Chronic insomnia is trouble falling or staying asleep at least three nights a week for three months with daytime impairment. First-line treatment is cognitive behavioral therapy for insomnia (CBT-I), which outperforms medication long term. Short-term medication options include doxepin, trazodone, ramelteon and newer orexin antagonists, with sedative-hypnotics used sparingly. Treating coexisting depression or anxiety is essential.
Stedfast Psychiatry treats insomnia by first finding out why you are not sleeping. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment and often works better than medication over time. When medication is needed we choose it carefully, prefer short courses, and treat the underlying anxiety, depression, ADHD or trauma that is keeping you awake.
Symptoms of insomnia
- Taking more than 30 minutes to fall asleep most nights
- Waking during the night and struggling to get back to sleep
- Waking an hour or more before you need to and not returning to sleep
- Unrefreshing sleep despite enough time in bed
- Daytime fatigue, sleepiness or low energy
- Irritability, low mood or anxiety about sleep
- Difficulty concentrating or remembering
- Dreading bedtime or watching the clock
- Relying on alcohol or over-the-counter sleep aids
Causes and risk factors
Insomnia usually begins with a trigger (stress, illness, a new baby, shift work, travel) and becomes chronic through the habits that follow: going to bed early to catch up, lying awake for hours, napping, using the bed for work or screens, and growing anxiety about sleep itself. The bed becomes associated with wakefulness. Psychiatric conditions are the most common underlying contributors: depression causes early waking, anxiety causes trouble falling asleep, PTSD causes nightmares and hypervigilance, ADHD causes a delayed sleep phase, and bipolar disorder can reduce the need for sleep. Medical causes include sleep apnea, restless legs, chronic pain, menopause, thyroid disease and nocturia. Caffeine, alcohol, nicotine, stimulants, some antidepressants, beta blockers and steroids all disrupt sleep.
About one third of US adults report insomnia symptoms, and roughly 10 percent meet criteria for chronic insomnia disorder.
Source: American Academy of Sleep Medicine
More than one third of US adults report sleeping less than the recommended seven hours per night.
Source: CDC, Behavioral Risk Factor Surveillance System
CBT-I is recommended as the first-line treatment for chronic insomnia in adults, ahead of medication.
Source: American College of Physicians Clinical Practice Guideline (2016); American Academy of Sleep Medicine (2021)
People with insomnia have about twice the risk of developing depression compared with those who sleep well.
Source: Meta-analysis, Journal of Affective Disorders (Baglioni et al., 2011)
How we diagnose it at Stedfast Psychiatry
A sleep evaluation at Stedfast Psychiatry starts with a detailed sleep history: your schedule, time to fall asleep, number and length of awakenings, naps, caffeine and alcohol, screen use, and what you do when you cannot sleep. We use the Insomnia Severity Index and a two-week sleep diary, and we screen for depression, anxiety, PTSD, ADHD and bipolar disorder because insomnia is often the first visible sign of one of them. We screen for sleep apnea (snoring, witnessed pauses, morning headaches, daytime sleepiness) with the STOP-Bang questionnaire and refer for a sleep study when it is likely, because sedating medications can worsen untreated apnea. We review all medications and order thyroid tests, iron studies for restless legs, or other labs when indicated.
Treatment options
Medication management
When medication is appropriate we choose based on the pattern. Low-dose doxepin (3 to 6 mg) is FDA-approved for sleep maintenance and is not habit-forming. Trazodone 25 to 100 mg is widely used off-label, especially when depression is present. Ramelteon acts on melatonin receptors and helps with sleep onset. The orexin receptor antagonists suvorexant, lemborexant and daridorexant are newer options that reduce wakefulness without the next-day grogginess of older drugs. Mirtazapine helps when depression, poor appetite and insomnia occur together. Sedative-hypnotics such as zolpidem and eszopiclone work quickly but carry risks of tolerance, dependence, complex sleep behaviors and falls, so we use them short term and rarely in older adults. We avoid benzodiazepines for chronic insomnia. Medication is reviewed every four to eight weeks with the goal of tapering as CBT-I takes effect.
Psychotherapy
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment recommended by the American Academy of Sleep Medicine and the American College of Physicians. Over four to eight sessions it uses sleep restriction (temporarily limiting time in bed to consolidate sleep), stimulus control (bed is for sleep only; get up if awake more than 20 minutes), fixed wake times, cognitive work on anxiety about sleep, and relaxation training. CBT-I improves sleep in 70 to 80 percent of patients and the gains last after treatment ends, which medication cannot claim. It can be delivered by telehealth and combined with medication during the first weeks when sleep restriction is hardest.
What to expect
Your first visit is a 45 to 60 minute evaluation, in person or by video, and we may ask you to keep a sleep diary beforehand. You leave with a working diagnosis of what is driving the insomnia and a plan that may include CBT-I, medication, treatment of an underlying condition, or a referral for a sleep study. Follow-ups are every two to four weeks at first. Telehealth works especially well for CBT-I and medication follow-up, and we see patients across Florida and South Carolina.
When to seek help
Seek help if you have been sleeping poorly three or more nights a week for a month, if you are dependent on alcohol or sleep aids, if poor sleep is affecting your mood, driving or work, or if you snore loudly or stop breathing in your sleep. Severe insomnia with a sudden drop in the need for sleep and racing thoughts can signal mania and warrants prompt evaluation. If sleeplessness is accompanied by thoughts of suicide, call or text 988.
Types of insomnia
Sleep-onset insomnia is trouble falling asleep and is most often linked to anxiety, a delayed body clock, caffeine or screens. Sleep-maintenance insomnia is waking during the night, commonly from alcohol, sleep apnea, pain, nocturia or depression. Early-morning awakening points toward depression. Short-term insomnia follows a clear stressor and lasts under three months; chronic insomnia persists beyond that and typically has become self-sustaining through conditioning. Paradoxical insomnia is the experience of sleeping far less than objective measures show, and it still responds to CBT-I.
Insomnia and psychiatric conditions
Sleep is both a symptom and a driver in nearly every psychiatric condition. In depression, insomnia often precedes the episode and persisting insomnia after recovery predicts relapse, so we treat it directly rather than waiting for the antidepressant to fix it. In bipolar disorder, sleep loss can trigger mania, which makes a fixed sleep schedule a core part of treatment. In PTSD, nightmares and hypervigilance fragment sleep and prazosin or targeted therapy helps. In ADHD, a delayed sleep phase and difficulty winding down are common, and stimulant timing matters. In anxiety disorders, worry at bedtime is the main obstacle and CBT-I's cognitive techniques address it. Treating the insomnia often improves the other condition faster.
Sleep apnea and other medical causes
Obstructive sleep apnea affects an estimated one in four middle-aged men and one in ten women and is frequently mistaken for insomnia or depression. Loud snoring, pauses in breathing, morning headaches and falling asleep during the day are the clues, and a home sleep test confirms it. Sedating medications worsen apnea, so identifying it changes the plan. Restless legs syndrome, often tied to low iron, causes an urge to move the legs at night. Chronic pain, reflux, menopause-related hot flashes, an overactive bladder and thyroid disease are other common contributors we look for.
Sleep hygiene that actually matters
Sleep hygiene alone rarely fixes chronic insomnia, but it supports treatment. The most useful habits are a fixed wake time seven days a week, no caffeine after noon, no alcohol within three hours of bed, getting bright light in the morning and dimming lights in the evening, keeping the bedroom cool and dark, and getting out of bed if you are awake for more than 20 minutes. The least useful advice is to spend more time in bed; that is the habit CBT-I reverses.
Prognosis
Chronic insomnia rarely resolves on its own, but it responds well to CBT-I, with most patients achieving normal sleep within two months and maintaining it. When insomnia is driven by a psychiatric condition, treating that condition is essential and usually restores sleep. Patients who learn CBT-I skills handle future bouts of poor sleep without relapsing into chronic insomnia, which is the main advantage over medication.
Frequently asked questions
Is medication or CBT-I better for insomnia?
CBT-I is better for chronic insomnia. It works for 70 to 80 percent of people, the gains hold after treatment ends, and it carries no risk of dependence. Medication works faster and has a role in short-term insomnia, during the first weeks of CBT-I, and when an underlying condition such as depression needs treatment. Our usual plan is CBT-I as the foundation with medication as a bridge if needed.
What is the safest sleep medication for long-term use?
Low-dose doxepin, ramelteon and the orexin antagonists (suvorexant, lemborexant, daridorexant) have the best safety profiles for ongoing use and do not cause dependence. Trazodone is widely used and generally safe. Zolpidem and similar drugs are best kept to short courses. Over-the-counter diphenhydramine (Benadryl, ZzzQuil) is a poor choice for regular use, especially in older adults, because of next-day impairment and anticholinergic effects.
Why do I wake up at 3 a.m. and cannot get back to sleep?
Early-morning waking is a classic pattern of depression, and we screen for it first. Other causes include alcohol (which fragments the second half of the night), sleep apnea, going to bed too early, and the conditioned arousal of chronic insomnia where the brain has learned to wake at the same time. Treating depression if it is present, limiting alcohol, and CBT-I techniques that consolidate sleep address it.
Can insomnia be treated by telehealth?
Yes, and CBT-I is one of the therapies with the best evidence for video delivery. Sleep diaries, sleep restriction scheduling and follow-ups all work remotely, and patients often find it easier to keep the regular contact that CBT-I requires. Non-controlled medications such as doxepin, trazodone and ramelteon can be prescribed by telehealth. Controlled sleep medications have additional rules that we will explain. We see patients across Florida and South Carolina.
How long does insomnia treatment take?
CBT-I is four to eight sessions over six to ten weeks, and most people notice improvement by the third week once sleep restriction consolidates sleep. Medication works within days but is reviewed every four to eight weeks with a plan to taper. When insomnia is driven by depression or anxiety, sleep improves as the underlying condition is treated, typically over two to three months.
Is insomnia treatment covered by insurance?
Yes. Evaluation and medication management are billed as specialist visits and covered by most major plans and Medicare with your usual copay. CBT-I is covered as psychotherapy under outpatient mental health benefits. Our self-pay rate for a new evaluation is $185. Most sleep medications are inexpensive generics; the orexin antagonists are brand-name and may require prior authorization, which our staff handles. A sleep study, if needed, is billed by the sleep lab.
Should I take melatonin?
Melatonin is most useful for shifting the timing of sleep (jet lag, delayed sleep phase, shift work) and for some older adults; it is less effective for ordinary chronic insomnia. If you use it, a low dose (0.5 to 3 mg) taken two to three hours before bedtime works better than a large dose at bedtime. Supplement quality varies, so choose a USP-verified product. It is safe for most people but is not a substitute for addressing the cause of insomnia.
Do you treat insomnia in children and teens?
Yes. Insomnia in teens is often a delayed sleep phase worsened by screens and early school start times, and in children it is frequently behavioral or tied to anxiety or ADHD. Treatment is behavioral first; melatonin is sometimes used, and we are conservative with prescription sleep medication in young people. Our child and adolescent providers address sleep as part of the broader evaluation.
Where to get treatment for insomnia
Evaluation and treatment for insomnia is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.