The Carlat Psychiatry Podcast

Today, we’re tackling a deceptively simple question that comes up all the time in clinical practice: When should we prioritize medication, when should we emphasize psychotherapy, and when can we recommend both? This question comes up especially often with patients who are new to treatment. They’ll ask, “Do I need a medication?” or “Can I just do therapy?” And while it’s tempting to answer in generalities, the evidence actually gives us much clearer guidelines, depending on the substance that the patient is using. 

CME: Take the CME Post-Test for this Episode
Published On: 09/07/2026
Duration: 10 minutes, 57 seconds

Noah Capurso, MD, and Suzanne Decker, PhD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Dr. Donn Posner is a leading expert in Cognitive Behavioral Therapy for Insomnia (CBT-I), founder and president of Sleepwell Consultants, and an adjunct clinical associate professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. He is co-author of Cognitive Behavioral Therapy for Insomnia: A Session-by-Session Guide, and he has trained and consulted with clinicians nationally and internationally across nearly four decades of clinical practice. 

In this second of two episodes, the conversation turns from what CBT-I is to how clinicians actually learn and deliver it. Dr. Posner reviews the available training pathways and what proficiency really requires, and explains why sleep hygiene — the advice most patients have already heard many times over — does not treat chronic insomnia, even though it has a place later in the work. He identifies the high-yield principles any clinician can apply immediately, including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping. He then examines sleep effort as a perpetuating factor and CBT-I as fundamentally a therapy of acceptance, describing how he prepares patients for a treatment that will make them feel worse before it makes them better, and how cognitive work addresses the fear and resistance that follow. He closes with what clinicians should expect from a course of treatment — typical length and spacing, responder and remitter outcomes, and the durability of gains — along with how he handles sleep medication and why guidelines place CBT-I ahead of hypnotics.

Learning Objectives
After completing this educational activity, participants should be able to:
Explain why sleep hygiene is ineffective as a monotherapy for chronic insomnia, and describe the more limited role it plays within a full course of CBT-I.
Identify high-yield behavioral sleep medicine principles — including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping — that clinicians can apply before completing formal CBT-I training.
Describe sleep effort as a perpetuating factor, and summarize how the cognitive and acceptance-based components of CBT-I address the dysfunctional beliefs and resistance that arise during treatment.
Summarize the expected course and outcomes of CBT-I (including typical session number and spacing, responder and remitter outcomes, and durability of gains) and explain why guidelines position CBT-I ahead of hypnotic medication.

Topics Covered in This Interview
Pathways to training in CBT-I and behavioral sleep medicine
Board certification in behavioral sleep medicine
Why sleep hygiene alone does not treat chronic insomnia: the dental hygiene analogy
Where sleep hygiene does belong within CBT-I
Available CBT-I training programs and online options
How clinicians become proficient: consultation, community, and case experience
High-yield behavioral sleep principles any clinician can apply
Sleep regularity, fixed wake times, and morning light exposure
Why getting out of bed is the hardest intervention for patients to accept
Sleep effort as a perpetuating factor
What good sleepers do — and do not do — to fall asleep
CBT-I as a therapy of acceptance
Preparing patients for the work: “I'm going to make you worse before I make you better”
The cognitive component: uncovering and debunking dysfunctional beliefs
Common patterns of resistance, and exposure as the remedy
Typical treatment length, session spacing, and pacing
Responders versus remitters, and what the outcome data show
Durability of gains and the role of sleep self-efficacy
Managing and tapering sleep medication alongside CBT-I
Why guidelines position CBT-I ahead of hypnotic medication

Dr. Donn Posner is one of the most active educators in CBT-I. He's founder and president of Sleepwell Consultants, adjunct clinical associate professor in Psychiatry and Behavioral Sciences at Stanford, and spent twenty-five years before that as director of behavioral sleep medicine at the Sleep Disorders Center of Lifespan Hospitals.

In this first of two episodes, Dr. Posner explains that chronic insomnia is a disorder in its own right — not just a symptom of something else — driven by perpetuating factors that become the targets of treatment. He covers:
How insomnia disorder is defined, and what a proper CBT-I assessment looks like
The sleep diary as the clinician's version of an X-ray
The two core behavioral components — sleep restriction (more accurately, time-in-bed restriction) and stimulus control — and the mechanisms each one targets: homeostatic sleep drive and conditioned arousal
Why sleep can't be willed — it's never under a patient's voluntary control
How far the protocol can flex for individual patients
The evidence base showing CBT-I works even alongside depression, anxiety, PTSD, or chronic pain — and that those conditions don't need to be treated first

Length: 28 Minutes

How to separate adult ADHD from other causes of cognitive problems like bipolar disorder, sleep apnea, medication effects, brain injury, temperament, and malingering.

CME: Take the CME Post-Test for this Episode
Published On: 08/17/2026
Duration: 15 minutes, 35 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

The modern DSM began as a short list of 12 well-validated diagnoses. But the list expanded as the authors changed the goals from validity to reliability. Lost in this history is a missing page that helps separate adult ADHD from its mimics.

CME: Take the CME Post-Test for this Episode
Published On: 08/10/2026
Duration: 14 minutes, 39 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.