If your brain has decided that 3 a.m. is the perfect time to replay every awkward thing you’ve ever done, you’re in familiar territory. Insomnia is one of the most common complaints we see across depression, bipolar disorder, and ADHD at Advanced Psychiatry Associates (APA), and it’s rarely “just bad sleep.”
This article is a psychiatry guide to insomnia treatment with medications: when we treat sleep directly, how choices change with depression, bipolar disorder, and ADHD, and what to know about the main agents, doxepin, trazodone, mirtazapine, Z-drugs, and orexin antagonists. We’ll mention sleep hygiene briefly, but the focus here is medication strategy, not therapy.
Across APA California offices, this all lives inside structured Medication Management, not “here’s some sleeping pills, see you in six months.”
Primary vs. comorbid insomnia: what are we actually treating?
Step one is always: what is driving the insomnia?
In depression, trouble falling or staying asleep often sits alongside early-morning awakening, low energy, and loss of interest.
In bipolar disorder, insomnia can be a warning sign of hypomania/mania, or a residual symptom between episodes.
In ADHD, insomnia may be driven by evening stimulants, racing thoughts, screen overuse, or irregular routines.
We ask:
Is this primary insomnia (sleep is the main issue)?
Or is it secondary to a mood or attention condition that also needs treatment?
Why it matters:
If you only chase sleep with sedatives but don’t treat the depression, bipolar disorder, or ADHD, you usually end up layering meds without real stability.
If you treat the core condition well, you often need less sleep medicine for a shorter time.
At APA, we usually work through our service lines in parallel:
Core agents we use and what they’re good at
Low-dose doxepin
Doxepin in very low doses is a histamine-blocking medication for sleep maintenance (staying asleep), not so much for sleep onset.
Pros:
Non-habit-forming at low doses
Good for people who fall asleep but wake at 2–3 a.m. and can’t get back to sleep
Cons:
Possible next-day grogginess
Higher doses (antidepressant range) bring more anticholinergic side effects (dry mouth, constipation), so we usually avoid those just for sleep
Trazodone
Trazodone is an “old favorite” sedating antidepressant used off-label for insomnia, especially in depression.
Pros:
Can help with both sleep onset and maintenance
Sometimes improves middle-of-the-night awakenings in depressed patients
Cons:
Next-day sedation or “hangover” feeling
Dizziness or orthostatic hypotension (standing up quickly)
Rare but serious priapism (we always warn patients)
We’re careful with trazodone in bipolar disorder, it’s generally safer than many antidepressants, but still used inside a clear mood-stabilizing plan.
Mirtazapine
Mirtazapine is a sedating antidepressant that can be extremely helpful when depression + insomnia + low appetite travel together.
Pros:
Strong sleep support, especially at lower doses
Can boost appetite and help with weight gain when underweight
Cons:
Weight gain and increased appetite are very common
Can cause morning grogginess if dosed too late
We often consider mirtazapine in depression with severe insomnia, but we are more cautious in bipolar patients because of antidepressant-associated mood switching and metabolic issues.
“Z-drugs”: zolpidem, eszopiclone, zaleplon
These are the classic modern hypnotics many people have heard of.
Zolpidem, Ambien, and generics
Eszopiclone Lunesta
Zaleplon Sonata
Pros:
Effective for sleep onset (zaleplon, zolpidem)
Eszopiclone can help with sleep maintenance as well
Very fast onset → useful for short-term, situation-based insomnia
Cons:
Tolerance and dependence risk with long-term nightly use
Complex sleep behaviors, sleep-walking, sleep-driving, have been reported
Next-day impairment, especially if taken late or with alcohol
In bipolar disorder, aggressively “knocking out” sleep without mood stabilization can sometimes mask emerging hypomania, not fix it
We tend to use Z-drugs short-term, at the lowest effective dose, with clear rules about timing and no driving or alcohol on treatment nights.
Orexin antagonists
Newer agents like suvorexant, lemborexant, and daridorexant block orexin, a wake-promoting neuropeptide.
Pros:
Target the brain’s wake system rather than GABA directly
Useful for both onset and maintenance, depending on the agent
Lower risk of dependence than classic benzodiazepines
Cons:
Can still cause next-day drowsiness
Cost/insurance coverage may be more challenging
Not for people with certain types of narcolepsy
We often consider these for chronic insomnia where Z-drugs aren’t appropriate, especially in patients with comorbid depression or ADHD who want to avoid habit-forming sedatives.
Special cases: insomnia in depression, bipolar disorder, and ADHD
Depression + insomnia
Here we ask: Will an antidepressant that improves mood also improve sleep?
For many patients, optimizing a depression regimen (SSRI, SNRI, bupropion, mirtazapine, etc.) and cleaning up timing, no activating meds late in the day, reduces insomnia. Short-term use of trazodone, low-dose doxepin, or another sedating medication can bridge the gap while the antidepressant takes effect.
Bipolar disorder + insomnia
This is where care has to be extra precise.
Insomnia can signal an impending manic or hypomanic episode.
The priority often becomes securing mood stabilization, with lithium, lamotrigine, or atypical antipsychotics, and then layering sleep support.
We are very cautious with:
Antidepressants without mood stabilizers
High-dose sedatives that hide early mania without stabilizing mood
ADHD + insomnia
Classic patterns:
Stimulant taken too late in the day
Strong evening hyperfocus on screens/work
No fixed bedtime routine
In many ADHD cases, adjusting stimulant class, dose, and timing, e.g., earlier XR, avoiding late IR boosters, or switching to non-stimulants like guanfacine/atomoxetine, improves sleep more than any hypnotic.
We then add brief pharmacologic help if needed, e.g., very low-dose trazodone, melatonin in some cases, while reinforcing a regular schedule.
Risks and red flags: dependence, bipolar switching, and safety
A few principles we repeat with every patient:
Short-term vs. long-term: Most pure hypnotics (Z-drugs, benzodiazepines) are best as short-term tools, not nightly forever.
Bipolar switching: Any new antidepressant or sedating antidepressant in bipolar patients gets started only within a mood-stabilized plan, with clear monitoring for mood elevation.
Substance use: Alcohol, cannabis, and over-the-counter “PM” meds can interact with prescribed sedatives and worsen sleep architecture.
Driving and safety: No driving, machinery, or risky activities after taking hypnotics; complex sleep behaviors must be reported immediately.
This is why we emphasize psychiatry-led Medication Management over casual prescribing
Sleep hygiene the ultra-short version
We do cover sleep behavior in visits, but briefly:
Fixed wake time every day
No big meals or caffeine close to bedtime
Screens down before bed; bed reserved for sleep and sex
If you can’t sleep after ~20–30 minutes, get up, quiet activity, then try again
The heavy lifting in this article, though, is medication choices and timing; sleep hygiene alone rarely solves insomnia in complex depression, bipolar disorder, or ADHD.
How sleep care works at APA in California
At Advanced Psychiatry Associates, insomnia in the context of mental health is never treated in isolation. Instead, we:
Identify whether insomnia is primary or linked to depression, bipolar disorder, ADHD, or another sleep disorder.
Adjust core psychiatric medications first, then add targeted sleep medications when needed.
Choose among doxepin, trazodone, mirtazapine, Z-drugs, or orexin antagonists based on diagnosis, medical history, substance risk, and metabolism.
Set clear rules for duration and follow-up, so sleep meds help rather than become the next problem.
See all California locations or book a visit here:
Those reinforce that you’re aligning your prescribing with mainstream medical guidance, not fad sleep hacks.
Insomnia deserves more than a random “PM” pill. Done right, psychiatric insomnia treatment is about understanding the whole mood/attention picture, then using the right medication at the right time, for sleep that’s actually restorative, not just knocked out.
