Sleep meds quick guide for psychiatry
Start with CBT‑I habits and a fixed wake time. Meds are tools, not cures.
Treat the driver (trauma, OSA, pain, substances, circadian) while you help sleep now.
Use the ladder: lowest risk first, step up only if needed, and reassess weekly.
Step 0 — Diagnose the “why” before the “what”
Screens: insomnia severity (ISI), PTSD screen if trauma, STOP‑BANG for OSA risk
Contributors: caffeine, alcohol or cannabis near bedtime, shift work, pain, RLS/PLMD, mood/anxiety, meds (stimulants, activating antidepressants)
Baseline: sleep schedule, latency, awakenings, total sleep time, daytime function
Step 1 — Foundation (CBT‑I basics)
Fixed wake time every day, protect morning light
30–60 min wind‑down routine, bed only for sleep or sex (stimulus control)
Limit naps; avoid late caffeine/alcohol; dark, cool room; phone out of bed
Consider a CBT‑I app or brief IRT if nightmares
Step 2 — Low‑risk options (try first)
Melatonin 0.5–3 mg (dim‑light timed for circadian issues; otherwise 3–5 mg qHS)
Doxylamine 12.5–25 mg qHS or diphenhydramine 25 mg qHS (short term only; avoid in older adults/anticholinergic burden)
Ramelteon 8 mg qHS (circadian support, minimal next‑day effects)
Step 3 — Targeted add‑ons by phenotype
Sleep onset trouble: doxepin 3–6 mg qHS; consider gabapentin 100–300 mg qHS (renal dose) when pain, anxiety, or RLS features exist
Maintenance insomnia: low‑dose doxepin; consider trazodone 25–100 mg qHS if depression/anxiety comorbid (watch next‑day sedation, orthostasis)
RLS/PLMD: check ferritin (<75 ng/mL → replete); gabapentin/pregabalin at bedtime
Circadian delay/shift work: timed melatonin (0.5–3 mg), bright‑light therapy A.M., anchor wake time; consider ramelteon
Step 4 — PTSD‑linked nightmares (adjunct)
Prazosin: start 1 mg qHS → increase by 1 mg every 2–3 nights as tolerated; many need 2–6 mg; monitor BP and dizziness
Teach Imagery Rehearsal Therapy (IRT): rewrite one nightmare with a safe ending; rehearse 5–10 min daily for 2–4 weeks
Step 5 — When to refer or escalate
Suspected OSA (snoring, witnessed apneas, daytime sleepiness) → sleep study
Severe depression, suicidality, or complex polypharmacy → psychiatry consult or higher level of care
Persistent insomnia despite CBT‑I and stepped meds → formal CBT‑I program
Follow‑up cadence and monitoring
Recheck weekly for the first 2–3 weeks, then space out as stable
Track: sleep latency, awakenings, total sleep, daytime function, side effects
Step down meds when habits hold for 2–4 weeks
““We’ll build sleep from the foundation up. We start light, and only add what you need. The goal is better days, not perfect nights.””