When You Cannot Sleep and Nothing Has Worked: Insomnia, Mental Health, and Why a Psychiatrist Should Be Part of the Conversation

Most people who struggle with sleep have already tried the obvious things. Better sleep hygiene, melatonin, limiting screen time, white noise, weighted blankets, cutting caffeine. Some of it helps for a while. Most of it does not hold. The sleep problem persists, and over time it stops feeling like a sleep problem and starts feeling like the way things are.

What often gets missed is that chronic insomnia is rarely just about sleep. It is frequently a symptom of something else, something that sleep hygiene and over-the-counter supplements were never designed to address. Anxiety, depression, PTSD, ADHD, and other psychiatric conditions all disrupt sleep, and they do so through mechanisms that no amount of lavender tea or blackout curtains can reach. Until the underlying condition is identified and treated, the insomnia does not resolve. It just becomes the thing a person learns to live with.

That adaptation comes at a cost. And the cost compounds.

What Chronic Insomnia Does Over Time

Short-term sleep loss is uncomfortable. Chronic insomnia is something different. When disrupted sleep becomes the pattern rather than the exception, the effects reach into every part of daily functioning.

Cognitive performance declines. Memory, concentration, and decision-making all deteriorate with sustained sleep deprivation. The decline is often gradual enough that people do not recognize how far their baseline has shifted until something forces the comparison.

Emotional regulation breaks down. Irritability increases. Frustration tolerance drops. Reactions that would normally be proportional become disproportionate. Relationships take the strain, often without either person connecting the pattern to sleep.

Physical health is affected. The research on chronic sleep deprivation and cardiovascular risk, immune function, metabolic health, and inflammation is well established. Insomnia is not a quality-of-life issue only. It is a health issue.

Mental health conditions worsen. Insomnia and psychiatric conditions feed each other. Poor sleep amplifies anxiety and depression. Anxiety and depression prevent sleep. The cycle reinforces itself, and breaking it from the sleep side alone rarely works when the psychiatric side is driving it.

Why Insomnia Is Often a Psychiatric Symptom

Sleep disruption is one of the diagnostic criteria for several psychiatric conditions. It is not a secondary feature. It is part of the condition itself.

In depression, insomnia often presents as early morning awakening, the kind where someone falls asleep without difficulty but wakes at 3 or 4 a.m. and cannot return to sleep. The mind turns on and will not turn off. Some people experience the opposite, hypersomnia, sleeping excessively but never feeling rested.

Both patterns are part of the depressive picture, not separate from it.

In anxiety disorders, the problem is usually at the front end. The mind races at bedtime. Worry loops run through scenarios, plans, mistakes, and contingencies. The body is physiologically activated. Heart rate is elevated, muscles are tense, the nervous system is on alert. Sleep in that state is not a matter of willpower or relaxation techniques. The system is not designed to sleep while it believes a threat is present.

In PTSD, sleep disturbance is one of the core symptoms. Nightmares, hyperarousal, and a nervous system that cannot fully stand down at night create a pattern where sleep becomes associated with vulnerability rather than rest. For some people, the avoidance of sleep becomes as much of a problem as the insomnia itself.

In ADHD, the relationship with sleep is often underrecognized. A brain that has difficulty regulating attention during the day does not suddenly regulate well at night. Racing thoughts at bedtime, difficulty winding down, and inconsistent sleep-wake patterns are common in ADHD and are frequently treated as a separate sleep problem when they are part of the same neurological picture.

The Problem with Treating Sleep in Isolation

Primary care providers prescribe the majority of sleep medications in the United States. That is not a criticism of primary care. It is a reflection of the fact that most people bring their sleep complaints to their general practitioner, and the most available tool in that setting is a prescription.

The issue is that a sleep medication treats the symptom without evaluating the cause. If insomnia is being driven by an anxiety disorder, a sleep aid may produce sedation but it does not address the activation that is preventing sleep. If depression is behind the early morning awakening, a sleep medication may extend sleep duration without touching the depressive process that is fragmenting it. The person sleeps more but does not feel better, because sleep was never the primary problem.

This is where a psychiatric evaluation changes the approach. A psychiatrist can assess whether the insomnia has a psychiatric driver, identify co-occurring conditions that are contributing to the pattern, and build a treatment plan that addresses the root cause rather than managing the surface symptom. That might include medication for the underlying condition, a different class of medication than what a sleep-focused approach would use, therapy to address the cognitive and behavioral patterns maintaining the insomnia, or a combination.

Why Integrated Care Matters for Sleep

Sleep problems that have a psychiatric component do not resolve through a single intervention. They require a provider who can hold the full picture: the sleep pattern, the mood, the anxiety level, the life circumstances, the medication history, and how all of it interacts over time.

In the standard model, a person with insomnia might see a primary care provider for a sleep aid, a therapist for stress management, and eventually a psychiatrist for medication. Each provider sees a piece of the picture. The primary care provider knows what they prescribed but not what is happening in therapy. The therapist knows what the patient is working through but cannot adjust the medication. The psychiatrist has 15 minutes every few months and limited context on either.

When one provider handles both psychotherapy and psychiatric medication management, the treatment for sleep-related concerns becomes more cohesive. The provider understands what is happening in the patient's life, how the sleep pattern is responding to therapeutic work, whether medication changes are helping or creating new problems, and how the full clinical picture is evolving. That integration is particularly valuable for insomnia because sleep sits at the intersection of so many other systems, biological, psychological, and situational.

At Empathy Therapy, Dr. Mark Chofla, DO, is a board-certified psychiatrist who provides both psychiatric medication management and formal psychotherapy. For patients whose insomnia is connected to anxiety, depression, PTSD, ADHD, or other conditions, that means one provider is tracking both the sleep problem and the condition driving it, in the same appointments, over time.

What to Expect at Empathy Therapy

New patient appointments are 75 minutes. For sleep-related presentations, that time allows for a thorough assessment of the sleep pattern itself, the timeline of when it started, what has been tried, what makes it better or worse, and what else is happening clinically that might be contributing. Most people with chronic insomnia have never had that level of evaluation. They have had a prescription written in under ten minutes.

Follow-up appointments are 45 minutes. Sleep responds to treatment gradually, and the pattern often shifts in stages rather than resolving all at once. Longer follow-up visits allow for ongoing adjustment, both of medication and of the therapeutic approach, as the picture changes.

All appointments are via secure telehealth. For people whose sleep disruption makes early morning or late evening appointments particularly important, telehealth provides flexibility that an office-based practice cannot. There is no commute to add to an already exhausting day.

Empathy Therapy is a private-pay, fee-for-service practice. Insurance is not accepted, but a superbill is provided after each appointment for patients with PPO plans who wish to seek out-of-network reimbursement. New patients are typically seen within days, not weeks.

Who This Is For

People who seek help for insomnia at Empathy Therapy have usually been dealing with it for a long time. They have tried the behavioral strategies. They may have tried over-the-counter options or medications from their primary care provider. The sleep problem has not resolved, and it is affecting their daytime functioning, their mood, their relationships, or their work.

Some suspect there is something else going on but have not had the kind of evaluation that would clarify what it is. Others know they have anxiety or depression but have been treating the sleep problem separately from the condition. Both situations benefit from a thorough psychiatric evaluation that puts the sleep complaint in its full clinical context.

Dr. Chofla works with adults and adolescents across California, Oregon, Washington, Arizona, Alaska, New York, and Florida via telehealth. If you have been managing a sleep problem that has not responded to the usual approaches, a psychiatric evaluation is a reasonable next step.

Book a New Patient Appointment

New patient intakes at Empathy Therapy are 75 minutes, conducted via secure telehealth, and typically available within days. No referral required.

Book your appointment here.

Frequently Asked Questions

Does Dr. Chofla provide therapy, or only medication management? Both. Dr. Chofla provides formal psychotherapy and psychiatric medication management. Patients receive whichever combination fits their situation, including therapy only or medication only when that is appropriate.

Does Empathy Therapy serve patients across all of California? Yes. Because the practice is fully telehealth, patients anywhere in California can be seen, including rural areas and communities outside major metros.

Which states does Empathy Therapy serve? Empathy Therapy serves adults, adolescents, and children across California, Oregon, Washington, Arizona, Alaska, New York, and Florida via telehealth.

How long are appointments? New patient intakes are 75 minutes. Follow-up appointments are 45 minutes.

How quickly can I be seen? New patients are typically seen within days, not weeks.

Does Empathy Therapy accept insurance? No. Empathy Therapy is a private-pay, fee-for-service practice. Patients receive a superbill after each appointment for potential out-of-network reimbursement.

How do I get started? Book online at www.empathytherapy.com