Understanding Insomnia

Insomnia affects millions of people. Approximately 30% of adults experience short-term insomnia at some point in their lives, and about 10% struggle with chronic insomnia according to sleep foundation research. But insomnia is more than just a few bad nights – it’s a persistent difficulty falling asleep, staying asleep, or waking too early and not being able to return to sleep, occurring at least three nights per week for three or more months. When insomnia becomes chronic, it significantly impacts your daytime functioning, mood, relationships, work performance, and overall quality of life.

At MindMED Behavioral Health, we recognize that insomnia is not a personal failure or a simple matter of “relaxing more.” It’s a complex medical condition that often has underlying causes – many of which are psychiatric in nature. Insomnia can be acute (related to a specific stressor) or chronic (long-standing and recurring). Some people struggle with sleep-onset insomnia (difficulty falling asleep), others with sleep-maintenance insomnia (frequent awakenings during the night), and still others with early morning awakening insomnia (waking up too early and unable to fall back asleep). The type of insomnia matters because it guides treatment strategy. And critically, when insomnia coexists with anxiety, depression, PTSD, bipolar disorder, or other psychiatric conditions, treating the underlying mental health condition is often the key to restoring sleep.

The Connection Between Sleep and Mental Health

Sleep and mental health have a deeply bidirectional relationship. This is one of the most important things we address at MindMED. Sleep isn’t just something your body does at night – it’s fundamental to emotional regulation, stress processing, memory consolidation, immune function, and neurochemical balance. When sleep is disrupted, depression, anxiety, and mood instability worsen. Conversely, untreated anxiety and depression cause insomnia. This creates a vicious cycle: poor sleep worsens mood, and worsened mood further disrupts sleep.

Research shows that insomnia can be one of the earliest signs that a mood or anxiety disorder is developing. Many people don’t realize their sleep problem is a symptom of depression or anxiety – they think they simply have a “sleep problem” and try to treat it in isolation. But when we evaluate insomnia from a psychiatric perspective, we often uncover underlying anxiety that’s creating racing thoughts at bedtime, depressive rumination that prevents sleep, or unprocessed trauma causing nightmares and hypervigilance. That’s why seeing a psychiatrist for insomnia is so valuable. We don’t just ask “How’s your sleep?” – we ask “What’s happening in your mind and body that’s preventing sleep?” This distinction changes everything about how we treat it. Addressing the psychiatric root cause of insomnia often leads to dramatically better sleep than medication alone could achieve.

Types of Sleep Disorders We Evaluate

• Chronic Insomnia Disorder – Persistent difficulty falling asleep, staying asleep, or early morning awakening occurring at least three nights per week for three or more months, with significant daytime impairment. This is the primary condition we treat, and we focus on understanding whether an underlying psychiatric condition is driving it.
• Insomnia Co-occurring with Anxiety – Racing thoughts, worry, and hypervigilance that keep you awake or prevent deep sleep. We address both the anxiety and its impact on sleep architecture through integrated treatment.
• Insomnia Co-occurring with Depression – Early morning awakening, inability to maintain sleep, or hypersomnia (sleeping too much) as part of major depressive episodes. Treating the depression improves sleep significantly.
• Insomnia Related to PTSD or Trauma – Nightmares, hypervigilance, and sleep fragmentation related to traumatic experiences. This requires specialized psychiatric approach combined with trauma-informed strategies.
• Sleep Disturbances in Bipolar Disorder – Decreased need for sleep during manic or hypomanic episodes (feeling rested after just 2-3 hours). This is often an early warning sign of an emerging episode and requires immediate attention.
• Circadian Rhythm Sleep-Wake Disorders – Misalignment between your internal sleep-wake rhythm and your desired or required sleep schedule, common in shift workers, night owls, or those with delayed or advanced sleep phase. We evaluate whether psychiatric factors are contributing.
• Medication-Related Sleep Disturbances – Some medications (stimulants, certain antidepressants, corticosteroids, beta-blockers) can disrupt sleep. We review your medications and work with your other providers to adjust timing or alternatives if needed.
• Restless Legs Syndrome Considerations – While restless legs is typically managed by sleep medicine or neurology, it often coexists with anxiety and depression. When indicated, we coordinate care with specialists and address psychiatric comorbidities.

Recognizing When Insomnia Needs Treatment

Not every poor night of sleep requires professional evaluation – occasional sleeplessness related to stress, travel, or caffeine is normal. But certain patterns suggest it’s time to see a psychiatrist. If you’re experiencing difficulty sleeping at least three nights per week that has persisted for three or more months, you should seek evaluation. Other red flags include: your insomnia is significantly affecting your daytime functioning (concentration, mood, energy, work performance, safety), you’re relying on alcohol or over-the-counter sleep aids to fall asleep, you’re experiencing daytime impairment that’s affecting relationships or work, or you’ve noticed that your sleep problem started or worsened around the time you experienced significant stress, loss, trauma, or changes in mood.

Your primary care doctor can be a good starting point, but there are several reasons to consider a psychiatric evaluation specifically: if your insomnia started with or is accompanied by anxiety, panic, depression, mood changes, or trauma; if you’re wondering whether anxiety or depression might be contributing to your sleep problem; if you’re currently on psychiatric medications and noticing sleep changes; if you’ve tried standard sleep hygiene and over-the-counter approaches without improvement; or if you want to understand the mental health factors underlying your sleep. A psychiatrist brings specialized expertise in the psychiatric roots of insomnia and can provide integrated medication management and behavioral strategies tailored to your specific situation.

Our Approach to Treating Insomnia

We take a comprehensive, integrative approach that goes well beyond simply prescribing a sleep medication. Your initial evaluation with Dr. Fredes is 60-90 minutes – unhurried time to understand the full picture of your sleep, your psychiatric history, your medical history, your lifestyle, your goals, and what has or hasn’t worked in the past. We gather detailed information about sleep patterns, what triggers your sleeplessness, when it started, what’s happened in your life since then, your mood and anxiety levels, your caffeine and alcohol use, your sleep environment, and your daytime symptoms.

Medications for Insomnia

When medication is appropriate for your insomnia, Dr. Fredes uses evidence-based options. It’s important to understand that not all sleep medications are the same, and she approaches medication selection thoughtfully and conservatively, with clear goals about duration and effectiveness. Here are the main medication classes used in modern insomnia treatment:

Non-benzodiazepine Hypnotics – These include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). These medications work by enhancing GABA signaling in the brain to promote sleep. They’re effective for sleep-onset insomnia, and when used appropriately at the lowest effective dose, they have a good safety profile. However, they carry some risk of dependency with longer-term use and can occasionally cause complex sleep behaviors (sleep-walking, sleep-eating) at higher doses.

Melatonin Receptor Agonists – Ramelteon (Rozerem) is an FDA-approved option that mimics melatonin, the body’s natural sleep hormone. It’s particularly effective for sleep-onset insomnia and circadian rhythm disorders. It has low abuse potential and is generally well-tolerated for longer-term use.

Orexin Receptor Antagonists – These are newer medications (suvorexant, lemborexant, daridorexant) that work by blocking wake-promoting signals in the brain. They’re effective for both sleep-onset and sleep-maintenance insomnia and have become increasingly popular because they work differently from traditional hypnotics, offering an alternative approach with good tolerability and safety data for extended use.

Low-Dose Trazodone – Originally developed as an antidepressant, trazodone at lower doses (25-50mg) is sometimes used off-label for sleep. It can be helpful, particularly when depression or anxiety is also present, though evidence for pure insomnia is limited. It’s often tolerated well.

Hydroxyzine – An antihistamine with sedating properties, sometimes used for sleep, particularly in people with anxiety. Effectiveness varies, and tolerance can develop with longer-term use.

Gabapentin – While primarily an anticonvulsant, gabapentin has sedating properties and is sometimes used for sleep, particularly in people with restless legs or neuropathic pain. Evidence is mixed, and doses for sleep are typically lower than for pain management.

Dr. Fredes’ approach to sleep medications emphasizes: (1) starting low and going slow – using the lowest effective dose, (2) regular monitoring – ensuring the medication is effective and not causing side effects, (3) periodically reassessing necessity – asking whether the medication is still needed as your sleep improves or as underlying psychiatric conditions are treated, and (4) avoiding benzodiazepines – these medications have high abuse potential, tolerance develops quickly, and they’re generally not appropriate for chronic insomnia treatment despite being prescribed in the past.

Sleep Hygiene and Integrative Strategies

Sleep hygiene – the habits and environmental factors that support good sleep – is foundational to insomnia treatment. While sleep hygiene alone doesn’t always resolve chronic insomnia (especially when psychiatric conditions are involved), it’s a crucial component of any treatment plan. Here are evidence-based strategies:

Consistent Sleep Schedule – Go to bed and wake up at the same time every day, even on weekends. This trains your body’s circadian rhythm. If your current schedule is chaotic, shift it gradually – 15-30 minutes earlier or later every few days until you reach your target bedtime.

Light Exposure Matters – Get bright light exposure in the morning (ideally within an hour of waking) to reinforce your circadian rhythm and suppress melatonin during the day. In the evening, dim lights and reduce blue light from screens 1-2 hours before bed. This is especially important if you struggle with delayed sleep phase (falling asleep too late).

Temperature Optimization – Your body naturally cools to initiate sleep. A bedroom temperature around 65-68°F (18-20°C) is ideal for most people. A cool room facilitates sleep; an overheated room prevents it.

Screen Management – The blue light from phones, tablets, and computers suppresses melatonin production, signaling your brain that it’s daytime. Stop using screens at least 30-60 minutes before bed. If you must use them, use blue-light filters or blue-light-blocking glasses.

Caffeine Timing – Caffeine has a half-life of 5-6 hours, meaning if you have coffee at 3 PM, half of it is still in your system at 8-9 PM. For better sleep, avoid caffeine after 2 PM. If you’re sensitive, consider cutting off earlier.

Alcohol Avoidance Before Sleep – While alcohol might help you fall asleep initially, it disrupts sleep architecture, reduces REM sleep, and causes nighttime awakenings. Avoid alcohol at least 3-4 hours before bed.

Exercise Timing – Regular exercise improves sleep significantly, but timing matters. Morning or afternoon exercise is ideal. Intense exercise within 2-3 hours of bedtime can be stimulating and delay sleep.

Relaxation Techniques – Progressive muscle relaxation (systematically tensing and releasing muscle groups), guided imagery, deep breathing (particularly 4-7-8 breathing), and meditation calm the nervous system and prepare your mind for sleep. Practicing these earlier in the evening, not just at bedtime, is often more effective.

Evidence-Based Supplements – Melatonin (0.5-3mg taken 30 minutes before bed) can be helpful, particularly for circadian rhythm disorders. Magnesium (200-400mg) may support sleep for some people, though evidence is mixed. Other options with some supporting research include glycine, L-theanine, and valerian root, though efficacy is variable and quality of supplements varies significantly. Always discuss supplements with Dr. Fredes before starting, as they can interact with medications.

Insomnia and Co-Occurring Conditions

Insomnia frequently coexists with other psychiatric and medical conditions, and treating the underlying condition often leads to sleep improvement.

Depression and Insomnia – Insomnia is a core symptom of major depression. It can manifest as early morning awakening (waking 2-3 hours earlier than desired), difficulty maintaining sleep, or paradoxically, hypersomnia (sleeping excessively). Treating the depression – through both medication and addressing underlying contributors like isolation, loss, or hopelessness – typically improves sleep significantly.

Anxiety Disorders and Insomnia – Generalized anxiety, panic disorder, and social anxiety all commonly disrupt sleep through racing thoughts, worry, and hypervigilance. Anxious thoughts at bedtime (“What if I can’t fall asleep? What if I’m tired tomorrow?”) paradoxically worsen insomnia. Treating the anxiety disorder addresses both the nighttime racing mind and the daytime anxiety.

PTSD and Nightmares – Trauma survivors often experience sleep fragmentation, nightmares, night sweats, and hypervigilance that prevent restorative sleep. Treating PTSD through trauma-informed psychiatric care, sometimes combined with trauma-specific psychotherapy, addresses both the traumatic responses and the sleep disturbance.

Bipolar Disorder and Sleep – A decreased need for sleep (feeling rested after just 2-3 hours) during manic or hypomanic episodes is a hallmark sign and often one of the earliest warning signs of an emerging mood episode. Tracking sleep changes is crucial in bipolar management. Insomnia during depressive episodes or mixed episodes also requires attention.

ADHD and Sleep – While some people with ADHD struggle with racing thoughts and difficulty winding down, others with ADHD have delayed sleep phase or difficulty maintaining consistent sleep schedules. Sleep deprivation worsens ADHD symptoms, creating a feedback loop. Treating ADHD, along with sleep hygiene support, often improves sleep.

Chronic Pain and Insomnia – Conditions like fibromyalgia, chronic headaches, and other pain disorders disrupt sleep, and sleep deprivation worsens pain perception. Integrated treatment addressing both the pain and the psychological factors (anxiety, catastrophizing) that interfere with sleep is important.

Menopause and Sleep – Hormonal changes during perimenopause and menopause cause hot flashes, night sweats, and insomnia. Addressing these physical symptoms while also evaluating for mood changes (depression and anxiety commonly emerge during menopause) provides comprehensive support.

Frequently Asked Questions About Insomnia

When should I see a psychiatrist for insomnia vs my primary care doctor?
A psychiatrist is uniquely qualified to evaluate insomnia that is caused by or coexisting with anxiety, depression, PTSD, bipolar disorder, or other psychiatric conditions. If your insomnia started or worsened after experiencing significant stress, trauma, or mood changes, psychiatric evaluation is essential. A psychiatrist can also identify medication side effects that may be contributing to sleep problems. Your primary care doctor can handle simple sleep issues or sleep apnea screening, but when psychiatric factors are involved, a psychiatrist provides specialized expertise.

Will I need sleeping pills?
Not necessarily. We start with a thorough evaluation to understand the root cause of your insomnia. Many people improve significantly with sleep hygiene optimization, addressing underlying anxiety or depression, stress management, and lifestyle modifications. If medication is appropriate for your situation, Dr. Fredes uses evidence-based options that are effective and safe. The goal is always the lowest effective dose for the shortest duration needed.

Is it safe to take sleep medication long-term?
Some sleep medications are safer for longer-term use than others. Dr. Fredes avoids benzodiazepines for sleep due to their addiction potential. Modern sleep medications like suvorexant, lemborexant, and melatonin receptor agonists have been studied for extended use and are generally safe when monitored appropriately. The approach is always individualized based on your specific situation, medical history, and goals. Regular follow-up appointments ensure that any medication remains effective and necessary.

Can insomnia be caused by anxiety or depression?
Absolutely. Insomnia is frequently a symptom of underlying anxiety, depression, or other psychiatric conditions. The relationship is bidirectional – untreated anxiety or depression causes sleep problems, and chronic sleep deprivation worsens mood and anxiety. Research shows that insomnia can even be a first sign that depression or anxiety is developing. Treating the underlying psychiatric condition often resolves the sleep problem without needing a separate sleep medication.

What is CBT-I?
CBT-I stands for Cognitive Behavioral Therapy for Insomnia. It’s an evidence-based psychological approach that addresses the thoughts, behaviors, and habits that keep insomnia going. CBT-I includes sleep restriction (consolidating sleep time to improve sleep quality), cognitive techniques to address racing thoughts and worry, stimulus control (using the bed only for sleep), and relaxation methods. Research shows CBT-I is highly effective, particularly when combined with psychiatric medication management for cases where underlying mood or anxiety disorders are involved.

How long does insomnia treatment take?
This varies based on the cause and severity of your insomnia. If insomnia is secondary to anxiety or depression, treating the primary condition often improves sleep within 4-6 weeks. For chronic insomnia, improvement typically begins within 2-4 weeks but may take 8-12 weeks to reach full benefit. If underlying psychiatric conditions are involved, treatment may take longer as we address both the sleep problem and the root cause. Dr. Fredes monitors progress at regular follow-up appointments and adjusts treatment as needed.

Do you treat sleep apnea?
Sleep apnea is a sleep medicine specialty condition that requires formal sleep study diagnosis and typically involves a sleep specialist and CPAP or other device management. Dr. Fredes evaluates for signs of sleep apnea during initial assessment and refers to a sleep medicine specialist when indicated. However, if you have obstructive sleep apnea that is being treated by a sleep specialist, Dr. Fredes can help manage any coexisting psychiatric conditions like depression or anxiety that often accompany sleep apnea.

Can supplements help with sleep?
Some supplements have evidence supporting their use for sleep. Melatonin is effective for certain types of insomnia, particularly circadian rhythm disorders. Magnesium may help some people relax, though evidence is mixed. Glycine, L-theanine, and valerian root have some supporting research. However, supplements are not regulated the same way medications are, so quality and potency vary significantly. Dr. Fredes reviews any supplements you’re taking, recommends those with the strongest evidence for your specific situation, and monitors for interactions with any medications.

Insurance & Pricing

We accept major insurance plans to make quality psychiatric care accessible:

For patients without insurance coverage, we offer self-pay options with transparent pricing. We also provide superbills for out-of-network reimbursement. View full pricing details →

Why Choose MindMED for Insomnia Treatment?

• Board-certified psychiatrist – Dr. Fredes trained at Icahn School of Medicine at Mount Sinai and brings specialized expertise in the psychiatric roots of insomnia
• Psychiatric focus – We treat insomnia as a psychiatric symptom often rooted in anxiety, depression, trauma, or other mental health conditions that deserve specialized attention
• Comprehensive evaluation – Initial appointments are 60-90 minutes, allowing thorough assessment of sleep, psychiatric history, medications, and underlying factors
• Integrative approach – We combine evidence-based medication management with sleep hygiene, lifestyle modifications, and CBT-I principles
• Conservative medication practice – We use the lowest effective dose for the shortest appropriate duration, avoiding benzodiazepines and prioritizing newer, safer alternatives
• Ongoing monitoring – Regular follow-up appointments ensure treatment effectiveness and allow adjustment as your sleep improves or life circumstances change
• Bilingual care – Services available in English and Spanish
• In-person and telehealth – Convenient options for patients across Texas, New York, and Virginia
• Insurance accepted – Aetna, BCBSTX, Cigna, Oscar, and United Healthcare