Insomnia and sleep problems

What sleep problems look like

• Insomnia — trouble falling asleep, staying asleep, or both.
• Early-morning waking — common with depression.
• Non-restorative sleep — you sleep, but you wake exhausted.
• Hypersomnia — sleeping too much; common with depression and certain medications.
• Disrupted sleep from anxiety — lying awake worrying or replaying the day.
• Sleep disrupted by nightmares — common with PTSD.

First, ruling out things that need a different specialist

Some sleep problems are medical, not psychiatric. Before treating insomnia as a primary problem, we screen for:

• Sleep apnea — if you snore loudly, stop breathing in your sleep, or wake unrefreshed despite long sleep times, we’ll refer you for a sleep study. Sleep apnea is incredibly common, often missed, and treatable.
• Restless legs syndrome (RLS) — an irresistible urge to move the legs, especially at night. Often related to iron deficiency.
• Thyroid problems — both over- and underactive thyroid can wreck sleep.
• Medication side effects — including ones you might not suspect (some blood pressure meds, decongestants, certain antidepressants).

How we treat insomnia

CBT for Insomnia (CBT-I) — the gold standard

CBT-I is the most effective treatment for chronic insomnia — more effective than sleep medications for long-term outcomes, and without the side effects or dependence risk. It usually takes 4–8 sessions and includes:

• Sleep restriction — counterintuitively, spending less time in bed (initially) consolidates sleep and improves quality.
• Stimulus control — reassociating the bed with sleep, not with worrying about not sleeping.
• Cognitive work on the worries about sleep that keep you awake.
• Relaxation training.

We can deliver CBT-I at Northline or refer you to a CBT-I specialist when that’s the right fit.

Sleep medication, used carefully

Sleep medications have a role — especially short-term during a difficult period. We tend to favor:

• Trazodone — not addictive, generally well-tolerated.
• Doxepin at low doses — specifically helpful for staying asleep.
• Melatonin — modestly helpful, particularly for circadian-rhythm issues.
• Hydroxyzine — an antihistamine sometimes used short-term.

We’re more cautious with the “Z-drugs” (zolpidem/Ambien, eszopiclone/Lunesta) and benzodiazepines (alprazolam, lorazepam) for sleep — they work, but they have dependence and tolerance issues that often make things worse over time.

Treating the cause underneath

If your sleep problem is downstream of depression, anxiety, PTSD, or substance use — treating the underlying condition is usually the most effective sleep treatment.