We will offer a sleeper at the first visit, but never one with addictive or withdrawal potential, and if it is worth taking it is worth taking nightly. Avoid them in untreated sleep apnea, and know that formal sleep guidance recommends against most of what psychiatrists actually use.
When we reach for them
We are willing to give a sleeper on the first visit, because we never prescribe one with addictive or withdrawal potential on the first visit, or the second, or the third.
“I'm always willing to give a sleeper on the first visit. And the reason is because I never really ever prescribe addictive potential withdrawal potential sleepers on the first visit or the second visit or the third or whatever”
36:33Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 The medications with regulatory approval for insomnia are benzodiazepines, Z-drugs, DORAs (dual orexin receptor antagonists), low-dose doxepin and ramelteon.
“So the meds that have regulatory approval are benzos and non-benzos, something like Z-drugs, the Doras, the dual orexin receptor antagonists, low-dose doxepin, and ramelteon”
18:49Insomnia and Sleep Medications in PsychiatryDec 2024
Dosing
We are not fans of as-needed dosing. If a sleep medication is worth taking, it is worth taking every night.
“As needed dosing as people who have listened to the other episodes know, I'm not really a fan of that. If it's worth taking a medication, it's worth taking it every night”
39:36Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026
Side effects and safety
Do not give sleep medications to someone with untreated sleep apnea. You will suppress the respiratory drive they need.
“you're not supposed to give sleep medications to untreated sleep apnea. It's not good, right? You're just going to be suppressing their respiratory drive that they need”
1:00:25Insomnia and Sleep Medications in PsychiatryDec 2024
Pitfalls and myths
Look for an algorithm for sleep and you will find none guiding psychiatrists, and the American sleep guidance recommends against all the medications we use for insomnia.
“If you actually go out and look for an algorithm for sleep, there's none guiding psychiatrists. Exactly. The American Sleep ASAM recommends against all the medications we use for insomnia”
1:11:00Insomnia and Sleep Medications in PsychiatryDec 2024
It also comes up on
- BenzodiazepinesA short-term sleeper can just as easily be high-dose hydroxyzine, low-dose trazodone, higher-dose gabapentin, or mirtazapine if you have to.
- DoxepinBy far one of our favorite sleep medications. It is FDA approved for sleep maintenance (we think the only one), and it helps with sleep onset as well.
- HydroxyzineWhen starting an antidepressant, give a non-habit-forming sleeper from day one. Trazodone and gabapentin come first; hydroxyzine is a fair choice if those do not suit. Most depressed patients have sleep problems that one medication will not fix right away.
- HydroxyzineA short-term sleeper can just as easily be high-dose hydroxyzine, low-dose trazodone, higher-dose gabapentin or, if you have to, mirtazapine.
- InsomniaIf you meet DSM criteria for a psychiatric disorder, you are excluded from the sleep medication studies. So the primary insomnia research and the sleep guidelines are nearly worthless for almost every patient in a psychiatric clinic.
- InsomniaAsk everyone you start on a sleep medication: do you snore? Does your partner say you snore? If you have an Oura ring, does it show a lot of disturbance or movement?
- Major depressive disorderParoxetine works quickly and is a sleeper on top of an antidepressant, a lot of bang for the buck in one tablet.
- ParoxetineIt has real strengths: it works quickly, it is a sleeper on top of being an antidepressant, it is easy to dose, and it comes in long- and short-acting forms. A lot of bang for your buck in one tablet.
From these episodes
- Sleep Medications Treatment Tier List: Best Insomnia Medications RankedAug 2026 · 2 points
- Insomnia and Sleep Medications in PsychiatryDec 2024 · 3 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.