Treatments for sleep in people with psychiatric conditions; subjective, with no stated criteria. From the Psychofarm podcast, August 2026: 33 ranked, each with the reason and the moment it was said.
First-line treatment for all insomnia. A good CBT-I therapist who takes insurance is hard to find, so the principles are taught piecemeal in medication visits or through an app or workbook.
Placed at the top beside strict waking time; the S label is implied by 'put CBTI up there'.
“For CBTI, it's first line for all insomnia treatment. I've never seen a good CBTI therapist who takes insurance. It's almost impossible to get”
Basic habits like blackout curtains and keeping the phone and its charger out of the bedroom make the biggest difference for most patients, though perfectionism about it can backfire.
“I have moved phone charger here. I'm putting this in S tier. I have cured insomnia by forcing a patient to move their phone charger out of the room”
If energy is not spent during the day it gets spent at night on rumination and trouble falling asleep.
Placed right behind strict waking time in S; the label is implied.
“You have daytime activity and exercise in there. Let's throw that in along with red light, blue light management. I want you to put daytime activity and exercise right behind straight waking time”
Important to screen for and treat, but primary sleep disorders are uncommon in psychiatric patients and treating one often does not solve the other problems.
Briefly proposed as S, then put back in A.
“The actual likelihood of a primary sleep disorder is actually on the lower side, in my experience. Because even when it's treated, it does not solve the other issues”
Low-dose doxepin is the favorite and most consistent sleep medication for simple sleep problems, with a cleaner side effect profile than other TCAs. It is not strong enough for a few patients.
“I'm going to pick my top two, going to tell you the caveats, and then I'm going to pick my bottom two. I want to do it at the same time. I'm going to put Doxepin in S tier”
Too many drawbacks: memory and learning problems, slower progress in therapy, addiction, withdrawal and tolerance. Fine for a minority of severe cases.
“The F tier is benzos and Z drugs. Why? Why are these down here when people love them so much and the sleep societies recommend them and they're FDA approved”
Same reasons as benzodiazepines: memory problems, slowed progress in therapy, dependence, withdrawal and tolerance.
“The F tier is benzos and Z drugs. Why? Why are these down here when people love them so much and the sleep societies recommend them and they're FDA approved”
Almost every psychiatric disorder comes with sleep disruption, so treating the underlying disorder, after a proper diagnosis, is what fixes the sleep.
“And then so to that end, let's put into the S tier treatment of primary disorder, which we should have labeled treatment of primary mental or psychiatric disorder. It didn't fit in the box”
Very effective for sleep onset and maintenance even at low doses, held out of S because of weight gain and appetite increase.
The other host also loves it, but warns of a few days of daytime hangover at the start.
“I think a very high ranking sleep medication must be mirtazapine. And I will put that one in the A class. Why do I not put it into S class? Sorry, not S class, A class”
Anticholinergic and causes weight gain, and there is little reason to use it instead of mirtazapine.
“Paroxetine is in C tier for different reasons. Again, both anticholinergic with the side effects and weight gain effects are really pushing it down there”
Very effective and loved by patients, which is part of the problem: people are afraid to stop it and it gets prescribed to people who should not be on an antipsychotic.
The other host expected B. Final placement C. Reasonable to keep if it is the only thing that has worked.
“Quetiapine is really effective. It works awesome. And the fact that it works so well and is so subjectively loved is another reason why I want to rank it lower”
It works, but it is very anticholinergic, which is part of why it works and which the show does not like for patients.
“Phenidramine and doxalamine, they work. They're very anticholinergic as well, which is also part of why they work, and I don't like that for patients, so they go into the C tier”
Same reasoning as diphenhydramine: it works, but it is very anticholinergic.
“Phenidramine and doxalamine, they work. They're very anticholinergic as well, which is also part of why they work, and I don't like that for patients, so they go into the C tier”
Effective because it acts on many receptors, and useful when the patient has another indication for it, though weight gain is a downside.
The other host thinks only amitriptyline fits that high and would put the other TCAs in C or F for sleep.
“They're effective because they're dirty medications. They work on a lot of different things. If you have another indication for them and it's safe to use in that particular patient for cardiac reasons”
Effective because they act on many receptors, and useful when the patient has another indication for them and no cardiac or constipation problem.
Only one host put the other TCAs in B; the other would put them in C or F for sleep.
“They're effective because they're dirty medications. They work on a lot of different things. If you have another indication for them and it's safe to use in that particular patient for cardiac reasons”
Mostly useful for regulating the sleep-wake cycle (shift work, travel, circadian problems) rather than as an as-needed sleeping pill.
“Melatonin has a hypnotic effect. It makes you sleepy, but it also has a sleep-wake cycle regulating effect. And I mostly use it for sleep-wake cycle regulation”
About the same efficacy as melatonin, well tolerated, and not really problematic.
Placed in C by 'in the same way' as melatonin.
“And in the same way to Remelition, which is a melatonin receptor agonist, I believe it's basically about the same efficacy, but some patients then want to pay out of pocket”
Not amazing and not for everyone, but it helps a lot of people with sleep or anxiety and is useful with restless legs, pain or migraine.
“I think it's a solid B. B tier, it's not amazing. It's not gonna work for everybody, but the fact is it does have some beneficial effects for a lot of people”
Not really a sleep medication. Low doses can disrupt sleep, higher doses may support it a little, and it is low risk.
Started in B, moved to between B and C, ended in C. Meant as high-dose buspirone.
“Buspirone is not really a sleep medication per se. I would put it in B tier nonetheless, but I would want to edit it if I could and say high dose Buspirone”
Not that it does not work, but the tardive dyskinesia risk, weight gain, appetite increase and sedation make it too big a gun for sleep alone. Fine if there is also a psychotic or refractory bipolar illness.
“Unfortunately, there are more people than you would like out there, internationally and locally, using olanzapine and risperidone for sleep problems and depression. Okay, I don't like that. I'm going to put an F tier”
Same reasoning as olanzapine: too many serious risks to use just for sleep, even if it works.
“Unfortunately, there are more people than you would like out there, internationally and locally, using olanzapine and risperidone for sleep problems and depression. Okay, I don't like that. I'm going to put an F tier”
Meant for diagnosed sleep disorders like narcolepsy under a specialist, not for insomnia.
Joked about needing an eighth circle of hell tier.
“The reason why is because we're putting an F tier is because it's not for the treatment of primary sleep insomnia. It's for sleep disorders. Leave that to the professionals”
These rankings are the hosts’ and guests’ opinions from one episode, for clinicians and the curious. They are education, not medical advice, and not a guide to choosing a treatment for any one person.
Educational content only. These resources are for education. They are not medical advice and not a substitute for clinical judgment, current guidelines, or individualized patient care.