What we treat
Evidence-based psychiatric care for insomnia and sleep problems
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. Chronic insomnia means trouble falling asleep, staying asleep, or waking too early at least three nights a week for three months or more, with real effects on mood, concentration, relationships, and work.
Insomnia is a medical condition, and it usually has causes underneath it, many of them psychiatric. It can be short-term (tied to a stressor) or chronic, and it can show up as trouble falling asleep, frequent waking, or early-morning waking. Each pattern points toward different treatment. When insomnia coexists with anxiety, depression, PTSD, or bipolar disorder, treating that condition is often the key to sleeping again.
Sleep and mental health run in both directions. Sleep supports emotional regulation, stress processing, and memory; when it breaks down, depression, anxiety, and mood instability get worse. Untreated anxiety and depression, in turn, cause insomnia, and the two feed each other: a bad night lowers mood, and low mood makes the next night harder. Insomnia can also be one of the earliest signs that a mood or anxiety disorder is developing. Many people who think they have a plain sleep problem turn out to have anxiety driving racing thoughts at bedtime, depressive rumination, or trauma causing nightmares and hypervigilance. That is what a psychiatric evaluation of insomnia is for: finding out what is keeping you awake, so treatment can address it rather than only sedate it.
Sleep apnea and restless legs are managed by sleep medicine or neurology. Dr. Fredes screens for them and refers when indicated.
An occasional bad night from stress, travel, or caffeine is normal. Sleep trouble three or more nights a week for three months is not, and neither is relying on alcohol or over-the-counter sleep aids to get to sleep. Daytime effects on concentration, mood, energy, work, or safety are another signal. Consider a psychiatric evaluation specifically if your insomnia began or worsened with anxiety, panic, depression, mood changes, or trauma; if you take psychiatric medication and your sleep has changed; or if sleep hygiene and over-the-counter approaches have not helped. Dr. Fredes can sort out the mental health factors behind your sleep and offer medication management and practical sleep guidance built around them.
Your initial evaluation with Dr. Fredes is 60 minutes. She takes a detailed sleep history (patterns, timing, triggers, what has and has not worked), screens for anxiety, depression, trauma, and mood disorders, reviews every medication and supplement you take, and asks about caffeine, alcohol, your sleep environment, and daytime symptoms.
When medication is appropriate, Dr. Fredes chooses conservatively, with a clear goal and a plan for how long you will take it. Not all sleep medications are alike. The main options:
Non-benzodiazepine hypnotics (zolpidem, eszopiclone, zaleplon) work on GABA signaling to promote sleep. They help with falling asleep and have a reasonable safety profile at the lowest effective dose. Longer use carries some risk of dependence, and at higher doses they can occasionally cause complex sleep behaviors such as sleepwalking.
Melatonin receptor agonists (ramelteon) mimic the body's own sleep signal. They suit sleep-onset insomnia and circadian rhythm problems, with low abuse potential.
Orexin receptor antagonists (suvorexant, lemborexant, daridorexant) block wake-promoting signals rather than sedating. They help with both falling and staying asleep and have longer-term safety data.
Low-dose trazodone, an antidepressant, is sometimes used off-label for sleep and is usually well tolerated, particularly when depression or anxiety is also present. Hydroxyzine, a sedating antihistamine, can help people whose anxiety keeps them awake, though tolerance can develop. Gabapentin has a role when restless legs or nerve pain is part of the picture. Evidence for any of these in insomnia on its own is limited.
Dr. Fredes' approach: start low and go slow, check for benefit and side effects at follow-up, and reassess at each visit whether the medication is still needed as your sleep and any underlying condition improve. She avoids benzodiazepines for sleep. Tolerance develops quickly, they carry a high risk of dependence, and they are not appropriate for chronic insomnia even though they were commonly prescribed for it in the past.
Sleep habits alone rarely fix chronic insomnia, especially when a psychiatric condition is involved, but they are part of every plan:
Melatonin, magnesium, and a few other supplements have some supporting evidence, but products vary in quality and potency. Talk with Dr. Fredes before starting one; some interact with medications, and she can tell you which have the best evidence for your situation.
Depression and anxiety: Insomnia is a core symptom of depression, often as early-morning waking or, less commonly, sleeping too much. Anxiety disorders disrupt sleep through racing thoughts and worry at bedtime, including worry about not sleeping, which makes the problem worse. Treating the depression or anxiety addresses both the nighttime and the daytime symptoms.
PTSD and bipolar disorder: Trauma brings nightmares, night sweats, and hypervigilance that fragment sleep. In bipolar disorder, a reduced need for sleep is often the first warning of a manic or hypomanic episode, so tracking sleep is part of managing the condition.
Chronic pain and perimenopause: Pain disrupts sleep, and poor sleep raises pain sensitivity. Hormonal changes in perimenopause and menopause cause hot flashes, night sweats, and insomnia, and mood changes often emerge at the same time. Dr. Fredes evaluates both the physical and the mood components. In each case, treating the underlying condition is a large part of treating the insomnia.
See a psychiatrist when insomnia is caused by or coexists with anxiety, depression, PTSD, bipolar disorder, or another psychiatric condition, or when it started or worsened after significant stress, trauma, or a change in mood. A psychiatrist can also spot medication side effects that disturb sleep. Your primary care doctor is a good fit for straightforward sleep problems and sleep apnea screening.
Not necessarily. The evaluation comes first, to understand what is causing the insomnia. Many people improve by treating underlying anxiety or depression, changing sleep habits, and managing stress. If medication makes sense for your situation, Dr. Fredes uses the lowest effective dose for the shortest time needed.
Some are safer for longer use than others. Dr. Fredes avoids benzodiazepines for sleep because of their dependence potential. Orexin receptor antagonists (suvorexant, lemborexant) and melatonin receptor agonists have been studied for extended use and are generally safe with monitoring. Regular follow-up checks that any medication is still working and still needed.
Yes. Insomnia is often a symptom of anxiety, depression, or another psychiatric condition, and the relationship runs both ways: untreated anxiety or depression disrupts sleep, and poor sleep worsens mood and anxiety. Insomnia can even be an early sign that depression or anxiety is developing. Treating the underlying condition often resolves the sleep problem without a separate sleep medication.
CBT-I is Cognitive Behavioral Therapy for Insomnia, a structured, evidence-based treatment that changes the thoughts and habits that keep insomnia going: sleep restriction, stimulus control (using the bed only for sleep), and techniques for racing thoughts. MindMED does not provide CBT-I. If you need it, we can refer you to a therapist who does and coordinate with them.
It depends on the cause. When insomnia is secondary to anxiety or depression, treating that condition often improves sleep within 4-6 weeks. For chronic insomnia, improvement usually begins within 2-4 weeks, with full benefit by 8-12 weeks. Dr. Fredes reviews progress at each follow-up and adjusts the plan.
No. Sleep apnea needs a formal sleep study and is managed by a sleep specialist, usually with CPAP or another device. Dr. Fredes screens for signs of it (loud snoring, gasping, unrefreshing sleep, daytime sleepiness) during the initial evaluation and refers when indicated. If you already have treated sleep apnea, she can manage the depression or anxiety that often comes with it.
Some have supporting evidence. Melatonin helps with certain types of insomnia, especially circadian rhythm problems. Magnesium, glycine, L-theanine, and valerian root have mixed or limited evidence. Supplements are not regulated like medications, so quality and potency vary. Dr. Fredes reviews what you take and checks for interactions with your medications.
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Schedule a consultation with Dr. Fredes to find out what is driving your insomnia and make a plan.