The Curbsiders Internal Medicine Podcast

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

Date: January 19, 2026
Host(s): Dr. Matthew Frank Watto, Dr. Paul Nelson Williams, Dr. Edison (Eddie) Jang
Guest: Dr. Ashley E. Mason, PhD, Associate Professor of Psychiatry, UCSF

Episode Overview

This episode explores practical, evidence-based approaches to insomnia and sleep optimization, focusing on Cognitive Behavioral Therapy for Insomnia (CBTI). Guest expert Dr. Ashley Mason shares clinical pearls, her stepwise process, and myth-busting advice for patients and clinicians dealing with sleep complaints. The discussion ranges from debunking sleep myths to navigating sleep hygiene, substances, sleep aids, and actionable ways to help patients (and yourself) sleep better.

Key Discussion Points & Insights

1. Dr. Mason’s Background and Perspective

• Introduction ([02:23]): Dr. Mason is a UCSF psychiatry professor focusing on depression, insomnia, and firefighter health with interests in both cognitive behavioral and thermal therapies.
• Work-Life “Balance” ([06:10]): Dr. Mason combines research and personal passion, admitting “research is me-search.”
• Favorite Advice ([06:50]):

  “You have a choice. You can be right or you can be effective. ... The long-term outcomes of just being effective are better.” — Ashley Mason ([06:50])

• Sauna Obsession ([04:06]): Linking her love of sauna (“thermal therapies”) to broader health and sleep health themes, Dr. Mason describes worldwide heat-practices as “such an awesome way to spend an afternoon” ([05:47]).

2. Patient Case: Ms. Ima Apel Knight ([08:41])

A 62-year-old with obesity, hypertension, anxiety, chronic pain, and "lifelong bad sleep."
Presentation:

• In bed by 9pm, wakes 3-4am (hot, mind racing), falls back asleep with distractions, then lingers in bed in the morning
• Uses wine, OTC antihistamines, and melatonin as sleep aids
• Seeks help for sleep improvement

Dr. Mason’s Approach:

• Start by eliciting patient goals and readiness: “Her goals are often not predictable... Sometimes people say goals that are reasonable. Sometimes people say goals that are highly unreasonable.” ([10:31])
• First Steps:
  • Safety: Rule out medical emergencies, confirm hypertension is controlled
  • Clarify specifics: How long to fall asleep, activities before bed, details about night sweats/hot flashes, frequency/substance use
  • Always begin with obtaining a sleep diary (“consensus sleep diary”) for at least 7 days ([16:12])
  • Preference for paper over wearables: “Wearables are most accurate for the best sleepers and the least accurate for the worst sleepers.” ([16:12])
  • Bedding: Strongly recommends switching out down comforters for cotton blankets to improve nocturnal cooling ([12:50])

3. Sleep Myths & Goal Setting

• Sleep Duration Myths ([24:42]):
  • Not everyone needs 8-9 hours: “Patients seeking sleep treatment come in shoulding all over themselves.” ([24:42])
  • Emphasize quality > quantity. Aging brings sleep changes: less deep sleep, more wake time at night—this is normal.
  • Notable Quote ([24:42]):

    “Let’s focus on the quality of your sleep. Would you rather have 9 hours of tossing, turning, garbage sleep or 7 hours of awesome... sleep?” — Ashley Mason

• Rising at the Same Time Predicts Bedtime Sleepiness: Focus interventions on consistent wake time rather than bedtime ([126:58]).
• Chronotype/Phenotype Matters ([31:07]): Some people are natural night owls; society favors early risers, but expectations must be realistic.

4. The Five Pillars of CBTI ([35:18])

CBTI = Cognitive Behavioral Therapy for Insomnia
Five Main Components:

1. Stimulus Control
   • Bed reserved only for sleep & sex. No reading, TV, work, etc., in bed. This “strengthens the bed as a cue for sleep” ([37:35]).
   • If you can’t sleep (or wake up and can’t fall back asleep in 20–30 minutes): Get out of bed and do a quiet, boring activity until sleepy.
   • “Activities in the middle of the night should be things you’d be embarrassed if your boss saw you doing at work.” ([49:58])
2. Time in Bed Restriction
   • Also called “sleep restriction”: Limit time in bed to match average sleep time, then adjust based on improvement ([40:03]).
   • The process: use wake time from the sleep diary most frequently achieved, allow free bedtime at first, then add 30 minutes to average sleep achieved for the new time in bed window.
3. Cognitive Tools
   • Address racing thoughts and anxieties ([57:40]).
   • Scheduling daily "worry time," deploying cognitive behavioral tools for rumination/worry ([59:57]).
   • Notable story: Having a morning belief “I’m never going to make it through this day” was dispelled when tracked throughout the day ([60:06]).
   • “If we believe a thought at different levels throughout the day, how true can it be?” ([60:06])
4. Relaxation Tools
   • Pre-sleep wind down routine of 1 hour to prepare mind & body for sleep; no email or stressful activities before bed ([53:33]).
   • Use behavioral cues (face mask, pajamas, low lamp lighting, planning for next day).
5. Sleep Hygiene
   • Key elements:
     • Cool bedroom temp (ideally 65-68°F), cotton bedding, finish last meal 2-3 hours before bed, exercise in the morning, avoid screens or use orange (blue-blocking) glasses in pre-sleep hour ([68:22]).
     • Avoid caffeine after 11am
     • Keep wake-time consistent (emphasized repeatedly as the “magic thing” ([126:58])).
     • Prudent nap recommendations: <25 min, only if functionally necessary ([76:41]).
     • Avoid alcohol, minimize medications/substances, “No phones/social media” in bed or the hour before.

“CBTI is first line treatment for insomnia disorder. ... Your first step is not going to be writing her a prescription for sleep drugs.” — Ashley Mason ([21:04])

5. Common Pitfalls, Substances, and Special Topics

Avoidance of CBTI “Perpetuators”

• Attempts to counteract sleep problems often reinforce them—rotating drugs, crutches, and habits can perpetuate insomnia.
• Getting up at consistent times helps build and regulate sleep pressure ([43:40]).

Medications & Supplements ([86:55], [92:38])

• Alcohol: Helps you fall asleep, then fragments sleep and reduces REM. Can affect sleep quality for two nights ([86:55], [106:11]).
• Benadryl (Diphenhydramine): Only ever for allergies; not a long-term sleep solution. “Not intended for long-term use...” ([114:43])
• Melatonin:
  • “There are very few patients who actually ... have a very, very good shot of needing to be on melatonin ... those are patients taking beta blockers.” ([93:08])
  • Cites clinical trial where 2.5mg of melatonin (for patients on beta-blockers) was highly effective ([93:08]).
  • For circadian shifting, 0.5mg, 3–4 hours before new bedtime ([99:40]).
  • “It’s not for just anyone who can’t sleep... unless you are on a beta blocker and you haven’t tried this yet, you should try this in a controlled fashion.” ([103:15])
  • Over-the-counter dosing is unpredictable, sometimes wildly off the label.
  • Melatonin as “hormone of darkness”—not always a cue for sleep in all species.
• Supplements (Magnesium, Ashwagandha, Glycine, CBD): Data lacking; if the supplement worked, “you wouldn’t be here.” Magnesium preferred placebo if needed.
• Cannabis/THC & CBD ([108:18]):
  • THC initially helps with sleep onset, but increases wake time after sleep onset and disrupts sleep architecture with long-term use.
  • Chronic users may experience prolonged, severe sleep disturbances with withdrawal, sometimes lasting months.
  • “If you want to use a medication [for sleep], there are better options ... this argument that it’s natural—it’s a plant—that’s got to die.” ([113:08])

Pharmacologic Sleep Aids ([113:55])

• Trazodone: Can be used, but potential for morning hangover/fogginess.
• Z Drugs (e.g., Zolpidem/Ambien): Should not be first-line, use caution especially in women (starting dose 5mg for women, 10mg for men) ([111:22]).
• Benzodiazepines: Avoid for chronic sleep issues, can reduce slow wave sleep and are harder to taper than many believe.
• DORAs (Dual Orexin Receptor Antagonists): Newer class, promising, expensive, but easier to taper off ([114:43]).
• Caution on abrupt stopping: Taper very gradually, use the Subjective Units of Distress (SUDS) scale with patients ([121:13]).
  • Example: Gradual reduction, using a gem scale to make micro-reductions in pill size ([121:15]).

Notable Quotes & Moments

• “Patients seeking sleep treatment come in shoulding all over themselves. I should be doing this, I should be doing that. ... And so one of the first things I do is I say, okay, says who?” — Dr. Mason ([24:42])
• “You can’t just become a morning person if you’re a person who naturally goes to bed at midnight and gets up around 7 or 8.” — Dr. Mason ([31:07])
• “If you can’t sleep, get out of bed and do something boring. ... We want to strengthen the bed as a cue for sleep.” — Dr. Mason ([37:35])
• “Caffeine is like a goalie ... blocking your adenosine receptors. As soon as the caffeine wears off, the adenosine rushes in — that’s your caffeine crash.” — Dr. Mason ([78:05])
• “If you want to use a medication [for sleep], there are better options [than marijuana]. This argument that, oh, it’s natural, it’s a plant, ... tobacco is a plant; arsenic is a plant. That’s got to die.” — Dr. Mason ([113:08])
• “CBTI is not rocket science. It’s not that hard. And you can fix your sleep. Fixed sleep can be fixed.” — Dr. Mason ([129:22])

Timestamps for Key Segments

| Segment | Timestamp | |---------|-----------| | Dr. Mason Intro, Sauna Obsession | 02:20–06:38 | | Best Career Advice: “Be effective, not right” | 06:50 | | Patient case introduction | 08:41 | | Sleep diary & assessment methodology | 16:12 | | Myths about sleep duration, aging, chronotype | 24:42–33:19 | | Defining CBTI – 5 core elements | 35:18 | | Stimulus control/out-of-bed protocol | 37:35, 49:58 | | Sleep restriction explained | 40:03 | | Sleep hygiene practicals | 68:22 | | Caffeine, food timing, napping | 73:40–77:59 | | Medications, supplements, cannabis | 86:55, 92:38, 108:18 | | Melatonin, beta-blockers | 93:08, 99:40 | | Tapering sleep drugs, SUDS scale | 121:13 | | Dr. Mason’s top take-home points | 126:58 | | Recommended resources/apps | 129:22 |

Resources & Further Reading

• CBTI Workbooks: Quiet Your Mind and Get to Sleep (recommended self-guided resource, [59:57])
• Digital CBTI: REST app (a digital CBTI platform Dr. Mason consults for, [127:31])
• Consensus Sleep Diary: For patient self-tracking ([16:12])
• Cotton Bedding Recommendation: Strong advocacy for cotton blankets/sheets, avoid down ([12:50], [127:24])
• Ongoing Clinical Trials: For those interested in body temperature and sleep studies ([71:12], [71:34])

Practical Take-Home Points from Dr. Mason ([126:58])

1. Wake up at the same time every day. This is the “magic” intervention that will naturally consolidate sleep and benefit most patients.
2. You do NOT need supplements for sleep. Most are ineffective and unnecessary.
3. Reserve bed for sleep and sex. Remove all other activities from the bed—TV, reading, texting.
4. CBTI is accessible. If you can’t find or afford a therapist, a workbook or credible digital app can work.

Plug Zone

• Cotton sheets & blankets for better nocturnal cooling.
• Oslo earbuds for patients with tinnitus and sleep problems.
• Digital CBTI: REST app; effective self-help for insomnia.
• Self-help resources: Quiet Your Mind and Get to Sleep workbook.

Summary for Busy Clinicians:
CBTI is first-line, highly effective, and accessible—even outside sleep specialist practices. Focus on consistent wake times, restricting bedtime behaviors to sleep/sex, and addressing cognitive contributors to insomnia. Get a sleep diary! Educate patients on sleep myths. Avoid quick fixes; pharmacotherapy should be reserved and, if present, tapered gently.

(For more, see full show notes at curbsiders.com and consider self-study options or digital CBTI for interested patients. CME available. Episode produced by Dr. Edison Jang.)