Sleep
Most sleep problems aren't really about sleep.
The loop nobody mentions
Anxiety keeps you awake, then being sleep-deprived makes you more anxious, and the next night is worse. You can't sleep your way out of it by trying harder, and you definitely can't Benadryl your way out of it either.
The ADHD piece
A brain that won't downshift at bedtime isn't being difficult.
Sleep onset is a real ADHD symptom. The brain stays in drive when it should be coasting down, and melatonin timing and structure help more than Ambien ever will.
30%
of adults report symptoms of insomnia, but in most cases the insomnia is downstream of something else, and treating only the sleep misses the point entirely.
What CBT-I actually is
The most evidence-backed sleep treatment isn't a pill.
In person and telehealth, Washington and Oregon
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A real person from our care team replies within a business day and figures out what's actually keeping you up.
Talk to a providerWhat Is Actually Keeping You Up
Most of the guys who come in describing an insomnia problem are really describing an anxiety problem, or an ADHD problem, or a depression problem that happens to hit hardest at night when there's nothing else to think about. The sleep is bad because the brain is doing something it shouldn't be doing at that hour, and handing them a sleeping pill without looking at why is the kind of medicine that technically works for a few nights and then stops working and then you need more of it.
The actual categories: anxiety keeps you wired and ruminating when your head hits the pillow. ADHD means the brain never really downshifts, bedtime is just a different setting for the same racing quality. Depression often flips the script and makes you sleep too much but still feel like garbage, or wakes you at 3am and won't let you back under. Stimulants and caffeine you already know. Alcohol you might not know is fragmenting your sleep in the second half of the night even when you fall asleep fine.
None of those respond well to Ambien as a first move. They respond to actually addressing what's making the brain run hot at night.
The real culprits
- AnxietyWired and ruminating at bedtime, can't turn the brain off, catastrophizing in the dark.
- ADHDBrain won't downshift, sleep onset takes forever, wakes easily, schedule is a wreck.
- DepressionCan't sleep or sleeps too much, wakes at 3am and can't get back under.
- AlcoholYou fall asleep fine, but the second half of the night is garbage and you wake up tired even after eight hours.
The loop
- Night 1Anxiety keeps you awake.
- Day 2You're sleep-deprived, which makes anxiety and cortisol worse.
- Night 2More anxious, more alert, worse sleep.
- Week 3You're anxious about not sleeping, which kicks in at 9pm when you start dreading bedtime.
The Anxiety-Sleep Loop
Anxiety keeps you awake. Being sleep-deprived makes the anxiety worse the next day because cortisol goes up and your nervous system's regulation goes down. So you're more anxious going into the next night, which means worse sleep, which means more anxiety. Once this has been going for a few weeks you've added a third layer: anxiety specifically about not sleeping, which starts firing around 9pm when you begin dreading what's coming.
You can't fix this by trying harder to sleep. The harder you try, the more activated you are, and activation is the opposite of sleep. What actually breaks the loop is lowering the underlying anxiety and restructuring the relationship with the bed so the brain stops treating it as a source of dread. That's the cognitive-behavioral piece, and it works better than any pill for this specific loop.
Medication can help alongside it, especially for the underlying anxiety. But you can't drug your way out of a feedback loop. The structural changes in how you think about sleep have to happen, or it keeps coming back.
What Actually Works
Cognitive Behavioral Therapy for Insomnia, CBT-I, has the most evidence of anything in the sleep space, and multiple studies show it outperforms medication at 12 months even when both work at week 4. It changes the behavioral patterns that maintain insomnia (getting in bed too early, lying there awake, clock-watching, catastrophizing about what bad sleep will do to tomorrow), and the improvements tend to stick after treatment ends in a way that prescriptions don't.
For the underlying issues that drive bad sleep, treating those directly is the other lever. An SSRI or SNRI for anxiety and depression often improves sleep substantially even without any specific sleep intervention, because you've removed the thing that was running the brain hot at night. Stimulant timing adjustments for ADHD. Honest conversation about alcohol. These aren't glamorous answers, but they're the ones that hold.
Meds do have a place. Trazodone at low doses is frequently used because it's sedating, non-habit-forming, and helps when depression is also present. Melatonin works well for circadian issues, especially ADHD-related sleep onset problems, though the dose most people take (10mg) is way higher than needed and lower doses (0.5 to 1mg) actually work better. Ambien and Lunesta are short-term tools, not a long-term plan, and we'll tell you that honestly instead of refilling them indefinitely.
The treatment hierarchy
- CBT-IFirst-line by evidence, outperforms meds at 12 months, and the results stick.
- Treat the underlyingAnxiety, ADHD, depression all wreck sleep directly, so treating those often fixes sleep as a side effect.
- TrazodoneLow-dose, non-habit-forming, good when depression is also present.
- MelatoninWorks for circadian problems and ADHD sleep onset, best at low doses (0.5-1mg, not 10).
- Ambien / LunestaShort-term only. Not a plan you build around.
How We Approach This
We start by figuring out what's actually causing the sleep problem, because that changes what you do about it. There's no prescription refill program here where we hand you Ambien every 30 days without looking at what's underneath. If the problem is anxiety-driven, we work on the anxiety. If it's ADHD, we work on that. If it's behavioral, you'll get the CBT-I framework and you'll actually do the work.
Medication is available when it's the right tool for the right situation. Trazodone, melatonin, sometimes an SSRI or SNRI that happens to be sedating and also addresses the underlying driver. When a sleep aid is genuinely what's needed short-term while the behavioral work takes hold, we'll use it for that, with a real plan to not need it indefinitely.
The goal isn't a pill that makes you sleepy. It's a brain that actually wants to sleep.
Telehealth across Washington and Oregon, in person in Vancouver. Real follow-up, not a conveyor belt. Sleep is one of the things that touches everything else, and we take it seriously as a medical issue rather than a lifestyle complaint.
How it goes
From first message to actually sleeping
Tell us what's going on, when it started, what you've tried, and what it's costing you. A real clinician reads it, not a questionnaire algorithm.
We look at the full picture, what the sleep actually looks like, what's driving it, and what else is going on, because treating insomnia without the context is just handing you a prescription for something that won't stick.
Behavioral work, medication when it fits, treatment of whatever's underneath. We adjust as you go, not just check in every 90 days and reprint the script.
Sleep and medications
The honest breakdown on sleep meds
Good for circadian timing problems and ADHD-related sleep onset delay. Most people take 10mg when 0.5 to 1mg works better. Not a sedative, it tells your clock what time it is.
Low-dose trazodone is probably the most commonly used sleep aid in psychiatry. Non-habit-forming, sedating, does double duty when depression is also present.
Heavily sedating antidepressant that helps with sleep and appetite when both are a problem. One of the more useful tools when depression is the driver.
Works for acute insomnia short term, but not a 30-day refill situation. Dependence risk is real, sleep quality is lower than it looks (less deep sleep), and rebound insomnia is brutal when you stop.
Same category as Ambien, similar caveats. Does have longer duration which helps with middle-of-the-night waking. Same thing about not being a long-term plan.
Leveling with you
Sleep questions we get a lot
I've just always been a bad sleeper, isn't that just how I'm wired?
Some people do have naturally shorter sleep needs or later chronotypes, and that's real. But "always been a bad sleeper" usually means anxiety or ADHD has always been in the background and nobody named it yet. It's worth figuring out which you're dealing with before you accept it as your permanent situation.
Can you just prescribe me something to sleep?
We can, and sometimes that's the right short-term move, but we're not going to hand you an indefinite Ambien refill without looking at what's causing the problem. That's not good medicine. We'll work on the thing causing it, and if a sleep aid helps while that work takes hold, we'll use it with a real plan to not need it forever.
What even is CBT-I?
It's a structured behavioral program for insomnia. The core pieces are sleep restriction (counterintuitive but effective), stimulus control (training your brain that bed means sleep, not anxious lying awake), and cognitive work on the catastrophizing that drives the anxiety-sleep loop. It takes some weeks and it requires doing uncomfortable things, but it has the best long-term evidence of anything in sleep medicine.
My sleep tracker says I'm not getting enough deep sleep.
Consumer sleep trackers are pretty good at detecting when you're asleep versus awake, but their sleep stage data is not especially accurate. If you're relying on an Oura or Apple Watch to tell you your deep sleep is low, take that with some skepticism. How you feel and how you function matters more than the app's sleep score.
I drink a few beers to wind down, is that actually a problem?
For sleep specifically, yes. Alcohol helps you fall asleep but disrupts the second half of the night, suppresses REM, and the sleep you do get is lower quality. You wake up tired even after 8 hours and the pattern compounds over time. It's also worth knowing that alcohol is one of the more effective ways to worsen anxiety the next day, which makes the next night worse. We're not telling you to stop drinking, we're just being straight about what it does.
Could this be sleep apnea?
Possibly, and if there are signs of it (snoring, waking unrefreshed, daytime sleepiness, partner reporting you stop breathing), we'll refer you for a sleep study. Apnea and psychiatric sleep disorders can coexist and apnea makes everything worse, including anxiety and mood. We don't just assume it's psychological without checking.
Ready to talk about sleep?
Drop a line. Our care team gets back to you within a business day and gets you sorted with the right clinician.
Sources
- Insomnia prevalence (30% of adults): Sleep Foundation
- CBT-I vs medication long-term: NCBI, Morin et al. (2009)
- Melatonin dosing: NCBI, Brzezinski et al.