While we tend to think of sleep deprivation as a postpartum issue, sleep problems are relatively common during pregnancy, with 15% to 80% of women reporting sleep problems during the first trimester and 66% to 97% of women in the third trimester. While some women use certain sleep-promoting medications during pregnancy, including benzodiazepines and sedative-hypnotic agents (Z-drugs), we should consider non-pharmacologic options first, especially in women who present with new onset sleep problems.
Cognitive-behavioral therapy (CBT) specifically designed for insomnia, also known as CBT-I, is a useful adjunct or alternative to medication. CBT-I typically involves 6-8 sessions with a trained provider, although some patients require fewer sessions. In addition, there are some options where CBT-I is delivered online or through a mobile app.
The Principles of Cognitive Behavioral Therapy for Insomnia
The first step of CBT for insomnia is to identify cognitions or beliefs that affect one’s ability to sleep, the negative thoughts and worries that prevent or interrupt sleep. The behavioral part of CBT-I involves developing good sleep habits and learning to avoid behaviors that disrupt sleep. CBT-I combines several different approaches to promoting sleep and preventing insomnia. Sessions may include cognitive, behavioral, and educational components, including:
Cognitive restructuring attempts to change inaccurate or distorted thoughts about sleep.
Sleep hygiene involves changing basic lifestyle habits that influence sleep, including drinking too much alcohol, smoking or drinking caffeine late in the day, not getting regular exercise, and using smartphones and other devices at night before going to bed. Good sleep hygiene also includes establishing routines which help one to wind down an hour or two before bedtime.
Sleep environment improvement focuses on optimizing the sleep environment, such as keeping the bedroom quiet, dark and cool, not having a TV in the bedroom, and hiding the clock from view
Stimulus control therapy helps remove factors that condition the mind to resist sleep. Examples of this strategy include setting consistent bedtime and wake times, avoiding naps, using the bed only for sleep and sex, and leaving the bedroom if sleep does not occur within 20 minutes.
Relaxation training may include approaches including meditation, imagery, and progressive muscle relaxation to promote relaxation and ultimately sleep.
Sleep restriction reduces the time the patient spends in bed, causing partial sleep deprivation, which ideally would increase sleepiness the following night. Once sleep has improved, the time spent in bed is gradually increased.
The program may vary based on the provider’s approach and the unique needs of each person.
Evidence Supporting the Use of CBT-I During Pregnancy
In a recent study, Manber evaluated the effectiveness of CBT for insomnia during pregnancy in a group of pregnant women between 18 and 32 weeks of gestation. This study excluded patients if they met diagnostic criteria for major psychiatric disorders, including major depressive disorder, or if they were receiving any other treatment outside of the study that could potentially affect sleep.
Women were randomly assigned to CBT for insomnia (CBT-I, n=89) or a control intervention of imagery exercises which paired patient-identified distressing experiences with patient-identified neutral images (n=90). Both treatments consisted of five individual therapy sessions. The Insomnia Severity Index score, a validated brief questionnaire, was used to assess patients’ symptoms.
Women assigned to CBT-I experienced greater reductions in insomnia severity (scores decreased from 15.4 ± 4.3 to 8.0 ± 5.2) compared to women in the control group (scores decreased from 15.9 ± 4.4 to 11.2 ± 4.9). Remission of insomnia (defined as an Insomnia Severity Index score of less than 8) was achieved by 64% of the women in the CBT-I group compared to 52% in the control group. Women receiving CBT-I experienced faster remission of insomnia, with a median of 31 days versus 48 days in the control therapy. Women receiving CBT-I also experienced a small but significantly greater decline in depressive symptoms measured using the Edinburgh Postnatal Depression Scale scores compared to the control group.
This randomized, controlled trial is the first to assess the effectiveness of CBT for the treatment of insomnia during pregnancy. While CBT-I might be an attractive option for many pregnant women with insomnia, we do not know if this particular intervention will work in the women we typically see in our clinic who have comorbid depression and/or anxiety disorders. This study excluded women with significant psychiatric disorders; however, they did observe an improvement in mood in women treated with CBT-I. This is consistent with what we observe clinically in pregnant and postpartum women, where treatments that improve sleep can have a robust impact on mood.
Online CBT Intervention for Insomnia
Felder and colleagues (2020) examined the efficacy of a digital CBT intervention in pregnant women with insomnia symptoms. In a randomized clinical trial pregnant women up to 28 weeks of gestation were randomized to receive either digital CBT-I (n?=?105) or standard treatment (n?=?103) for insomnia. Digital CBT-I consisted of 6 weekly sessions of approximately 20 minutes each. Women receiving standard treatment were free to pursue other treatments for insomnia, including medication and psychotherapy.
Participants completed outcome measures at 10 weeks (post-intervention) and at 18 weeks (follow-up) after randomization. All study visits were completed remotely, and the intervention was delivered digitally. Insomnia symptom severity was measured using the Insomnia Severity Index.
Women who received digital CBT-I experienced statistically significantly greater improvements in insomnia symptom severity from baseline compared to women receiving standard care. In addition, women who received digital CBT-I treatment reported greater reductions in the amount of time they lay awake in bed and greater improvements in global sleep quality, although there was no significant difference in sleep duration.. Remission rates were also significantly higher among women in the digital CBT-I group (44.0%) compared to standard treatment (22.3%). In addition, women in the digital CBT-I group had greater improvements in depressive symptoms and anxiety than women in the standard treatment group.
The benefits of digital CBT-I were similar to those observed in participants receiving in-person CBT-I (Manber 2019, described above). Importantly, the benefits of digital CBT-I treatment were maintained approximately 2 months after completion of treatment. Moreover, a digital intervention that women can access at their convenience is likely to be particularly attractive to pregnant women, who may have less time or may be less able to travel for in-person treatment.
Could CBT-I Be Used to Reduce the Risk of Perinatal Depression?
There have been several recent studies that indicate that poor sleep may predispose women to perinatal depression and/or may contribute to worsening of depressive symptoms. Whether sleep disturbance is an independent risk factor for depression or is, in fact, the earliest symptom of depression is not so clear; however, these findings raise an important clinical question. If sleep problems are managed early on, would it be possible to actually prevent perinatal depression?
There is at least one study which has tested this hypothesis. In this small study pregnant women (n=54) reporting sleep problems were randomized to receive trazodone (an antidepressant medication with sedative effects), diphenhydramine (Benadryl, an antihistamine with sedative properties), or placebo in order to determine whether these interventions reduce the risk of postpartum depressive symptoms.
Sleep efficacy and total sleep time improved in women treated with trazodone and diphenhydramine as compared to women receiving placebo. Trazodone and diphenhydramine treatment during the third trimester of pregnancy reduced the severity of PPD symptoms (assessed at 2 and 6 weeks after delivery). Sleep quality and depressive symptoms did not differ between trazodone and diphenhydramine groups. This study excluded women with a history of mood disorder prior to pregnancy, so we do not know if this sleep intervention would work for all women, particularly for women with histories of depression who are at higher risk for perinatal depression. Nonetheless, this is a finding which deserves further exploration.
We are now screening women for mood and anxiety disorders during pregnancy and the postpartum period, and the US Preventive Services Task Force (USPSTF) recommends that women at increased risk for perinatal depression be referred for appropriate “counseling interventions”, either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT).
We do not currently specifically screen for sleep disturbance in this population, and I am not advocating for the use of yet another screening tool. However, some screening tools, including the PHQ-9 but not the EPDS, ask about sleep. If sleep disturbance is the harbinger of perinatal depression, it might make sense to place more emphasis on this symptom. At the very best, prescribing an intervention to improve sleep may reduce risk for perinatal depression. At the worst, we would give new mothers some tools to manage a very distressing and common problem.
Ruta Nonacs, MD PhD
Bei B, Pinnington DM, Quin N, Shen L, Blumfield M, Wiley JF, Drummond SPA, Newman LK, Manber R. Improving perinatal sleep via a scalable cognitive behavioural intervention: findings from a randomised controlled trial from pregnancy to 2 years postpartum. Psychol Med. 2021 Jul 7:1-11.
Felder JN, Epel ES, Neuhaus J, Krystal AD, Prather AA. Efficacy of Digital Cognitive Behavioral Therapy for the Treatment of Insomnia Symptoms Among Pregnant Women: A Randomized Clinical Trial. JAMA Psychiatry. 2020 May 1;77(5):484-492. doi: 10.1001/jamapsychiatry.2019.4491.
Manber R, Bei B, Simpson N, Asarnow L, Rangel E, Sit A, Lyell D. Cognitive Behavioral Therapy for Prenatal Insomnia: A Randomized Controlled Trial. Obstet Gynecol. 2019 May;133(5):911-919. Free Article
Cognitive Restructuring and Sleep Medication Reduction Techniques (University of Massachusetts) – This is a manual for patients with clearly written lessons for those interested in learning cognitive restructuring to improve sleep and some techniques to assist patients in tapering sleep medications.
CBT-I App – A free app from the Veterans Administration which guides users through the process of CBT-I. Maybe not so pretty, but free and effective.