Tag: Articles

Why melatonin doesn’t work

Posted on November 2, 2025 by - Sleep Health

Melatonin doesn't work

We’ve all heard this from our patients:

“Melatonin doesn’t work for me.”

And to be honest, it often doesn’t work…at least not in the way most people are using it.

Melatonin isn’t a sedative. It’s a chronobiotic.

It’s a biological time cue that tells your body what time it is and helps regulate the sleep-wake cycle.

So when a patient says melatonin failed, the problem usually isn’t that melatonin doesn’t work.

It’s usually one of these 3 things:

  • Wrong timing
  • Wrong indication
  • Poor quality supplement

This week, I’m breaking down why melatonin doesn’t work and what to do about it.

In this 8-minute episode (Part 2 of my 3-part series on melatonin) I share two real clinical cases that illustrate how to make melatonin work for the right patient at the right time:

  • A 32-year-old who was misdiagnosed with insomnia and cycled through multiple hypnotics without relief
  • A man in his 60s with early-morning awakenings who tried melatonin without success, until he learned how to use it strategically

I’m also sharing:

  • How to time melatonin supplements relative to DLMO (dim light melatonin onset) instead of clock time
  • The optimal melatonin dose for circadian realignment
  • When to choose extended-release formulations
  • Why melatonin rarely works in isolation and how to use it most effectively

If you’ve ever wondered how to handle “melatonin doesn’t work” complaints in clinic, this episode will give you a roadmap.

Well worth the 8 minutes of your time.

Watch the full video here.

Then, stay tuned for Part 3, where we’ll explore melatonin use in perimenopause and menopause.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

Is Melatonin Safe?

Posted on October 24, 2025 by - Sleep Health

Is Melatonin Safe?

A 2023 research letter in JAMA (Journal of The American Medical Association) and 2017 study in JCSM (Journal of Clinical Sleep Medicine) highlighted serious issues with over-the-counter melatonin quality*.

One melatonin gummy was found to contain 347% more melatonin than what the label claimed.

That’s enough to make anyone pause.

It has definitely changed the way I recommend melatonin to patients.

But as I explain in this week’s video, the full story is more nuanced, and perhaps not quite as alarming, as the headlines suggest.

In this 10-minute episode (Part 1 of a 3-part series on melatonin), I unpack what every clinician needs to know about melatonin safety, including:

  • Why melatonin isn’t a sedative
  • What the JAMA and JCSM studies actually found
  • How to interpret dose variability and brand differences
  • What the research says about short, moderate, and long-term safety
  • My clinical take on when to use it…and when to rethink it

I also share a patient story that illustrates how melatonin, when used correctly, can retrain the circadian rhythm instead of becoming a nightly crutch.

If you’ve ever had a patient ask whether melatonin is “safe,” or wondered how to approach it in your own prescribing, invest 10 minutes of your time in this high yield video.

Click here to watch it.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

*References:
Cohen PA, Avula B, Wang YH, Katragunta K, Khan I. Quantity of Melatonin and CBD in Melatonin Gummies Sold in the US. JAMA. 2023 Apr 25;329(16):1401-1402. doi: 10.1001/jama.2023.2296. PMID: 37097362; PMCID: PMC10130950.

Erland LA, Saxena PK. Melatonin Natural Health Products and Supplements: Presence of Serotonin and Significant Variability of Melatonin Content. J Clin Sleep Med. 2017 Feb 15;13(2):275-281. doi: 10.5664/jcsm.6462. PMID: 27855744; PMCID: PMC5263083.

CBT-i Only Works If You Do This

Posted on October 21, 2025 by - Sleep Health

CBT-i Only Works If You Do This

We all see patients struggling with insomnia, but implementing CBT-I (cognitive behavioral therapy for insomnia) in real-world practice can feel daunting, especially when you’re not a sleep specialist.
I remember my first time recommending “sleep restriction” to a patient.

The look of panic on her face made me question if I was helping or just adding to their anxiety.
In fact, sleep restriction is often the thing that scares people away from CBT-i or leads to non-adherence with treatment.

This is where the art of clinical practice comes in: meeting patients where they are.
This week, I sat down with Dr. Parky Lau PhD, a sleep psychologist at Stanford, to talk about how to make CBT-I practical, flexible, and patient-centered, even for clinicians who don’t do this every day.

In this episode, Dr. Lau shares:

  • How to build a case formulation for insomnia (and why it matters)
  • How to practically implement time in bed restriction (and why he prefers that term over “sleep restriction”)
  • Practical analogies (like pizza dough and finger trap) to help patients understand sleep
  • How to adapt CBT-I for menopause and bipolar disorder
  • Tips for supporting patients who are anxious, perfectionistic, or dependent on sleep aids
  • How to build flexibility and empathy into a successful treatment plan
  • And more…

When your next patient mentions insomnia, you’ll have practical tools from this video to guide your clinical thinking.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:
Walker J, Muench A, Perlis ML, Vargas I. Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer. Klin Spec Psihol. 2022;11(2):123-137. doi: 10.17759/cpse.2022110208. PMID: 36908717; PMCID: PMC10002474.

3 Steps to End Sleep Anxiety

Posted on September 25, 2025 by - Sleep Health

One of the most common misconceptions about insomnia is that it’s just a matter of bad sleep hygiene.

But many of your patients with chronic insomnia have better sleep hygiene than anyone you know…and they’re still lying awake.

Here’s why: insomnia isn’t all about bad habits.

It’s more like a phobia.

The brain has learned to fear the very experience of being awake at night.

So people end up cycling through one sleeping pill or supplement after another, or trying gadgets and all the “sleep hacks” they heard about on podcasts, but it doesn’t get any better.

The paradox is that the harder patients try to “fix” it, the worse it gets.

In my new video, I share how I explain sleep anxiety to patients, plus 3 strategies that work far better than piling on more rules about caffeine and blue light.

It’s less than 5 minutes, designed for both clinicians and patients, and part 2 of a short series I’m creating on insomnia.

Feel free to share it directly with anyone in your care who’s caught in the cycle of sleep anxiety.

And if you (or your patients) want to go deeper, I’m teaching a free masterclass on how to quiet racing thoughts and sleep through the night.

It’s a deeper dive with tools you can use right away. You (and your patients) are welcome.

Register here. 

How to quiet your mind at night

Posted on September 23, 2025 by - Sleep Health

Stop Waking Up at Night

One of the most common things I hear from patients is this:

“My brain just won’t shut off at night.”

Do you hear that in your clinic too?

And most of them have already tried the usual fixes like meditation apps, relaxing harder, melatonin, sleep hygiene checklists, and so on.

The problem is: When you try to force the brain to relax, it’s like chasing a dog with the zoomies.

The more you try to contain it, the zoomier it gets.

In my new video, I explain why racing thoughts at night are so persistent, and three steps to redirect that energy so your patients can actually fall asleep and stay asleep. 

This video is part of a short series I’m creating for both clinicians and patients.

It’s less than 5 minutes but jam packed with the same info I share with my patients 1:1.

Feel free to share it directly with your patients and colleagues.
And if you (or your patients) want to go deeper, I’m teaching a free masterclass next week on how to quiet racing thoughts and sleep through the night.

You and your patients are welcome to attend that too.
Sign up here. 

The one phrase that could save your patient’s life (and your license)

Posted on September 12, 2025 by - Sleep Health

The one phrase that could save your patient’s life (and your license)

We hear a lot about drunk driving, but not nearly enough about drowsy driving.

We live in a sleep-deprived society, and, when driving, I often find myself wondering how many sleepy drivers are out on the road.

Ironically, during my sleep medicine fellowship, one of my co-fellows nodded off at the wheel after an overnight shift in the sleep lab…with all of us in the car. He startled awake just in time, and thankfully we avoided what could have been a disaster.

The reality is sobering: drowsy driving contributes to about 18% of fatal car crashes in the U.S. (1)

That’s why, during my sleep medicine elective in psych residency at Henry Ford Hospital, one of my attendings drilled this phrase into us to always include in the chart:

“Patient was counseled on the risks of excessive daytime sleepiness and advised not to drive or operate heavy machinery when drowsy, sleepy, or tired.”

At first it felt like overkill, but here’s why it matters:

✓ It protects your patient. Excessive sleepiness is a real safety risk. Documenting it reinforces the counseling and underscores its importance.

✓ It protects you. If there’s ever an accident or legal review, your note shows you addressed the risk.

✓ It saves you time. Once you create a dot phrase or template, you can drop it in every time.

Because of that early training, I’ve made it a standard in my own charting whenever a patient reports sleep issues.

I recommend you “steal” this phrase for your own notes.

If you struggle with getting your charts done on time, Dr. Junaid Niazi MD, a board-certified internist, pediatrician, and physician coach joined me on YouTube to share some tips. https://www.youtube.com/watch?v=4YDjhcds0E0

He helps clinicians chart more efficiently so you can leave your work at work and get your evenings (and sleep) back.

Dr. Niazi shares:

✓ Why charting has become such a burden for clinicians

✓ The connection between charting and sleep

✓ His best tips to reclaim your time and reduce charting overwhelm

Plus, he’s offering a free training, “Leave Your Work at Work” on September 10 at 5pm PT. Sign up here. https://www.chartingconquered.com/a/2148159050/jwtkLbaD

P.S. We’re opening doors to our next round of Effortless Sleep in 6 Weeks soon – our signature program for adults with insomnia. Stay tuned for the details.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals. https://champions.learner.plus/?champion=Dr%20Nishi%20Bhopal

References:
1. Tefft, B.C. (2024). Drowsy Driving in Fatal Crashes, United States, 2017–2021 (Research Brief). Washington, D.C.: AAA Foundation for Traffic Safety.

Does Magnesium Work for Sleep Issues?

Posted on August 19, 2025 by - Sleep Health

If you spend enough time on Instagram or in supplement aisles, you’ve noticed that magnesium is touted as a cure-all.

It’s said to alleviate cramps, fix constipation, cure sleep issues, do your taxes, help you look good in bangs…it’s a miracle!

But when we strip away the hype and look at the data on magnesium for insomnia and sleep disturbances, it’s not as magical as it’s made out to be.

The Evidence at a Glance

Observational studies have shown that higher dietary magnesium intake is linked to better reported sleep quality and longer duration [1,2,6].

But remember that correlation does not equal causation…and the link might be explained by healthier overall diets and lifestyles.

When it comes to sleep, there are some randomized controlled trials (RCTs). Small, mostly short-term studies in older adults and specific populations (e.g., diabetes) show:

‣ Sleep onset latency improved by ~17 minutes on average [3,4]
‣ Modest reductions in insomnia severity [3]

As for combination supplements (magnesium + melatonin ± zinc) often show better results, but the benefit can’t be attributed to magnesium alone [5].

The bottom line is that the evidence for magnesium on sleep is limited and results are inconsistent.

However, that doesn’t mean I don’t recommend magnesium supplements. In fact, I take them myself and recommend them to most of my patients, because of the fact that most adults aren’t getting sufficient Mg from diet alone.

How does it work?
Magnesium may support sleep through multiple pathways.

It modulates neurotransmitter activity by blocking excitatory NMDA-type glutamate receptors and activating inhibitory GABA receptors, reducing neuronal excitability and promoting relaxation for sleep onset and maintenance [1,2].

Magnesium also plays a role in melatonin synthesis and possibly supports deeper, more restorative stages of sleep [1].

Safety and Dosing Pearls

‣ Examples of food sources: pumpkin seeds, chia seeds, almonds, leafy greens, dark chocolate, soy, dried beans

‣ From supplements: Generally safe, but high doses can cause diarrhea and GI upset.
Avoid excess in advanced CKD; check for drug–nutrient interactions in high-risk patients.

‣ Typical doses in trials: 320–500 mg elemental magnesium daily, often split; forms include glycinate (better tolerated), citrate (laxative effects, good for constipation), threonate (crosses blood-brain barrier) and oxide (less bioavailable).

What to tell Patients

Magnesium is safe for most people and may offer a small, gradual benefit for sleep, but it’s not a sedative and shouldn’t replace proven treatments. Think of it as a gentle support in the background rather than a quick fix.

Want to learn more about sleep supplements? I’m hosting another series of masterclasses later this month – stay tuned for the details! I’ll send an email about that in the next few days.

References:

1. Zhang, Y., et al. “Association of Magnesium Intake With Sleep Duration and Sleep Quality: Findings From the CARDIA Study.” Sleep, vol. 45, no. 4, 2022, zsab276. Oxford University Press, doi:10.1093/sleep/zsab276.

2. Arab, A., et al. “The Role of Magnesium in Sleep Health: A Systematic Review of Available Literature.” Biological Trace Element Research, vol. 201, no. 1, 2023, pp. 121–128. Springer, doi:10.1007/s12011-022-03162-1.

3. Ji, X., et al. “The Relationship Between Micronutrient Status and Sleep Patterns: A Systematic Review.” Public Health Nutrition, vol. 20, no. 4, 2017, pp. 687–701. Cambridge University Press, doi:10.1017/S1368980016002603.

4. Cao, Y., et al. “Magnesium Intake and Sleep Disorder Symptoms: Findings From the Jiangsu Nutrition Study of Chinese Adults at Five-Year Follow-Up.” Nutrients, vol. 10, no. 10, 2018, p. E1354. MDPI, doi:10.3390/nu10101354.

5. Dhillon, V. S., et al. “Low Magnesium in Conjunction With High Homocysteine and Less Sleep Accelerates Telomere Attrition in Healthy Elderly Australian.” International Journal of Molecular Sciences, vol. 24, no. 2, 2023, p. 982. MDPI, doi:10.3390/ijms24020982.

6. Mah, J., and T. Pitre. “Oral Magnesium Supplementation for Insomnia in Older Adults: A Systematic Review & Meta-Analysis.” BMC Complementary Medicine and Therapies, vol. 21, no. 1, 2021, p. 125. BioMed Central, doi:10.1186/s12906-021-03297-z.

Sleep changes in Menopause

Posted on August 11, 2025 by - Sleep Health

Sleep changes in Menopause

Have you seen those videos on social media showing nostalgic clips from the ’80s and ’90s, like old Nintendo controllers, He-Man action figures, cartoon character lunchboxes with matching thermoses, and bustling malls?

(Btw – Orange Julius was my favorite at the mall foodcourt…I’ll share my homemade recipe sometime.)
Anyway, those videos always transport me back to simpler times.

If you’re old enough to remember those things, you might also be nostalgic for something else: the days when you could sleep straight through the night without interruption.
I know I am.

I used to be one of those kids who could sleep through the night like a rock.

But as I’ve aged, nighttime awakenings have become common and expected. And that’s true for a lot of midlife women.

Sleep disturbance affects up to 60% of women during the menopausal transition, and nighttime awakenings are the most common sleep complaint during perimenopause and menopause.

One study found that 30% of postmenopausal women report poor sleep quality (Pittsburgh Sleep Quality Index >5), compared to 14% of premenopausal women [Kim et al.].

The American Heart Association notes that sleep complaints, especially frequent awakenings, increase significantly during perimenopause, often in tandem with hot flashes, temperature swings, hormonal shifts, and psychosocial stressors.

As Dr. Andrea Matsumura MD says, “With the reduction of estrogen, you have a lot of middle of the night awakenings – that’s really because estrogen plays a role in calibrating your temperature, and when you lose that, sleep gets disrupted.”

If you’re seeing midlife women in your practice, you’re seeing sleep disruption.

To help you support these patients (or yourself), I sat down with Dr. Andrea Matsumura, “The Sleep Goddess,” for a deep dive into menopause, hormones, and sleep.

She shares practical, evidence-based strategies you can use right away.

In this episode, you’ll learn:

Why sleep fragmentation is often the first sign of perimenopause

  • When to consider melatonin, HRT, and sleep aids
  • How to screen for sleep apnea in women (and why home tests often miss it)
  • Dr. Matsumura’s DREAM method for holistic sleep care
  • What every clinician should ask about sleep (and the question that changed her practice)
  • Why “Sleep is the CEO of health” and how to help your patients reclaim it
  • And much more…

Quick clinical pearls to get you started:

‣ Don’t dismiss “I’ve always been a bad sleeper” as normal aging. Look under the hood to see what might be going on.


‣ Ask, “How many hours of sleep do you think you’re getting?” instead of “Are you sleeping well?”. It’s a subtle difference, but can reveal useful info.

‣ For women with midlife sleep issues, consider hormone therapy, but don’t forget about screening for other sleep disorders like sleep apnea.


‣ CBT-I is a powerful tool for menopause-related sleep disruption and can help with vasomotor symptoms like hot flashes.


If you’re ready to help your patients (and maybe yourself) get better sleep through menopause and beyond, don’t miss this conversation.


References:
1. Baker FC. Optimizing sleep across the menopausal transition. Climacteric. 2023

Jun;26(3):198-205. doi: 10.1080/13697137.2023.2173569. Epub 2023 Apr 3. PMID: 37011660; PMCID: PMC10416747.

2. Carmona NE, Solomon NL, Adams KE. Sleep disturbance and menopause. Curr Opin Obstet Gynecol. 2025 Apr 1;37(2):75-82. doi: 10.1097/GCO.0000000000001012. Epub 2025 Jan 17. PMID: 39820156.

3. Kim MJ, Yim G, Park HY. Vasomotor and physical menopausal symptoms are associated with sleep quality. PLoS One. 2018 Feb 20;13(2):e0192934. doi: 10.1371/journal.pone.0192934. PMID: 29462162; PMCID: PMC5819793.

4. Maki PM, Panay N, Simon JA. Sleep disturbance associated with the menopause. Menopause. 2024 Aug 1;31(8):724-733. doi: 10.1097/GME.0000000000002386. Epub 2024 Jun 25. PMID: 38916279.

A new option for CBT-i

Posted on August 11, 2025 by - Sleep Health

A new option for CBT-i

I was recently working with a woman in her 30s who’d been dealing with insomnia since her teenage years.

After so many years of struggling, she didn’t just have insomnia, she was insomnia.

“I’m a bad sleeper,” she told me.

And just like that, it had become part of her identity.

When people label themselves this way, it becomes a self-fulfilling prophecy.

As James Clear says in the above quote, holding on to an identity keeps people stuck in unconscious patterns.

It’s not just the behavior that needs to change, it’s also the identity underneath.

If you’re a clinician helping folks with sleep issues, start by getting curious about how your patients see themselves.

And if you’re personally struggling with sleep, ask yourself: What identity have I adopted around sleep?

To dig deeper into this, I interviewed Dr. Noelle Smith, PhD, VP of Clinical Care at Moona Health, an online CBT-i (cognitive behavioral therapy for insomnia) clinic.

Whether you’re a clinician looking for referral options, or someone trying to fix your own sleep, you’ll come away with practical takeaways, including Dr. Noelle’s #1 sleep tip.

In this episode, we cover

  •  The science behind CBT-i and how it changes physiological biomarkers
  • Why CBT-i works when sleep hygiene alone doesn’t
  • How it’s adapted for pregnancy, PTSD, menopause, and more
  • What to know about sleep meds and CBT-i
    …and more.

👉Quick refresher:

What is CBT-i and why should you care?
Cognitive Behavioral Therapy for Insomnia (CBT-i) is not just about avoiding caffeine or keeping your bedroom cool. That’s sleep hygiene, and while it matters, it’s not enough.

CBT-i is the first-line, gold standard treatment for chronic insomnia. It helps people unlearn the habits, thoughts, and behaviors that are keeping them awake…also known as the perpetuating factors of insomnia.

How long does it take?
Most people start to see improvements in 2 to 3 weeks. A full course is typically 6to 8 sessions. Unlike meds, the benefits last long after treatment ends.

Do you have to stop sleeping pills to start CBT-i?
No, people can start while still on medications. Many people choose to taper later as their sleep improves.


Is CBT-i right for your patient (or you)?
It’s effective for most people with chronic insomnia, including those with anxiety, depression, trauma, or menopause-related sleep issues. It can even be tailored for pregnancy or PTSD.

For clinicians:
If your patient has insomnia that’s interfering with their life, CBT-i should be your first-line referral.

Thanks to telehealth and digital tools, access is easier than ever, especially compared to when I was doing my sleep fellowship.

Bipolar, burnout, and 2 hours of sleep a night: How Bill found peace

Posted on July 24, 2025 by - Sleep Health

I just read The Borrowed Life of Frederick Fife. Have you read it?

Such a fun and heartwarming novel. It was written by Anna Johnston, a physician who worked in a nursing home, and was inspired by her grandparents.

I won’t spoil it, but I loved the above quote on sleep.
Sleep disturbances are a core feature of many medical conditions, including bipolar disorder.

It’s the “S” in the DIGFAST mnemonic for mania.*

Sleep issues in bipolar disorder aren’t limited to acute episodes of mania, hypomania, or depression.

You can also see persistent sleep issues during euthymic (interepisode) periods, showing up in a variety of ways, including chronic insomnia, hypersomnia, or irregular sleep-wake patterns.

Circadian rhythm disturbances, including delayed sleep phase, are also common, and are associated with greater mood instability and functional impairment.

That’s why stabilizing sleep is a key preventive strategy in bipolar disorder.

This week, I have a video for you that’s a little different.
It’s an interview with Bill Fitzgerald, also known as The Accidental Life Coach, and a patient with bipolar disorder in Ireland.

He shares his raw and inspiring journey of living with bipolar disorder and trauma, overcoming chronic insomnia, and rebuilding his life from the inside out.

Bill and I share an Irish connection, as we’re both UCC (University College Cork)alums – I went to med school in Cork, Ireland.

Here are some tips to get you started:

During mania or hypomania, the hallmark sleep change is a reduced need for sleep (not insomnia). People sleep significantly less without feeling tired.

During depression, you can see insomnia or hypersomnia. Hypersomnia is more common in bipolar depression than in unipolar depression. That’s a diagnostic pearl most people miss.

PSG (polysomnogram) and actigraphy show increased sleep onset latency (time to fall asleep) and increased REM density across all illness stages.

We also see more obstructive sleep apnea, restless leg syndrome in people with bipolar disorder…yet these may go undiagnosed.

Sleep changes are often early warning signs.

Trouble falling asleep or sleeping too much can show up weeks to months before a depressive episode.

Decreased need for sleep often precedes mania.

If you’re treating bipolar disorder, or managing it yourself or with a loved one, addressing sleep is vital.

It’s one of the most powerful tools we have for preventing relapse and protecting stability.

To see what that looks like in real life, listen to Bill’s story here.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals. 

P.S. DIGFAST is a mnemonic to remember the symptoms of mania. It stands for: Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity increased, Sleep decreased, and Talkativeness

References:
1. Kaplan KA. Sleep and sleep treatments in bipolar disorder. Curr Opin Psychol. 2020 Aug;34:117-122. doi: 10.1016/j.copsyc.2020.02.001. Epub 2020 Feb 13. PMID: 32203912.

2. Lewis KJS, Richards A, Karlsson R, et al. Comparison of Genetic Liability for Sleep Traits Among Individuals With Bipolar Disorder I or II and Control Participants. JAMA Psychiatry. 2020;77(3):303–310. doi:10.1001/jamapsychiatry.2019.4079

3. Palagini L, Miniati M, Caruso D, Massa L, Novi M, Pardini F, Salarpi G, Pini S, Marazziti D, Etain B, Riemann D. Association between affective temperaments and mood features in bipolar disorder II: The role of insomnia and chronobiological rhythms desynchronization. J Affect Disord. 2020 Apr 1;266:263-272. doi: 10.1016/j.jad.2020.01.134. Epub 2020 Jan 22. PMID: 32056887.