activity that you do in the meantime should only be slightly fun, slightly engaging, and slightly boring. If you are going to watch something, ideally it should be a 20 minute episode and then check if you are sleepy enough to go back to bed. Do not do anything productive! We don’t want to associate being up in the night with being productive.

Time-in-Bed Restriction

As the name implies, time-in-bed restriction gives a specific time to wake up as well as a time to go to bed. The way one arrives at this begins with a sleep diary (patient tracking the times they naturally fall asleep and wake), then calculating/deciding on a reasonable consistent wake up time, then tracking what time they feel tired enough to fall asleep with that consistent wake up time, and then calculating/deciding on a reasonable and consistent sleep time. This used to be called sleep restriction.

More details on this are described in the podcast as well as in a book called Quiet Your Mind and Get to Sleep.

Cognitive Tools

One popular cognitive tool is scheduling worry time. If a patient has a lot of thoughts that keep them up at night, ask them whether they are ruminating about the past or worrying about the future, then schedule a specific time (e.g. every day at 8:00 – 8:30 pm) where they are allowed to worry; any other time during the day/night they should write their worries onto a notepad or note file to be visited at the scheduled worry time. 

Many other cognitive tools can be found in the book Quiet Your Mind and Get to Sleep.

Medications/Supplements/Substances and Sleep

At minimum, clinicians should review a patient’s medication list to ensure they are taking medications at appropriate times, e.g. not taking stimulants too late in the day or a medication with potential stimulant side effects, like bupropion, at night.

Alcohol and other Sedative-Hypnotics

In general, alcohol and other sedative-hypnotics (benzodiazepines and the Z-drugs such as zolpidem) can make you fall asleep faster, but significantly affect sleep architecture. One can think of it as becoming unconscious faster. REM sleep is reduced overall, and there are more awakenings in the second half of the night, as well as sleep fragmentation. Important to know that these effects can persist for more than just 1 night, and REM rebound can also occur which then displaces non-REM sleep.

Magnesium

Dr. Mason sees magnesium as the preferred placebo, as long as there are no diarrheal effects.

Melatonin

There is a clear indication for melatonin to treat beta blocker-induced insomnia, as it inhibits melatonin secretion by the pineal gland (Scheer et al. 2012; Stoschitzky et al. 1999). Dr. Mason however does feel in general that melatonin is commonly taken too close to bedtime and at a higher dose (5 – 10 mg) than recommended. A lower dose 0.5 – 1 mg may be as effective when taken 3 – 4 hours before the target bedtime. It is also important to look for reliable suppliers which are NSF certified, as many products can contain other non-melatonin products (Erland and Saxena 2017; Cohen et al. 2023). Check the brand on consumerlab.org; Dr. Mason has found reliability with the brands Pure Encapsulations and Life Extension.

Cannabis

Overall there are still not enough data on cannabis due to its status as a scheduled I controlled substance. Cannabis and THC (the main psychoactive component) does help with becoming unconscious faster, however it negatively impacts sleep architecture by inducing more light sleep (stage 1/N1 sleep), more awakenings after sleep onset, and decreasing REM sleep (Althoff et al. 2024). Cannabis withdrawal can induce REM rebound which can be quite prolonged (up to and even over 1 month). Cannabis use has been found to have a negative association with vascular endothelial dysfunction, which could be another reason for decreasing its use when counseling patients (Mohammadi et al. 2025).

Trazodone and Dual Orexin Receptor Antagonists (DORAs)

Trazodone and DORAs appear to be the least offensive medications for sleep. Things to look out for with Trazodone is that sometimes patients can still feel drowsy in the morning, and when tapering off you have to be mindful that it is also an antidepressant. For DORAs, these can be very expensive medications due to non-generic status, but seem to be the easiest to taper off of.

Ashwagandha and Other Supplements

In general there are not great data for Ashwagandha and other sleep supplements like glycine, and they can be expensive.

Tapering off Medications

Tapering off medications that a patient has been on for 10 years or more can be daunting. Slow and steady wins the race. Dr. Mason advises patients to get a gem scale (high precision digital scale), and then will slowly taper the dose by small increments of 0.25 – 0.5 mg roughly every 2 weeks until the patient is completely weaned off the medication.

Sleep Divorce

Sleep divorce is a viable option for partners and is more common than people think. There are some estimates that one third of American married couples sleep separately from their partner. A sleep divorce could prevent a real divorce. Additionally, separate top sheets and top blankets could be a solution. 

Dr. Mason’s Take-Home Points

• Wake up at the same time every day.
• You don’t need supplements for sleep.

Links

1. Sleep Diary Instructions (PDF)
2. Sleep Log (PDF)
3. Quiet Your Mind and Get to Sleep (book)
4. CBT-I App (Rest App) with Coaching (App)
5. CBT-I App (Rest App) with Coaching – Clinicians Page (App)
6. Ozlo Sleepbuds for patients with tinnitus (product)
7. Manta Sleep Mask (product)
8. Sleep Bonnet that can be pulled over the eyes  (product)

Goal

Listeners will develop an approach for troubleshooting sleep complaints in primary care.

Learning objectives

After listening to this episode listeners will…  

1. Counsel patients on proper behaviors around sleep.
2. Help patients implement stimulus control and time-in-bed restriction.
3. Help patients regain confidence in their sleep and wean them off sleep medications.

Citation

Jyang E, Mason AE, Williams PN, Watto MF. “#512 Sleep Optimization and CBT for Insomnia”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date January 19, 2026.