Dr. Amanda Swain (Host): Welcome everyone to the Penn Primary Care Podcast. I'm Amanda Swain, your co-host. And tonight, I have with me Dr. Phil Gehrman to talk about behavioral sleep medicine and insomnia. Dr. Gehrman is a Professor of Psychology in the Department of Psychiatry of the University of Pennsylvania School of Medicine and a clinical psychologist at the Philadelphia VA Medical Center. He directs the Sleep Neurobiology and Psychopathology Lab at Penn. And I have to give you kudos for the acronym there, the SNAP Lab. It's very clever.

So Phil, it's a pleasure to have you. I am a big fan. I think your work is really amazing, and you're an excellent teacher, and I speak from personal experience. And I would love to just start with hearing a bit about how you came to the field of behavioral sleep medicine and what your practice currently entails.

Dr. Philip Gehrman: Sure. Thanks, Amanda. It's great to be on and always great to chat with you. So, my beginnings in sleep actually all started at Penn. I was an undergrad at Penn a few years ago. And my senior year, I took a course on sleep, and was just really enthralled with the topic. So then, I already knew at that point that I wanted to go into psychology, but wanted to take a couple of years off before going to graduate school to get some research experience.

And lo and behold, I managed to get a job in the sleep center at Penn, not knowing at the time that it was one of the premier sleep centers in the world, and really got to work with some great people. So when I was applying for psychology programs, I specifically looked for places where I could continue focusing on sleep. So, it really began with that one class that piqued my interest, and then the opportunity to develop it further with a research position.

Host: It's so funny how sometimes one little decision or experience informs what will be such a huge part of your career. Sometimes when people ask me how I became interested in insomnia and something called cognitive behavioral treatment for insomnia, which we're going to talk about, I look back and say, you know, I trained to become a physician and didn't really think that much about sleep. But when I suddenly had two small children, that is when sleep became really important. And all of a sudden, I wanted to learn all about it. And here I am many years later, still very interested in it. Nowadays, there's a lot in the news about sleep and insomnia and what we should or should not be doing to support our sleep health. And insomnia is a huge issue. You know, very prevalent, the most prevalent sleep disorder in the general population.

And this is the data I just found in The New England Journal of Medicine in 2024, approximately 10% of adults meeting criteria for insomnia disorder, and another 15% to 20% reporting occasional insomnia symptoms. So, it's certainly something that we talk a lot about, but I think a lot of primary care physicians could benefit from some more education about insomnia.

And also, generally, I think about behavioral sleep medicine, which is not something that a lot of people really get any formal education in. So, maybe we could just start with talking a little bit about what is behavioral sleep medicine and what is behavioral sleep medicine used to treat in terms of sleep disorders?

Dr. Philip Gehrman: Yeah. Good question. I often say that when I first was pursuing a degree in psychology with a focus on sleep, and people asked me what I was doing, they'd look at me funny and they'd say, "So, you mean like you're going to interpret people's dreams?" Because sleep just wasn't something that we were talking about back then. And so, it is really exciting for us in the field to see it to be such a popular topic.

But we also know that the average number of hours that medical students get of training in sleep is about two. And so, despite the fact that we spend a third of our lives on it, doing it, it's just not part of medical school or really any clinical degree part of the training. So, it really started a lot with focus on sleep apnea. And then, as the broader range of sleep disorders was recognized, psychologists were at the table from the beginning.

And so, the idea of behavioral sleep medicine is—while some of our sleep disorders are best treated with medical interventions, whether it's CPAP for sleep apnea, whether it's medication, that there are behavioral psychological interventions that can go a really long way for insomnia, and can also be part of the treatment package for other sleep disorders as well. And that's where the field of behavioral sleep medicine came from. It's really just that recognition that we need to approach sleep medicine from a more holistic perspective.

Host: One really, I would say, popular intervention, popular not that a lot of people know about it perhaps, but popular in terms of the enthusiasm in which the medical community, recommends it, is a behavioral sleep medicine treatment specifically for insomnia, which is called cognitive behavioral therapy for insomnia, which for the purposes of keeping this episode slightly shorter than it could be, I'm just going to call CBT-I throughout the episode.

Now, I think a lot of people have heard about CBT for other conditions. So, a lot of times we think about CBT for anxiety and depression, but CBT for insomnia or CBT-I is something that has a tremendous amount of evidence behind it. It is actually the first-line recommended treatment for insomnia, but it is not always something that people with insomnia, even those that have been struggling for decades, are introduced to. And so, what I'd like to spend a little time on is maybe having you explain what is CBT-I, and then we can delve into more details about it.

Dr. Philip Gehrman: So, CBT-I is based on the idea that people develop insomnia for a thousand different reasons. You know, life stress is probably most common. Young kids, as in your example, interfere with sleep. Anxiety, pain, effects of medications. There's so many reasons people have trouble sleeping.

Now, for a lot of people, over time, you know, those factors will fade, and their sleep will get back to normal. But for other people, it doesn't. And because what starts to happen is there are these patterns of thinking and behavior that end up developing these cycles that feed into insomnia.

And, you know, one of the classic examples I always use is people start having trouble sleeping at night, and then as bedtime approaches, they start worrying, "Am I going to be able to sleep tonight?" And they get into bed, and they try really hard to sleep. Those are natural things to do when you can't sleep.

But of course, the problem is the harder we try to sleep, the more we worry about being able to sleep, the harder it is to sleep. So, it feeds into that cycle. And sometimes people will even say to me, "You know, I first started having trouble sleeping when such and such was going on in my life, but that was fifteen years ago. I don't understand why my sleep has not gotten back on track."

So, what CBT-I does, it consists of a series of different strategies to try to identify what are those cycles that people are getting stuck into, and how can we teach them techniques that can break that cycle? And I often describe it as sleep training, to retrain their body into a healthy pattern of sleep again. And so, that's really the goal of what CBT-I is trying to accomplish.

Host: So a lot of people, when I meet them in the office, I might start to explain about CBT-I or just generally about behavioral strategies, depending on how much time I have in the office. And a lot of people will say, "I already tried sleep hygiene. I don't even have my phone in the bed. I don't watch TV in bed." And I know we're not knocking sleep hygiene, but maybe you can—

Dr. Philip Gehrman: Well, I am.

Host: I do too. But maybe you can explain also why CBT-I is not sleep hygiene.

Dr. Philip Gehrman: Yeah, absolutely. It's one of the most common misunderstandings in the field, as you know. So, sleep hygiene is the idea that there are certain practices or behaviors that we do often during the day that can impact our ability to sleep at night. And it's really kind of a grab bag of things. So, things like excessive caffeine use during the day, uncomfortable bedroom environment, it's a lot of different things. And when people have mild sleep problems, correcting some sleep hygiene can be helpful.

By the time someone has a chronic insomnia, sleep hygiene is really not going to fix the problem 99% of the time. I often use as an example, when I have done some clinical trials of CBT-I, I've used sleep hygiene as my control condition. And because we just know that for people with chronic insomnia, sleep hygiene alone is not effective.

Now, is it an important ingredient of CBT-I? Yes. But as a standalone intervention, it's ineffective. And what happens is exactly what you described, which is that someone's given a list of some sleep hygiene tips, it inevitably does not help. Then, they come to see someone like me and they say, "Oh, I've done this already." So, one of the providers in my department once a number of years ago said that they give out a list of sleep hygiene tips to their patients all the time. And they said they realized they should ask me what my sleep hygiene list is, because I probably have something better than them. And I said, "Not only do I not have a sleep hygiene list, please stop giving them out because you're making my job harder." I said it nicer than that, but that was the gist of it, is that you're giving people something that's not really going to make a difference.

Host: The good thing about so much sleep information being readily accessible now is I think the vast majority of people with chronic insomnia have tried sleep hygiene. I don't make light of their efforts. I think people come in and they say, "Listen, I keep my bedroom cool, and it's dark, and it's quiet, and I cut out caffeine at least eight to 10 hours before bed." They know the sleep hygiene checklist. They've gone down it. And maybe we can just clarify, and correct me if I'm wrong, but I believe when we are saying chronic insomnia, we're talking about more than three nights a week, more than three months. Is that still the criteria?

Dr. Philip Gehrman: Correct. Still the diagnostic criteria.

Host: Okay. So, maybe we could also talk—when we're talking about things that maybe don't work as well as we'd like them to, what's your take on people that are already using sleep medication and whether or not there's a role for CBT-I in their treatment?

Dr. Philip Gehrman: I know some CBT-I providers who are kind of anti-sleeping medication, and I'm not. I think every treatment approach has its role to play. CBT-Is work. Not everyone wants to do or has the availability to do the work involved in CBT-I. It is often the case that people come to me and they're already taking sleeping medications, but either—well, the most common scenario is they're taking medications and the medications just aren't doing enough for them. They feel like maybe they're getting some relief, but only partial, or another scenario is people are sleeping well with medication, but they don't want to have to keep taking it, so they're trying to get off the medication. So oftentimes what we'll do is work with people to taper off sleeping medication while teaching them CBT-I strategies.

So, it's never an even swap that, like, oftentimes people sleep worse before they sleep better. But CBT-I can be a great way to reduce people's need for sleeping medication.

Host: I tend to have a fairly flexible approach to sleep medication use and CBT-I. And maybe at this point also, we can start to delve into a little bit of what we're really talking about when we say CBT-I. And we'll talk about how people access CBT-I a little bit later. But for the relatively uninitiated, how would you lay out what CBT-I looks like, perhaps the number of sessions or how long you're spending with a patient, and then broadly speaking, what you're doing during those sessions?

Dr. Philip Gehrman: It's typically six to eight sessions on average. Some people more, some people less. So as far as therapies go, cognitive behavior therapies, it's fairly brief. So, it's six to eight typically weekly sessions, sometimes every other week, usually 30 to 60 minutes per appointment. And what we'll do is, well, one, throughout the time people are in CBT-I, we have them keep a daily record of their sleep, what we call a sleep diary. So, each morning you answer some questions about what time you went to bed the night before, how long it took you to fall asleep. And we use that information, the night-to-night patterns, to inform treatment so that we're tailoring it to that person's specific sleep patterns. So, that's kind of woven throughout treatment.

And then, each session, we're teaching one or two new components. And because generally, when people have had insomnia for a while, and oftentimes when people come in, it's been years for a lot of people. It's not going to be one strategy or two strategies that really breaks that cycle. It's the collection of things over time that does it.

In fact, I tell people first session, "I don't expect you to come back next week or even the week after doing much better." I tell them, "I'm just not that good." I say, "It's going to take a while for your body to get trained into its current pattern. It's going to take time for this retraining to occur." And so, we keep building up the strategies, adapting them to their specific sleep patterns until they're hopefully doing better.

Host: And so, when we are thinking about questions that we can be asking in primary care to start to understand someone's sleep challenges, what do you think are some questions that are going to really give us a sense of what people are struggling with? And I realize that that's a very open-ended question, but I would say the definition of insomnia is fairly open-ended, right?

I mean, difficulty initiating sleep and/or maintaining sleep, and also the daytime dysfunction, which if you just kind of ask someone to answer those questions, you're actually not really getting a ton of helpful information. So, what are some questions that you find really helpful to start to get the history that you're going to need when someone's struggling?

Dr. Philip Gehrman: The first one I think is just say, "How have you been sleeping?" Because studies have shown that oftentimes in primary care settings, there's so much to try to cover in a short amount of time that there are no questions about sleep. So at a minimum, just saying, "How have you been sleeping?" And if people say, "I have not been sleeping well," I'd like a good open-ended question. Like, "Tell me, what does that look like for you? Because the thing is, like, people use the term—I don't even like to say, "Do you have insomnia?" Because people use the term a lot of different ways. Sometimes people say, "Oh, I suffer from insomnia." But when I dig deeper, like you said, they're not taking a while to fall asleep at the beginning of the night. They're not waking up in the middle of the night, but they're sleepy during the day. And so, they're calling that insomnia. What people call insomnia is not always what we would call insomnia. So, I like to just have them describe the nature of their sleep problems so I can get a sense of what's the primary complaint.

Host: And then, once you have some more information about, generally speaking, what's going on when they're trying to fall asleep, what's going on overnight. Are there certain, let's say, red flags perhaps, if someone mentions something they're experiencing or another medical condition they have? Are there things that really would give you pause in terms of recommending someone engage in CBT-I?

Dr. Philip Gehrman: And one thing I like to ask is, how do you feel like not sleeping well is affecting you? Because there are some people who will say, "Well, I don't sleep great at night, but it's not a big deal. My energy level's okay during the day." I mean, not that we ignore it in that case, but it's not a red flag.

But when people, they start to express, "It's taking over my life. I can't do anything." I mean, we know that insomnia is an independent risk factor for increased suicidality. And so, for some people, insomnia has wrecked such havoc in their life that we need to do something about this as soon as possible. And so, I think just asking about that, that impact. Again, another open-ended question, but just trying to get in their own words how much of it's affecting their life.

Host: We started to learn from you the CBT-I is happening over approximately six to eight sessions. And you're talking about behavioral strategies, you know, kind of structuring someone's approach to when they're physically getting into bed, when they're getting out of bed, working on a variety of things in that. And so, that's the behavioral, that's the B.

Dr. Philip Gehrman: Yeah.

Host: And then, there's the C, which is cognitive therapy, cognitive strategies. And I often find that I have to kind of tiptoe into this a little bit because I think a lot of people look at me, and I should preface this now for the audience saying I do CBT-I in my clinical practice at Penn Family Care. People often look at me with what I imagine to be the thought of like, "I've been thinking all of this time that I want to be sleeping. So, how are you going to tell me that what I'm thinking is preventing me from sleeping?" So, I'd love to hear your thoughts on how you even introduce the idea of cognitive therapy and cognitive strategies to help with insomnia.

Dr. Philip Gehrman: One of the things that's true of CBT as a whole, both the behavioral and cognitive components, is sometimes people are their worst enemy, and like they've developed these patterns that are making it worse. So, they're doing things that are making it worse. And so, it's really important to not say it in a way that's like blaming them because like sometimes people spend too much time in bed at night. Well, I think if I was having trouble sleeping, that would seem like the logical thing for me to do. And so, a lot of the ways people think and behave around insomnia just makes sense, but it is unfortunately counterproductive at times. And so, I really try to frame things in a way that I'm not saying, "Oh, you're the problem, that you're causing this."

Specifically in terms of this kind of sleep-related thoughts, the way I introduce it is I try to feed a lot of it into how people like are feeling about their sleep, kind of tying it to the emotional side. And I'll say things like, "You know, at night when you go to bed, when you're getting ready for bed, what's going through your mind as far as your sleep is concerned?" And oftentimes people say, "Oh, I'm just dreading going to sleep. You know, I'm wondering, is this going to be another night of tossing and turning?" And I'll say like, "It sounds like, you know, you're having a lot of thoughts, negative thoughts about sleep at night." So, I'm trying to, like, get them to kind of come up with that idea.

And then, I might say something like, "What a lot of people find is if they're thinking a lot about their sleep or really worrying about their ability to sleep, that it actually makes it harder. Do you feel like that's true for you?" So, I'm kind of trying to normalize that this is the way that we think. And inevitably, they say, "Oh yeah, that's definitely true for me." And then, I can say, "Well, I wonder if there would be value. It might be value instead trying to look at the some of the ways you think about your sleep to see if changing the way you think about your sleep actually could help you sleep better."

So, I try to frame it that way, not like harnessing in yet, because I'm trying to get their buy-in in the general concept before talking about like specific sleep-related thoughts they might have.

Host: I mean, so much of how I think a lot of people struggling with insomnia view their time in bed and feel about the experience of sleep, it is very negative. Of course, they've come into your office presumably with many, many nights of poor quality sleep. And so, the expectation logically now is, well, this is what my night is going to hold for me.

Dr. Philip Gehrman: There's often a lot of hopelessness by the time people get in to see me or someone like me, where they're saying, "This has been going on so long. Nothing I've tried has been effective. I'm just never going to be able to sleep better again."

Host: In terms of the cognitive therapy piece, you're talking about really exploring people's thoughts and beliefs about sleep and maybe gently trying to do some retraining, so to speak. And then, let's take a step back maybe to the behavioral piece. So, maybe you can talk a little bit about how the two pieces work with each other, right?

Dr. Philip Gehrman: Absolutely. And there even been some nice studies comparing full CBT-I to behavioral components only and cognitive components only. And what we've found is that we often start with the behavioral components because they tend to work more quickly. But what these studies have found is that if you don't address the cognitive piece, people tend to get worse again over time.Whereas if you treat both sides, the improvements people get tend to be more sustained over time.

So, the idea is like we're trying to get people to adapt new patterns of whether it's their sleep schedule or what do they do before bed to relax and winding down. What should they do if they can't sleep at night? And so, we kind of look at a number of ways that they could make behavioral changes in their patterns that could help break the cycle of insomnia. And so, we kind of get them moving, try to get them making some changes. And then, often over this time, like some of their sleep-related thoughts are just kind of emerging as part of these discussions. And not for everyone, but typically that's something we address like a partway through once we've got some of the behavioral components in place.

Host: What do you think is one of the really common beliefs that people with insomnia have about their sleep that you have to work with them to kind of reexamine and reframe?

Dr. Philip Gehrman: I think, culturally, we've kind of developed this obsessive focus about total sleep time and how many hours of sleep we get per night. And so, that's not unique to people with insomnia, but oftentimes they'll develop these beliefs. You know, they read in the news, in the magazines, and online, "I'm supposed to be getting eight hours of sleep." So, they develop this belief like, "I need to get eight hours to function the next day." And it's a good example of how, like, there is some truth to that. Like eight hours, seven to eight hours seems to be optimal for most adults. But like a healthy statement would be, "I feel best when I get seven to eight hours of sleep." That's accurate. But to say, "I need seven to eight hours or else the next day is a waste." Like, now, that thought has been magnified to the extent that it's unrealistic, it's not accurate, and it tends to then fuel anxiety.

Host: I am sure you will agree here that often it is devices that put these thoughts into people's heads, meaning watches or rings that track sleep. And sometimes it's people not even needing to track their sleep, though sometimes it is people with insomnia using these devices, and then coming in quite worried about the data that is being fed to them. And if there was an existing sleep concern, it is now magnified because the data is now showing X, Y, or Z. And then, that's a whole other issue now that we need to address.

Dr. Philip Gehrman: Yeah. In fact, one sleep researcher, Kelly Baron, has coined this term orthosomnia, where because her research has found that there are people who are sleeping fine, but then from tracking their sleep so closely, they develop this kind of obsessive focus about their sleep, and now they're sleeping worse as a result.

So, the devices themselves are driving their sleep problems. More commonly, what I see and kind of what you're talking about is someone who says, "You know, every morning I check my device—my ring, my watch—to see how I slept last night." And they treat the data from the device as ground truth. And they'll say, "You know what? I thought I slept really well last night, but my device told me I didn't, so therefore I didn't." And so, I really try to get people to say, "You know, you need to take these data with a grain of salt, that they're not always accurate."

And especially I'm very skeptical of their ability to detect different sleep stages. And so, you know, I have patients who come in and they'll say, "Oh, my device tells me I'm not getting enough REM sleep," or "Not enough deep sleep." And, yeah, I'm always a little skeptical about those times.

Host: Same. Yes. Well, since we're talking about sleep and how we approach it behaviorally, which I want to talk a little bit more about, maybe now is a good time to just briefly touch upon when we're talking about stages of sleep.

Dr. Philip Gehrman: So, we have a total of four stages of sleep. The one that has captured people's attention to the most is our REM, our rapid eye movement sleep, which tends to be when most dreaming occurs. But I often say that that's very creative name for a stage, and the creativity ended there because everything else is just called not REM sleep or non-REM sleep.

And there are three stages of non-REM sleep. stage I is very light sleep. It's like when you're first falling asleep and your sleep is so light that if someone called your name, you might still respond. And so, it's kind of at that border between sleep and wakefulness. Then, you settle down into stage II. I often describe it as kind of average sleep. It's not real light, it's not real deep. And then, stage III is our deepest, most restorative sleep. So, we want to get as much of that as possible. And so, we cycle through these different stages of sleep approximately every 90 minutes throughout the night. And typically, in the early part of the night, our sleep cycle, each 90 minutes is called a sleep cycle. In the early part of the night, our sleep cycles are dominated with a lot of that deep stage III sleep. In the latter part of the night, it's dominated more by REM sleep.

Host: Let's talk about what happens in the middle of the night when someone wakes completely from sleep. So, they are not in any stage of sleep. They are fully awake, or they feel fully awake. I think this is a very common issue that people struggle with and people even without insomnia can have this happen and be very frustrated. So, is there any kind of blanket statement, pun intended, that you say about how people should manage that overnight waking or wakefulness?

Dr. Philip Gehrman: First, I want to get a sense of how long are they up? Because sometimes it's a not too uncommon scenario where someone comes in, I'm gathering my data, and they say, "Oh, I wake up a couple of times per night." "How long are you up?" They say, "Oh, five, ten minutes. You know, I might use the bathroom and go back to sleep." And I say, "Well, that's kind of normal. Like, we expect that." And oftentimes, they'll say, "But when I was younger, I slept through the night." I say, "Well, you're not younger anymore." Again, I say it nicer than that.

But one of the things I want to make sure is people have a realistic expectation about what sleep is like. We do not expect people beyond, like, teenage years to sleep straight through the night without awakenings. So, sometimes after having that conversation with people, they're like, "Oh, I guess I'm just normal. I don't actually have insomnia." So, I want to get that out of the way first, make sure that's not the issue. If it's more like people are having these long awakenings in the night, the way I describe it to people is I say, "Well, when people wake up in the night, typically they have five, 10, 15 minutes that their mind's relatively calm and relaxed, their body's relatively calm and relaxed, and hopefully they're going to fall back to sleep.

But if that doesn't happen, you start to reach a point where you start thinking about the fact that you haven't gotten back to sleep yet." And they always nod their head. They always know exactly what I'm talking about. We've all been there. We've all had that. Well, once you reach that point where now you're thinking about your sleep and the fact that you haven't gotten back to sleep, it often starts this cycle of thinking more and more about sleep, trying harder and harder to sleep, getting frustrated about not being able to sleep, and you end up becoming more wide awake at that point. And so, like, one of the first things we tell people to do is if you can't sleep, get up, go do something relaxing, and return to bed once you feel sleepy again, because it's like just the long periods of tossing and turning in bed just adds fuel to the fire.

Host: A lot of people are very surprised by that advice because it seems like once we get into bed, we should not remove ourselves because something will happen. When our feet hit the floor and potentially we expose ourselves to light, that it's an irreversible shift. You know, we will not get back to sleep.And I think that's a very common myth that peoplehave, that if you wake overnight, actually, staying in bed is the best thing because the longer you spend in bed, the more likely you are to get sleep or, ultimately, the greater total of sleep you'll get. So, it's very counterintuitive to tell people to do the opposite.

Dr. Philip Gehrman: I totally agree, and it's a perfect example of how the things that logically you would do when you can't sleep end up actually being harmful. Because if I'm in bed, I might fall asleep. If I'm out of bed doing something else, I definitely won't. So, the probability is enhanced by staying in bed. And what I tell people is, one, we just know that actually on average, people get back to sleep faster when they take a break than if they stay in bed.

And two, I say to them, "And I'm going to bet that that time you spend tossing and turning in bed is just miserable." And people, "Oh, absolutely. I Hate it. It's the worst." Often I tell them, like, a lot of times after people start following this, this component, this strategy is they come back and they say, "You know what? What a relief it is to not just lie there feeling miserable for sometimes hours on end." And if they're skeptical still, I say, "Let's give it a shot. How about if we do an experiment for the next week? Let's see how it goes, and we'll revisit it."

Host: It's the leap of faith approach. Well, so now someone's out of bed. So, what kind of guidance do you give them about what they should be doing with themselves if they're not trying to sleep?

Dr. Philip Gehrman: I often say what I'm aiming for is kind of this middle zone. I don't want something under-stimulating. And what I mean by that is, like, back when we used to have phone books, I would sometimes have patients say, "Well, when I can't sleep, I get up and I read the phone book." But that requires such little cognitive effort that you're half reading it, you're half thinking, "Can I go back to sleep?" But, like, you're still thinking about your sleep. That's under-stimulating. You want something engaging enough that you're not just sitting there thinking about your sleep.

Now, of course, you don't want something so stimulating that now you're more wide awake and alert and getting further from sleep. So, that middle zone. And what's in that middle zone is different from person to person. Some general guidelines I give are, like, a lot of people like to turn on TV. And some people disagree with me with that one, because of the light from the TV. But also—I mean, if you're on your phone, the light source is six inches from your eyes. Most people don't sit six inches from the TV. Usually, the TV's across the room, and the effects of light on alertness drop off pretty quickly with distance. So, again, other people disagree with me, but I think the TV's okay. But if you're going to watch TV, don't turn on the news. Don't put on an action movie that now you're going to get sucked into or, you know, the Eagles game from earlier in the night where you're either going to get revved up or just so frustrated with how they did that you're just not going to be able to fall asleep.

Or if you're going to read, you're going to do some light reading, turn on a small reading light, but don't turn on lots of bright overhead lights. And don't read a suspenseful murder novel. You know, do some light reading. And so, it's just a discussion of, like, for you, what do you think would be relaxing?

Host: I'm a big fan of HGTV for this purpose.

Dr. Philip Gehrman: There you go.

Host: Just put it out there in public. Nothing like an episode of "House Hunters International" to be just stimulating enough.

Dr. Philip Gehrman: Yeah, I don't think too many people get revved up from that.

Host: Let's hope not. So actually, then we can also talk a little bit about how this relates to people approaching bedtime. So, are there certain activities that you recommend people avoid outright in the hour or two before bed? And the contrary, I mean, are there certain activities that you feel are actually quite beneficial if people start to introduce them around bedtime?

Dr. Philip Gehrman: I like to start by just asking people in the 30 to 60 minutes before you go to bed, what are you doing typically? Because for a lot of people, people live busy lives and they're kind of going, going, going until they can't go anymore, and then they want to just be able to rapidly switch off their brain and go to sleep. And most of us can't do that. I say most people need a good 30 to 60 minutes of relaxing, winding down activities before bed. It can be the very same types of activities that we were just talking about for the middle of the night if people can't sleep. I try to keep people off their phones close to bed.

That's often a losing battle these days, but ideally I would like them not on their phones because they might be scrolling through social media, and that tends to be more stimulating than relaxing. Again, they're getting kind of that light source close to the eyes.

Now, some people do like relaxing podcasts on their phone. Like something like that I'm not concerned about. Yeah, scrolling through social media, I generally advise against. Email before bed, not a great idea. All our primary care docs listening, Epic charting right before bed, not a great idea. Although that's when I know a lot of it happens.

Host: There has to be a complete disconnect between being on Epic and even being within 10 feet of your bedroom, I would say. Let's just say outright.

Dr. Philip Gehrman: So, anything like that. I mean, things that are work. I mean, for some people, some light housework can be relaxing. I actually find ironing shirts to be really, really relaxing. And so, it can—

Host: You have to pay attention, right? You can't be disengaged. You don't want to burn something.

Dr. Philip Gehrman: Yeah. I think it's what would be relaxing for you.

Host: I would imagine that a fair number of people will be listening to this and saying, "But I find TV relaxing, so why can't I watch TV in bed?"

Dr. Philip Gehrman: Yeah, the key being in bed. So, the idea of the getting out of bed when you can't sleep is because what we want people to have is this learned connection between their bed and sleep. So in an ideal world, tonight someone gets into bed and they fall asleep. Tomorrow night, they get into bed and they fall asleep. And the next night they get into bed and fall asleep. And they just develop that connection between the bed and sleeping. As a result, when they get into bed, it starts to trigger this automatic response of increased sleepiness.

Well, when people have had insomnia for a while, and they've spent night after night lying awake in bed tossing and turning, the opposite pattern can develop where people will say, I feel tired at night, but then when I get into bed..." I've had patients say, "It's like someone flipped a light switch on in my head, and now all of a sudden I'm awake, I'm thinking about things, and I can't sleep." Well, that's a sign that they've developed this learned pattern between the bed and wakefulness. So, what I say to people is, "Well, I want to teach you some ways to reteach your body that the bed is for sleep rather than wakefulness."

One, by reducing that time spent tossing and turning in bed, which we already talked about that. But also, we want your brain to know that the bed is a place for sleep. So, the more you do non-sleep activities in bed, the less your body knows that the bed is for sleep. Now, will say, like if someone says, "I get into bed and I watch 10 minutes of TV and it's relaxing and I fall asleep," that's not what I'm concerned about. Or, "I pick up my book, I read for a few minutes and I'm falling asleep, so I lay down." That's fine.

I had a patient once say, I love how he put it. He said, "So you mean I shouldn't use my bed as a place to hang out?" I said, "Bingo. You've nailed it on the..." I borrowed his expression for years now. That's right. The bed should not be where hanging out takes place.

Host: Right. I mean, I think it's a great way to think about it, because ultimately what you want someone to recognize is that the bed should be a place unlike any other, right? The bed is reserved for sleep and yes, sex. Of course, there are other things that people may do in bed. However, you really want to minimize the number of activities that happen in bed because of that link there, which if we're going to use the psychological term, I suppose we could say conditioning. Okay. If people want to take the time to delve into some research, they will see that there's a tremendous amount of evidence behind CBT-I. And it stands to reason then that there should be a lot of people that get CBT-I, and there are not nearly as many as we would like. And maybe you could talk a little bit about why that is, what does it seem like the barriers are. And then, we can talk a little bit about maybe how to help our patients climb those barriers.

Dr. Philip Gehrman: Yeah, I think the biggest barrier is awareness. I mean, we do pretty, I think, better up here at Penn than in a lot of places because, I mean, there's been such a strong sleep medicine program here for such a long time that I think there's a greater awareness of CBT-I as a treatment alternative compared to a lot of other places where they don't even know it's an option.

So, I think first step is just awareness, like to know that this is an option. It's not—because, I mean, some patients will say, "I don't even mention my sleep to my doctor because I know they're just going to write me a prescription, and that's not what I want." So, educating both providers and patients that, no, it's not the only option. So, I think that's step one in terms of getting people the care that they need.

Step two is really to think about what are all the options out there for doing CBT-I. And what I mean by that is insomnia is so prevalent, and the statistics you quoted at the beginning, it's a lot of people. I have job security. We're never going to have enough providers to do individual CBT-I with every person who needs it. But there are app versions of CBT-I. There are web-based versions of CBT-I, especially for people who are pretty motivated and kind of tech-savvy. Not everybody needs to see a provider for it. I mean, the data for the digital versions is pretty good. And so, I think a awareness it exists, awareness of the options for getting it, and then if someone wants to see someone for one-on-one care, knowing how to get that within our health system or whatever health system people are in.

Host: Yeah. Speaking from the primary care perspective, I will say I don't think most doctors want to prescribe sleep medication for their patients. I think most doctors that are doing that do so because they either are not aware of other options or don't have patients that are able to access other options. So, I think talking about the apps is a great point, and there are some really great apps that are free and also web-based resources. And then at Penn, there's the sleep center. But a lot of communities have sleep centers, and I often recommend that patients that are not within easy access of Penn, even the community practices, just look up a local sleep center and ask, "Do you provide CBT-I? Do you have resources that you give patients for how to access this treatment?" And that can really help guide people to care.

Dr. Philip Gehrman: Yeah. I agree. even if they don't have someone on staff who can provide it, they will hopefully at least be able to give you names of people in the community.

Host: So, I'm curious if you have any recommendations for primary care physicians who do not have sessions necessarily that are designed around talking about insomnia? Or are there certain questions you think might really help get us information?

Dr. Philip Gehrman: Yeah. I think getting a sense of how long it's been going on. Like if someone says, "Oh, I've only been having a problem the last few weeks," they probably don't yet need CBT-I. But if it's been going on for a while, and kind of to the point that we were discussing earlier and if they really feel like it's really taking a toll on them, then that's a good indication that a referral for CBT-I would be effective.

I mean, in an ideal world, it would be great to say give them like the 30-minute spiel about CBT-I, to say there's a non-medication approach that can be very effective, but you have to put in the work and really make the changes consistently for it to be effective, because it takes time to get in to see someone who does CBT-I. There's plenty of times I meet with someone, they've been referred, and I think they're a great candidate, but they're like, "Oh, I don't want to do all that. I just want a pill." And like, well, I've kind of wasted their time to a certain extent, and I could've seen someone else in that time that maybe really wanted to do the work.

So if there's the ability to give, like I said, the 30-minute overview of what it entails to see if it's even something that's of interest to them, sometimes when people are like, "No, I don't want to do all that work," that can actually be an indication that maybe their insomnia is not so bad.

Host: I think that's a great point. Yeah. I mean, I think there is so much of insomnia that is subjective, and it's a conversation to have with a patient what they think is going to benefit them in the short term. And I would say it's certainly not a waste of your time if you've spoken to someone about CBT-I because it certainly plants a seed that there are other treatments out there.

I think a lot of people when they think about medication use, they like it because they can appreciate that there will be a fairly quick uptake, right? They may even feel better tonight, and CBT-I is not going to give them that kind of response. And CBT-I certainly is work at putting new sleep schedules into place and managing how you're dealing with overnight wakefulness, among many other things.

But I would say, I would make a statement, a very broad statement saying that I would imagine almost everyone with insomnia does not want to continue with the condition. And even when they are getting a good response from sleep medications, I think there's a lot of fear of being on sleep medications, which I certainly don't want people afraid. But I think to have some healthy concern about the long-term effects of sleep medications, which we still aren't really clear on. But certainly, when I see an older patient on sleep medication, I am worried about their risk of falls, and I want to have something else in the toolkit to offer. So, I think that's where CBT-I can be such a tremendous education, even if people don't necessarily put it into effect 100% when we give them that information.

Dr. Philip Gehrman: Yeah, I totally agree. I mean, so many people are afraid they're going to become dependent on their sleeping medication. And I mean, we know that most of the time, even when sleeping medications work really well, if people stop taking them, the insomnia typically comes back. Like, they're not usually curative.

So, like, when I'm talking with people and they say, "Well, I don't really want to have to take this the rest of my life," like, they're okay with it now, but the idea of like, "I'm going to have to keep taking this if I want to keep sleeping," that often motivates people to be more interested in non-pharmacologic options.

Host: And I think I would venture in your experience as well, but certainly in mine, when people do CBT-I, when they go through the process and they see the hard elements and they work through it, and then they start to see an improvement in their sleep quality and sometimes quantity as well, a lot of people say, "Oh, you know, it's actually not that hard."

And I love hearing that because I love telling people it's actually not. It's just not very intuitive, right? But that's, I think, the beauty of CBT-I is when people get that sleep education, they put those techniques into effect, they do some troubleshooting with some support from us maybe, and then they get on track. That is something they'll take with them for the rest of their life. They're not going to forget that.

Dr. Philip Gehrman: Absolutely. And in fact, in my last session with people and when they've done well and they're sleeping better, like a lot of the discussion is, "Well, what has helped you break this cycle of insomnia?" And we review. And I say, "Now, let's say...—" I always tell them, "I would love to be able to say that now that you're sleeping better, that you will never have a bad night of sleep the rest of your life." And they always chuckle. I say, "Yeah, why is that unrealistic?" And they say, "Well, a bad night now and then is normal." Which is important for them to understand and to accept that. And then, I say, "Well, let's say you start having a string of bad nights again a year from now, two years from now. What should you do at that point?"

And my hope is they're going to say, "Oh, I should make sure I'm following a regular schedule." Like you said, they now know what to do if that happens to nip it in the bud and not need to come and see me again. And I tell them that. I say, "You know, don't take this the wrong way, but I hope I never see you again because I'll know you're doing well with your sleep. But we're here for you if you need it."

Host: Yes. My variation on that speech is saying, you know, you would think that as much talking about insomnia as I do, I would never have a night of poor sleep. But that is not true. So clearly, you can be trained in CBT-I, you can practice it, you can be helping people with their own insomnia, but that does not mean that you will no longer have a night of insomnia. Because if I still have some insomnia, then you will too. So, are there any kind of final thoughts, pearls, things about either behavioral sleep medicine generally or CBT-I specifically that you really want to make sure that you convey to our audience of primarily primary care providers, but also patients and other people in the healthcare world?

Dr. Philip Gehrman: Yeah. I think probably number one is take sleep seriously. That, oftentimes we have relegated it to the secondary symptom, but take it seriously. Don't assume that medications are the only option. And even just, a few questions about people's sleep can sometimes go a really long way towards getting them plugged into the care that they need.

Host: Well, we will end on that very wise note. Thank you so much, Dr. Phil Gehrman. It's been a pleasure having you on the Primary Care Podcast. And I hope people that have listened tonight are inspired to maybe Google CBT-I. You can learn a little bit more about it. Also, check out the resources in your community, certainly in our Penn community. We have excellent access through the Penn Sleep Center. And thank you everyone for listening, and we'll see you on the next episode.