Psychiatric Care for Sleep Difficulties

Sleep difficulties include trouble falling asleep, waking during the night, waking too early, or sleep that does not feel restful. They often travel with anxiety, depression, ADHD or stress, and they can make each of those harder to manage. Ongoing poor sleep affects mood, focus, health and performance at work or school.

How our physicians help

Our physicians look at sleep in the context of your whole health, including mood, medications, routines and medical factors. Care can include behavioral approaches such as cognitive behavioral therapy for insomnia, careful medication decisions, and treatment of related conditions. When a sleep study or specialist is needed, we coordinate referrals.

Signs your sleep needs attention

• Dreading bedtime, or feeling wide awake the moment you get into bed.
• Needing alcohol, cannabis or an over-the-counter sleep aid to drift off.
• A partner who says you snore loudly, gasp or stop breathing in your sleep.
• Getting drowsy in meetings or behind the wheel.
• Restless, creeping feelings in your legs at night.

When a child or teen is not sleeping well

Tired children often seem wired instead of sleepy, so sleep problems can pass for behavior or attention problems.

• Long bedtime struggles, or needing a parent in the room to fall asleep.
• Nightmares, sleepwalking or night terrors, which are episodes of screaming without fully waking.
• Loud snoring or restless sleep.
• A teen who falls asleep very late, cannot wake for school and sleeps until noon on weekends, which can mean a late-running body clock.

Finding the cause of poor sleep

We start by mapping your sleep. You may keep a sleep diary for a week or two, noting bedtime, wake time, naps and caffeine. We ask about work hours, travel, pain, pregnancy or menopause, and we review everything you take, including supplements, cannabis and alcohol. Stimulants, steroids and some antidepressants can affect sleep.

We also ask whether this is insomnia or something that needs a different plan. Sleep apnea, in which breathing stops again and again during sleep, restless legs syndrome, narcolepsy and body clock disorders can all look like insomnia. We pay close attention if you are sleeping much less but feel full of energy, since that can be a sign of bipolar disorder.

CBT for insomnia and other treatments

Cognitive behavioral therapy for insomnia (CBT-I) is usually the first treatment recommended for long-lasting insomnia. Stimulus control rebuilds the link between your bed and sleep, partly by getting up when you cannot sleep. Sleep restriction briefly limits time in bed so your natural drive to sleep builds up. Cognitive work eases worries about sleep itself, such as 'if I do not sleep, tomorrow is ruined.' The first weeks can leave you more tired, and sleep restriction is not right for everyone, including people with bipolar disorder or seizures. Good habits help, but alone they rarely resolve long-standing insomnia.

Medication can help some people, often for a limited time or alongside CBT-I. Classes include sedative sleep medicines, orexin blockers (which quiet a brain chemical that keeps you awake), sedating antidepressants and melatonin-type medicines. Trade-offs can include next-day grogginess, memory problems, unusual behavior during sleep, falls in older adults, and for some medicines, dependence. Many help only while you take them. For children and teens, we start with routines and work with parents, and medication is rarely the first step.

When to see a doctor about sleep

If long sleepless stretches have left you hopeless or thinking about suicide, call or text 988 (the Suicide & Crisis Lifeline) or call 911. We are not an emergency service.

Long-standing insomnia can still respond to treatment. Reasons to call us include:

• Poor sleep several nights a week that has lasted a month or longer.
• You have nearly nodded off while driving.
• Low mood, panic or worry comes with the sleepless nights.
• You need far less sleep than usual and feel unusually energized.

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