Tag: Articles

Why “8 Hours of Sleep” Might Be Making Insomnia Worse (Clinician Guide)

Posted on May 9, 2026 by IntraBalance - Sleep Health

Pop Quiz

True or False:

If a patient reports feeling “amazing” after 8–9 hours of uninterrupted sleep following a stressful week, the clinician should help the patient achieve this every night.

(Answer below)

A Story From Training

I’m sitting in the interview room with my psychiatry attending after completing an oral exam testing my clinical skills.

He asked if I was going into a fellowship after training and I replied,

“Yes, I’m applying for sleep medicine.”

“Sleep?!” he exclaimed incredulously.

“We’re supposed to keep our patients awake, not put them to sleep!”

Back then, sleep was not a hot topic the way it is now.

Wearables, “sleepmaxxing,” sleepy girl mocktails, AI-enabled mattresses, influencer podcasts, melatonin in every medicine cabinet—none of this existed.

But to me, it was obvious:

Helping patients sleep is one of the most direct ways to help them feel more alert, awake, and alive.

The Problem: Too Much Sleep Advice

Fast forward to today.

Sleep is everywhere.

And the messaging has shifted—from neglecting sleep to obsessing over sleep.

That might sound like progress.

But there’s a growing concern:

We may be overcorrecting—and making insomnia worse.

The American Academy of Sleep Medicine 2025 Sleep Prioritization Survey found:

76% of respondents have lost sleep due to worries about sleep problems

In other words:

People aren’t just losing sleep.

They’re losing sleep worrying about sleep.

Why This Matters for Clinicians

If your patients are more anxious about sleep than ever…

Then more advice isn’t necessarily the solution.

Better messaging is.

This is where the work of Michelle Jonelis MD becomes highly relevant.

She’s a sleep physician, neurologist, and lifestyle medicine doctor who is reframing how we think—and talk—about sleep in clinical practice.

Watch the Full Discussion

Watch the full video here:

What You’ll Learn (Clinician Takeaways)

Why your sleep advice might be making insomnia worse
The hidden reason patients feel better after an “8-hour night”
What rebound sleep is (and why wearables can mislead patients)
Why many adults cannot consistently sleep 8 hours
The concept of a sleep set point
How to use the SLEEPY acronym to identify what’s disrupting sleep
The one word that can reduce sleep anxiety almost immediately
And more

Key Concept: What Is Rebound Sleep?

Rebound sleep refers to a temporary increase in sleep duration and depth after a period of:

Stress
Sleep restriction
Illness
Travel
Lifestyle disruption

Patients often interpret this as:

“This is how I’m supposed to sleep every night.”

But that’s incorrect.

Rebound sleep is not a baseline—it’s a correction.

Trying to replicate it nightly creates:

Unrealistic expectations
Increased sleep effort
Heightened anxiety
Worsening insomnia

Clinical Insight: Sleep Is Not a Performance Task

One of the most important reframes:

Sleep is not something patients can force.

It behaves more like a vital sign than a skill.

That means:

You can’t “try harder” to sleep better
More effort often leads to less sleep
The focus should shift from sleep itself → sleep conditions and habits

A Practical Tool: The SLEEPY Acronym

Dr. Jonelis introduces a simple framework to assess sleep in clinic:

SLEEPY

S – Safe and settled (stress, hyperarousal)
L – Long enough awake (sleep drive)
E – Entrainment (circadian rhythm alignment)
E – Engagement (mental, physical, social activity)
P – Practices (habits, environment, substances)
Y – Your sleep opportunity fits your need

Instead of chasing sleep duration, this helps you:

Identify what’s actually disrupting sleep

A Simple Language Shift That Changes Everything

Most clinicians say:

“Sleep is important.”

A more effective version:

“Healthy sleep habits are important.”

Why this works:

Sleep itself is not directly controllable
Habits are
This reduces pressure and performance anxiety

Answer to the Pop Quiz

False.

Those “perfect” 8–9 hour nights are often rebound sleep.

They feel amazing—but they are:

Temporary
Physiologic
Not reproducible nightly

Trying to achieve them consistently leads to:

Increased sleep effort
Frustration
Worse insomnia

Final Takeaway for Clinicians

We’ve spent decades telling patients:

“Get more sleep.”

Now we’re seeing the unintended consequence:

They’re trying too hard—and sleeping worse.

The opportunity moving forward:

Shift from quantity to context
Shift from control to conditions
Shift from sleep to habits

Continue Your Learning

Did you learn something new?

Explore CME and structured learning here:
https://champions.learner.plus/?champion=Dr%20Nishi%20Bhopal

References

1. American Academy of Sleep Medicine. Sleep Prioritization Survey 2025: Losing Sleep to Worries. Published 2025.

Sleep, Insulin Resistance, and the Dawn Phenomenon: Clinical Insights from an Endocrinologist

Posted on May 4, 2026 by IntraBalance - Sleep Health

What causes the dawn phenomenon in insulin resistance and diabetes?

The dawn phenomenon refers to an early-morning rise in blood glucose (typically between 3–8 a.m.) driven by hormonal signals, including cortisol, growth hormone, and adrenaline. It is not primarily caused by late-night eating, although lifestyle habits can influence its magnitude.

Pop Quiz for Clinicians

True or False:
The “dawn phenomenon” observed in patients with insulin resistance is primarily an effect of nighttime snacking and can be mitigated by ensuring the last meal is consumed 3–4 hours before sleep.
(Answer at the end.)

What a Continuous Glucose Monitor Taught Me

Last year I experimented with wearing a continuous glucose monitor (CGM) and it was eye-opening.
One of the things I learned was that even a small amount of rice causes a large spike in my blood glucose, while something like dark chocolate barely moves the needle.

Given my family history and South Asian predisposition to type II diabetes, those insights helped me create a more tailored lifestyle approach to metabolic health.

CGMs can reveal metabolic patterns that routine labs often miss.

But one thing that became increasingly clear is that metabolic health isn’t just about food. Sleep plays a major role as well.

Watch the Interview

This week we’re diving deeper into metabolic health and sleep with preventive endocrinologist Chhaya Makhija, MD.

Dr. Makhija is the founder of Unified Endocrine and Diabetes Care in California, and a colleague with whom I’ve shared patients.

If you see patients with insulin resistance, metabolic syndrome, or unexplained fatigue, this conversation includes several practical clinical pearls worth watching.

Prefer watching? The full interview is below.

Key Clinical Insights from the Conversation

Sleep Is an Overlooked Vital Sign in Metabolic Health

One of the most important takeaways from the discussion is that sleep deserves the same clinical attention as diet, exercise, and laboratory markers.

“Sleep is an important vital sign.”

For clinicians managing patients with metabolic disease, sleep disruption may be an upstream contributor to worsening glucose control.

Sleep Disruption Can Worsen Insulin Resistance

Poor sleep does not simply affect daytime fatigue.

It directly influences metabolic regulation.

“Poor sleep directly and indirectly affects glucose control, insulin resistance, and metabolic health.”

Sleep fragmentation increases stress hormones such as cortisol and adrenaline. These hormones signal the liver to release more glucose into the bloodstream.

Over time, this can increase insulin demand and contribute to metabolic dysfunction.

Cortisol and Stress Hormones Affect Overnight Glucose

Stress physiology can significantly affect nighttime glucose levels.

“Cortisol tells the liver to produce more glucose—even when you're not eating.”

This process helps explain why patients may see elevated fasting glucose levels despite making dietary improvements.

Circadian Rhythm Stability Matters for Hormone Health

Sleep timing is another important factor in metabolic regulation.

“Consistent wake-up times help keep cortisol, growth hormone, insulin, and glucose metabolism in sync.”

Irregular schedules, shift work, and inconsistent sleep timing can disrupt these hormonal rhythms.

Using CGMs as a Clinical Education Tool on

Continuous glucose monitors can provide powerful behavioral feedback for patients.
However, interpretation requires context.

“The goal is not to chase perfect numbers but to learn patterns.”

For example, one of the simplest lifestyle interventions Dr. Makhija recommends is movement after meals.

“Simple activity after meals can lower glucose by 20–30 mg/dL.”

Even short walks after meals can significantly influence glucose levels.

Breathwork and Stress Physiology

Another interesting clinical insight is the role of nervous system regulation.

Dr. Makhija often recommends brief breathing practices:

when patients wake up
before bedtime

These practices activate the parasympathetic nervous system, which may help stabilize stress physiology and glucose regulation.

The Dawn Phenomenon Explained

Many patients with insulin resistance or diabetes experience the dawn phenomenon, which appears clearly in CGM data.

“The dawn phenomenon is the rise in blood glucose before waking, driven by cortisol, adrenaline, and growth hormone.”

This physiologic glucose rise occurs even in the absence of food intake.

Lifestyle interventions that may help reduce its impact include:

finishing dinner 3–4 hours before sleep
taking a short walk after dinner
incorporating stress-reducing practices before bed

Sleep Disorders and Hormonal Health in Men

Sleep disorders can also influence reproductive hormones.

Untreated sleep apnea and metabolic dysfunction can contribute to:

erectile dysfunction
reduced libido
lower testosterone production

“The body prioritizes survival hormones like cortisol over reproductive hormones during chronic stress.”

This is another example of how sleep and metabolic health are closely connected.

Dr. Makhija goes into more detail in the interview about which labs to order and how to evaluate suspected testosterone deficiency, so be sure to watch the full discussion if this is something you encounter in your practice.

Why Sleep Should Be Part of Every Metabolic Evaluation

For clinicians treating metabolic disease, sleep evaluation can provide critical diagnostic clues.
Sleep issues may present as:

fatigue
insomnia
depression
hyperarousal or “tired but wired” symptoms
worsening glucose control

Addressing sleep health may help identify upstream drivers of metabolic dysfunction.

Pop Quiz Answer

False

The dawn phenomenon is a physiologic rise in glucose in the early morning hours (approximately 3–8 a.m.), driven by hormonal signals such as cortisol and growth hormone.

While lifestyle habits such as earlier dinners may influence glucose patterns, the underlying mechanism is hormonal rather than dietary.

Further Learning

Did you learn something today?

Clinicians interested in earning CME/CE credit through reflection-based learning can explore the Learner+ platform here:
https://champions.learner.plus/?champion=Dr%20Nishi%20Bhopal

Growth Hormone, Slow-Wave Sleep, and Metabolic Health: What Clinicians Should Know

Posted on May 2, 2026 by IntraBalance - Sleep Health

Quick Clinical Answer

Is growth hormone secretion circadian or sleep-dependent?

Growth hormone secretion is primarily slow-wave sleep–mediated, not circadian-mediated.

The largest pulses of growth hormone occur during stage N3 slow-wave sleep (deep sleep), meaning sleep quality and sleep architecture directly influence metabolic health.

Pop Quiz for Clinicians

True or False: Growth hormone secretion is largely circadian-mediated. (The answer is at the end of this article)

A Midlife Shift in Sleep Physiology

When you’re in your mid-40s, health often stops being an afterthought and starts taking a more central role in day-to-day life.

That has certainly been true for me. When I was younger, I didn’t give it much thought because I was fortunate not to have any significant health problems.

Now, with age and a family history of metabolic disease, cancer, and other health conditions, the risks feel much more tangible.

My daily step count, nutrition, stress regulation, and sleep quality are now part of a lifestyle-first approach to health.

Interestingly, this same stage of life is also when meaningful changes occur in sleep physiology.

During the midlife window (ages 35–50), research shows a decline in slow-wave sleep alongside a reduction in growth hormone (GH) secretion. (1,2)

Why Growth Hormone Matters in Midlife

Growth hormone plays an important role in adult physiology.

In midlife adults, GH helps:

Maintain lean muscle mass
Regulate body fat distribution, especially visceral fat
Support bone density
Influence metabolic health

This is also when metabolic changes begin appearing, including:

Central obesity
Muscle loss
Declining bone density

These changes are often attributed solely to aging.

However, sleep physiology suggests a modifiable contributor.

The Sleep–Growth Hormone Connection

Growth hormone is secreted during slow-wave sleep (stage N3), also known as deep sleep.

When slow-wave sleep is reduced or fragmented, GH secretion is impaired.

For patients, this means sleep quality influences more than daytime energy.

Poor sleep quality can impair GH secretion and contribute to:

Increased visceral fat and decreased lean muscle mass
Dyslipidemia and insulin resistance
Reduced bone density
Fatigue and reduced exercise capacity

This makes sleep quality a key upstream factor in metabolic health.

What to Tell Patients

A simple explanation for patients:

“Your sleep quality affects more than how rested you feel. Deep sleep regulates hormones that influence metabolism, body composition, and energy.”

Framing sleep in hormonal terms often increases patient motivation.

Clinical Implications for Practice

The sleep-growth hormone relationship highlights several intervention points.

Screen for Sleep Disorders

Conditions that disrupt slow-wave sleep, like Obstructive Sleep Apnea (OSA), can suppress the growth hormone axis.

Treatment matters.

Research suggests CPAP therapy can restore growth hormone secretion by improving sleep architecture. (1,2)

Address Obesity

Obesity worsens GH suppression.

Studies suggest each unit increase in BMI reduces GH secretion by approximately 6%. (3)

Because obesity and sleep disorders frequently coexist, treating both can improve metabolic outcomes.

Optimize Sleep Quality

Encourage patients to prioritize:

Consistent sleep schedules
Adequate sleep duration
Reducing sleep fragmentation

Sleep fragmentation significantly reduces slow-wave sleep.

For a deeper explanation, see my video on sleep fragmentation:
https://intrabalance.com/normal-sleep-study-now-what/

Encourage Regular Exercise

Exercise improves both sleep and metabolic health.

Research shows regular exercise can:

Increase growth hormone secretion
Increase slow-wave sleep (4)

Avoid Alcohol

Alcohol fragments sleep and disrupts slow-wave sleep architecture.

Even moderate evening alcohol can impair deep sleep and reduce GH release.

Reframe “Normal Aging”

Symptoms attributed to aging—fatigue, central obesity, reduced exercise capacity—may partly reflect modifiable sleep-driven hormonal changes.

Treating sleep disturbances often improves metabolic function.

Why Sleep Is a Preventive Tool in Midlife Medicine

Metabolic health, body composition, and bone density are often addressed after disease develops.

However, sleep quality represents an upstream lever.

Optimizing sleep in midlife may reduce downstream metabolic complications.

Sleep may be one of the most underutilized interventions in preventive metabolic medicine.

Coming Next Week

Stay tuned for next week’s post, where I’ll share a new video exploring the clinical applications of sleep and metabolic health with Preventive Endocrinologist Chhaya Makhija, MD.

Key Clinical Takeaways

Growth hormone secretion is slow-wave sleep mediated, not circadian mediated.
Deep sleep (stage N3) is the primary driver of GH pulses.
Slow-wave sleep declines during midlife (35–50).
Sleep disorders such as OSA suppress GH secretion.
Improving sleep quality may improve metabolic health.

Clinical FAQ: Sleep and Growth Hormone

Is growth hormone secretion circadian or sleep dependent?

Growth hormone secretion is primarily sleep-dependent, occurring during slow-wave sleep rather than following circadian rhythms.

Which stage of sleep releases growth hormone?

Growth hormone is released primarily during stage N3 slow-wave sleep, also known as deep sleep.

Does sleep apnea affect growth hormone?

Yes. Obstructive sleep apnea disrupts slow-wave sleep and suppresses GH secretion. Treatment with CPAP can restore growth hormone release.

Why does growth hormone decline in midlife?

Several factors contribute:

Reduced slow-wave sleep
Increased sleep fragmentation
Obesity
Circadian disruption

Because GH release depends on deep sleep, changes in sleep architecture play a key role.

Can improving sleep increase growth hormone?

Improving sleep quality—particularly increasing slow-wave sleep—may improve GH secretion.

Helpful strategies include:

Treating sleep apnea
Increasing exercise
Improving sleep continuity
Reducing alcohol intake
Maintaining consistent sleep timing

Pop Quiz Answer

False. Growth hormone secretion is largely slow-wave sleep mediated, not circadian mediated.

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) Van Cauter E, Leproult R, Plat L. Age-related changes in slow wave sleep and REM sleep and relationship with growth hormone and cortisol levels in healthy men. JAMA. 2000 Aug 16;284(7):861-8. doi: 10.1001/jama.284.7.861. PMID: 10938176.

(2) Chennaoui M, Léger D, Gomez-Merino D. Sleep and the GH/IGF-1 axis: Consequences and countermeasures of sleep loss/disorders. Sleep Med Rev. 2020 Feb;49:101223. doi: 10.1016/j.smrv.2019.101223. Epub 2019 Nov 1. PMID: 31778943.

(3) Melmed S. Pathogenesis and Diagnosis of Growth Hormone Deficiency in Adults. N Engl J Med. 2019 Jun 27;380(26):2551-2562. doi: 10.1056/NEJMra1817346. PMID: 31242363.

(4) Baranwal N, Yu PK, Siegel NS. Sleep physiology, pathophysiology, and sleep hygiene. Prog Cardiovasc Dis. 2023 Mar-Apr;77:59-69. doi: 10.1016/j.pcad.2023.02.005. Epub 2023 Feb 24. PMID: 36841492.

How to Treat Insomnia in Clinical Practice (When Medications and CBT-I Aren’t Enough)

Posted on April 6, 2026 by IntraBalance - Sleep Health

If you treat patients with insomnia, you’ve probably heard this before:

“Can you just give me something to knock me out?”

Your patients are exhausted.
They’ve tried everything—sleep medications, supplements, CBT-I, sleep trackers, lavender sprays, new pillows, and every sleep tip they could find online.

As the clinician, you genuinely want to help.
But at some point, insomnia visits can start to feel like a cycle you can’t break either.

You adjust medications.
You suggest behavioral strategies.

You refer to CBT-I.

And the patient comes back… still not sleeping.

It’s frustrating—for both of you.

The truth is, many clinicians were never taught a clear framework for managing insomnia in clinical practice.

And without that framework, it’s easy to get pulled into a cycle that unintentionally reinforces the problem.

The Real Driver of Chronic Insomnia: Sleep Effort

One of the biggest hidden drivers of chronic insomnia is sleep effort.

When sleep becomes something a patient is trying to force, the brain shifts into a state of performance pressure and hyperarousal.

Patients start monitoring:

“Am I falling asleep yet?”
“Why am I still awake?”
“How many hours do I have left before morning?”

Ironically, the harder someone tries to sleep, the harder sleep becomes.

Clinicians can get pulled into this loop as well.

The patient tries harder to sleep.

The clinician tries harder to fix it.

More medications.
More supplements.
More sleep gadgets.

I call this dynamic:

The Dance of Sleep Effort.

And it’s one of the most common reasons insomnia persists despite treatment.

Why Standard Insomnia Treatments Sometimes Fall Short

Current sleep guidelines recommend Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment.

And for many patients, CBT-I works extremely well.

However, in real-world practice:

CBT-I improves insomnia in about 60–70% of patients
Access to trained CBT-I therapists is limited
Some patients continue to struggle with hyperarousal and sleep anxiety

This is why many clinicians are looking for a more integrated approach to insomnia treatment.

Effective insomnia care often requires addressing multiple factors simultaneously, including:

Sleep drive
Circadian rhythm timing
Cognitive pressure around sleep
Conditioned arousal in the bedroom
The patient’s relationship with wakefulness

When these elements are addressed together, outcomes can improve dramatically.

Four Clinical Shifts That Improve Insomnia Outcomes

In the video below, I share four practical clinical shifts that can change outcomes for patients with chronic insomnia—even those who have struggled for years.

These shifts help clinicians:

Break the cycle of sleep effort
Reduce nighttime hyperarousal
Reframe wakefulness in a healthier way
Move beyond medication-only approaches

These strategies are especially helpful for patients who:

Have tried multiple sleep medications
Completed CBT-I but still struggle
Experience sleep anxiety or performance pressure
Feel increasingly frustrated about their sleep

What to Say When Patients Ask for Sleeping Pills

One of the most common moments in an insomnia visit is this request:

“Can you give me something to help me sleep?”

It can feel difficult to redirect that conversation.

In the video below, I share a simple script you can use that:

validates the patient’s frustration
explains the insomnia cycle clearly
introduces a more effective treatment direction

This approach helps maintain trust while shifting away from a purely medication-driven strategy.

Watch the Video: Practical Insomnia Treatment Strategies for Clinicians

In this video you’ll learn:

4 clinical shifts that change insomnia outcomes
Case examples from real clinical practice
Exactly what to say when patients ask for another sleeping pill
How to help patients change their relationship with wakefulness

If you’ve ever finished an insomnia visit wondering whether there might be a better approach…

There is.

And when clinicians learn how to guide patients through insomnia effectively, it becomes one of the most rewarding problems to treat in clinical practice.

Frequently Asked Questions About Treating Insomnia

Why do sleeping pills often stop working for insomnia?
Sleeping medications can provide short-term relief, but they do not address the behavioral and cognitive drivers of insomnia. Over time, tolerance, dependence, or conditioned sleep anxiety may develop.

Why do patients still struggle after CBT-I?
Some patients continue to experience insomnia due to ongoing hyperarousal, circadian rhythm issues, or persistent anxiety about sleep. Integrative approaches that incorporate behavioral, cognitive, and physiologic strategies can be helpful.

What causes the cycle of chronic insomnia?
Chronic insomnia often develops when sleep effort, sleep anxiety, and conditioned arousal reinforce each other, creating a self-perpetuating cycle of wakefulness and frustration.

For Clinicians Who Want a Structured Insomnia Framework

Most clinicians receive very little formal training in sleep medicine.

Yet insomnia is one of the most common complaints in clinical practice.

If you’re interested in learning a structured, practical approach to insomnia assessment and treatment, this is something I teach in my clinician education programs, where we focus on real-world frameworks and case-based learning.

Because when clinicians understand how insomnia actually works, the treatment approach becomes much clearer.

How to Evaluate Insomnia: A Clinical Workflow for Clinicians

Posted on April 5, 2026 by IntraBalance - Sleep Health

Many clinicians find insomnia frustrating to evaluate and treat.

Patients often present after trying multiple medications or referrals without much improvement. But in clinical practice, most insomnia cases come down to a handful of underlying factors. Once you know what to look for, the evaluation becomes surprisingly straightforward.

In this article, I’ll walk through a practical clinical workflow clinicians can use to evaluate insomnia in everyday practice.

This post accompanies Part 2 of my 3-part insomnia series for clinicians, where I walk through the exact evaluation process I use in my clinic.

Clinical Quick Guide: How to Evaluate Insomnia

A structured insomnia evaluation helps clinicians identify the drivers of sleep disruption before jumping to treatment.

A practical clinical workflow includes five steps:

1. Clarify the sleep complaint

Determine whether the patient has difficulty falling asleep, staying asleep, early morning awakening, or non-restorative sleep.

Assess duration, severity, and daytime functioning.

2. Assess sleep schedule and circadian timing

Review bedtime, wake time, schedule variability, light exposure, and social or work schedules that influence circadian rhythms.

3. Evaluate sleep drive and behavioral factors

Assess time spent in bed, napping, caffeine intake, alcohol use, and evening screen exposure.

4. Screen for contributing conditions

Consider medical, psychiatric, and sleep disorders that commonly present with insomnia, including:

obstructive sleep apnea
restless legs syndrome
circadian rhythm disorders
anxiety and depression
medication effects

5. Identify patterns that guide treatment

Most insomnia cases involve multiple contributing factors rather than a single cause.

When clinicians evaluate sleep systematically, the treatment path becomes clearer.

Watch: Clinical Workflow for Evaluating Insomnia

In this video, I walk through the exact workflow I use in my clinic to evaluate insomnia, including key questions that often reveal the underlying causes of sleep problems.

A Lesson From Learning the Sitar

In my first year of university, I decided to learn the sitar.

I showed up to my teacher’s house for my first lesson, left my shoes at the door, sat cross-legged on her basement floor, and eagerly waited to see what would happen next.

Across from me sat her 10-year-old musical prodigy daughter with a tabla, ready to play.

My teacher began singing sa-re-ga-ma while her tiny dog yapped and two bunnies watched from a cage in the corner.

On the surface it looked chaotic.
But I had learned piano as a child.

I understood scales, music theory, and the process of practicing a phrase until your fingers stopped thinking about it.

The sitar was a completely different instrument, but the foundation was already there.

What looked chaotic had an underlying structure.

I often think about this when clinicians approach insomnia.

Many assume insomnia is outside their wheelhouse, it’s either too behavioral, too specialized, or too time-consuming.

So the default approaches often become:

referring patients out
cycling through sleep medications
revisiting the same sleep complaint repeatedly

But most clinicians already have the core skills needed to evaluate insomnia.

If you can take a thorough clinical history, recognize patterns, and perform a thoughtful evaluation, you already have the foundation.

Insomnia simply requires a clear framework layered on top of those skills.

A Clinical Case: When the Cause of Insomnia Is Missed

One patient illustrates how easily important contributors can be overlooked.

She was in her early forties and had been referred for insomnia after trying several sleep medications, including zolpidem.

During the evaluation I asked a question I now ask nearly every insomnia patient:

“Tell me about your sleep environment.”

She lived in a small San Francisco studio apartment and had been sleeping in a closet because it was the only separate room.

The room was poorly ventilated and very hot at night.

We moved her bed closer to a window.

Her sleep improved almost immediately.

But that wasn’t the whole story.

Further evaluation revealed subtle symptoms of obstructive sleep apnea that had never been assessed.

Testing confirmed sleep apnea, and combined with behavioral sleep interventions she eventually tapered off zolpidem and began sleeping better than she had in years.

What stood out about this case was that several clinicians had treated her insomnia, but no one had systematically evaluated the underlying contributors.

Insomnia rarely has a single cause.

It’s usually a pattern across multiple factors.

The FEEM Framework for Evaluating Insomnia

After evaluating many insomnia patients, I noticed that contributing factors usually fall into four categories.

I use the acronym FEEM to remember them.

Food

Dietary contributors to poor sleep may include:

caffeine
alcohol
reflux from late meals
low ferritin contributing to restless sleep

Environment

Sleep environment factors include:

bedroom temperature
light exposure
noise
inconsistent sleep schedule
sleep hygiene habits

Emotional factors

Psychological contributors include:

anxiety
rumination
trauma
conditioned hyperarousal around sleep

Medical conditions

Medical contributors commonly include:

obstructive sleep apnea
restless legs syndrome
circadian rhythm disorders
medication effects

Evaluating these categories systematically often reveals the pattern driving insomnia.

Questionnaires That Simplify Insomnia Evaluation

Standardized questionnaires can make insomnia assessments much more efficient.

Helpful tools include:

Insomnia Severity Index (ISI)
Epworth Sleepiness Scale
GAD-7
PHQ-9
Mood Disorder Questionnaire

Many clinicians also have patients complete a sleep history form or sleep diary before the visit, which allows appointment time to focus on clinical decision-making.

The American Academy of Sleep Medicine provides free templates that work well in practice.

Understanding the Patient’s Relationship With Sleep

Sometimes the most important perpetuating factor in insomnia is not behavioral or medical.

It is the patient’s relationship with sleep itself.

A helpful interviewing framework is FIFE:

Feelings — How do you feel about your sleep problem?
Ideas — What do you think is causing it?
Functioning — How is it affecting your daily life?
Expectations — What are you hoping treatment will accomplish?

These questions often reveal beliefs that reinforce insomnia, such as fear of not sleeping enough or pressure to achieve perfect sleep.

Understanding these beliefs is often one of the most important parts of an insomnia evaluation.

What Clinicians Often Notice

Once clinicians start evaluating insomnia systematically, patterns begin to emerge.

Instead of insomnia feeling mysterious, clinicians start to recognize:

environmental contributors
behavioral sleep patterns
medical sleep disorders
cognitive or emotional drivers

Once those factors are identified, treatment becomes far more targeted.

Often the interventions themselves are surprisingly simple.

Frequently Asked Questions About Evaluating Insomnia

What is the first step in evaluating insomnia?

The first step is clarifying the patient’s sleep complaint and determining whether the issue involves sleep onset, sleep maintenance, early awakening, or non-restorative sleep.

What conditions should clinicians screen for?

Common contributors include sleep apnea, restless legs syndrome, circadian rhythm disorders, anxiety, depression, and medication effects.

What questionnaires are useful for insomnia assessment?

Common tools include the Insomnia Severity Index, Epworth Sleepiness Scale, GAD-7, PHQ-9, and sleep diaries.

Do clinicians need specialized sleep training to evaluate insomnia?

Most clinicians already have the foundational skills. A structured framework for evaluating sleep can make insomnia assessments far more manageable.

Insomnia Education for Clinicians

If you found this helpful, you may also enjoy other articles in this clinical insomnia series:

Understanding insomnia patterns
Treating insomnia in clinical practice

Coming Next in the Series

In the next article and video we’ll discuss how to treat insomnia in clinical practice, including behavioral strategies clinicians can begin using right away.

Nishi Bhopal MD
Board Certified in Psychiatry and Sleep Medicine

PS: Many clinicians use CME as a starting point, then continue refining and applying sleep medicine concepts through live, case-based discussion and training inside The Clinical Sleep Kit.

Why Insomnia Treatment Isn’t Working: 3 Things Clinicians Often Miss

Posted on March 30, 2026 by IntraBalance - Sleep Health

If your insomnia patients aren’t getting better despite trying multiple interventions, the problem is rarely effort — it’s framework. Most clinicians were never taught a systematic way to evaluate and treat insomnia, which means the factors actually maintaining the condition often go unaddressed. Here’s what to look for.

Nobody Wants to Treat Insomnia — Here's Why I Leaned In Anyway

Near the end of my psychiatry residency, I was preparing to apply for sleep medicine fellowship. I was chatting with one of my attendings in the sleep clinic at Henry Ford Hospital when he gave me a piece of advice I’ve never forgotten.

“Tell them you want to treat insomnia. You’ll get in for sure.”

Why? Because nobody wants to treat it.

I understood exactly what he meant. Even after completing my sleep medicine fellowship — with a solid CBT-I foundation — and coming in as a psychiatrist with both CBT and psychodynamic training, I’d still feel a quiet dread when I saw an insomnia patient on my schedule. I knew that visit was going to run long in a slot that wasn’t built for it.

And I was better equipped than most.

The Real Reason Insomnia Patients Stay Stuck

Here’s what I kept noticing: most clinicians don’t have a clear framework for evaluating or treating insomnia. So they do what’s available to them — cycle through medications, revisit sleep hygiene, maybe refer for CBT-I that the patient never follows through on.

The insomnia persists, the patient comes back, and the frustration compounds for everyone involved.

That revolving door isn’t a failure of effort. It’s a framework problem.

Understanding why insomnia treatment isn’t working requires looking beyond the obvious. Chronic insomnia is almost never maintained by a single factor. It’s a combination of biology, behavior, and cognition — and treating only one thread rarely unravels the whole knot.

3 Things That Are Commonly Missed in Clinical Practice

1. Targeting the wrong perpetuating factors
The 3P model of insomnia — predisposing, precipitating, and perpetuating factors — is foundational in behavioral sleep medicine, but it’s often skipped in training. The perpetuating factors are what keep insomnia alive long after the original trigger is gone: time in bed awake, irregular schedules, conditioned arousal, catastrophic thinking about sleep. When treatment doesn’t address these specifically, patients don’t get better — even with the right medication or the right referral.

2. Trying to force sedation instead of rebuilding sleep drive
One of the most counterintuitive aspects of insomnia treatment is that trying harder to sleep often makes things worse. Increasing sedating medications, spending more time in bed, or napping to compensate can undermine sleep drive and deepen conditioned arousal. Effective insomnia treatment works with the brain’s natural sleep systems — not against them.

3. Missing the cognitive and behavioral layer entirely
Even when clinicians address the biological piece, the behavioral and cognitive side often goes untouched. Rigid beliefs about sleep, hyperarousal in the bedroom, and anxiety about not sleeping are powerful perpetuating factors that medications don’t touch. CBT-I and ACT for insomnia work because they directly dismantle these patterns — but only when they’re properly implemented.

Watch: Part One of a Three-Part Series on Insomnia

If you’ve ever felt stuck with an insomnia patient who isn’t responding, this is where I’d start.

In this first video I walk through these three commonly missed factors in clinical practice — including why trying to force sedation can backfire, and how targeting the wrong perpetuating factors keeps patients stuck in a cycle that’s hard to break.

▶ Watch Part One Here — it’s the framework I wish I’d had in residency.

About the Author

Nishi Bhopal MD is board certified in both Psychiatry and Sleep Medicine (ABPN). She specializes in non-pharmacological insomnia management and holistic, integrative sleep medicine, and teaches clinicians evidence-based frameworks for evaluating and treating chronic insomnia through The Clinical Sleep Kit program.

Normal sleep study. Now what?

Posted on March 21, 2026 by IntraBalance - Sleep Health

You ordered the sleep study. You were pretty sure it was going to show sleep apnea.

The pattern was classic: waking every 2-3 hours, never feeling rested, fatigue through the day.

Then the results came back showing…

“No significant sleep apnea”.

And now you’re sitting with the patient who’s still struggling, a normal-ish sleep study, and not much of a roadmap for what to do next.

This scenario comes up more than you’d think, and it’s exactly what inspired this week’s video.

A reader wrote to me asking:
“Do you have any information on treatment for interrupted sleep patterns, for example, waking every 2-3 hours in the context of a negative home sleep study?”

It’s such a good question because a home sleep apnea test tells you one thing but misses a lot of others.

In this week’s video, I’m sharing what to do next, including the 4 broad categories that drive most sleep fragmentation, some case examples, and a personal sleep fragmentation story of my own.

Fair warning: I was recording this while getting over an upper respiratory infection, so please excuse the congestion.

It actually felt fitting, because nasal congestion is one of those commonly overlooked factors that can fragment sleep, and I got a firsthand reminder of that while making this video!

Med adjustments for DST

Posted on March 11, 2026 by IntraBalance - Sleep Health

I’m writing this from Vancouver, BC, where I’m visiting family, and where the clocks just sprung forward for the last time:
BC has officially adopted permanent Daylight Saving Time.
As a sleep doctor, my first reaction was… complicated.
Sleep and circadian researchers (including the American Academy of Sleep Medicine) have been pushing to abolish the clock change for years.

But the recommendation has always been permanent Standard Time, not permanent DST.

Standard time is more aligned with our circadian biology. BC went in the other direction, driven by economics and public preference rather than scientific consensus.
So here we are.
While one hour might sound trivial, the spring transition is associated with a 6% increase in fatal car accidents, a 24% higher risk of heart attacks, an 8% increase in strokes, and an 11% rise in depressive episodes, all in the days following the switch.

Daylight Saving Time is a public health issue hiding in plain sight

So this is a good time to talk about ways to help your patients through it.

The Basics

The most important thing you can do is keep it simple. Behavioral interventions are the mainstay.. Some tips:

Consistent wake times, even on weekends
Plenty of bright light during the day, especially in the morning
Avoiding alcohol, caffeine, and heavy meals late in the day
Short 15–20 minute naps for a few days if patients are struggling
Setting expectations:: “You might feel a little jet-lagged this week. It can take a couple of weeks to adjust..”

For patients on antidepressants

Chronotherapeutic adjuncts may enhance treatment response.

Evening chronotypes (your later-to-bed, later-to-rise patients) tend to struggle most with the spring transition. Morning bright light exposure (10,000 lux for 30 minutes) can help resynchronize their rhythms. Low-dose melatonin (0.5–5 mg) in the late afternoon or early evening can also support a phase advance, but timing should be individualized.

For cardiovascular patients

The spring transition carries the highest cardiovascular risk, so this population deserves a closer eye. The American Heart Association recommends optimizing circadian health through behavioral interventions rather than medication timing changes during DST.

Focus on consistent meal times, regular exercise, and morning light exposure to maintain circadian alignment.

For patients on sleep medications

Again, no dose adjustments are needed. Instead, use light and dark regulation to help patients adapt. Your evening chronotypes require more time to adjust to DST transitions and are most vulnerable to sleep disruption.

Who to watch most closely

Keep a closer eye this week on patients with mood disorders, cardiovascular disease, evening chronotypes, and anyone on medications with narrow therapeutic windows.

The good news: most people adjust within a week. The goal is just to make that week a little smoother.

If you want a ready-to-use system for managing sleep cases, not just the theory, but the actual clinical tools, The Clinical Sleep Kit is opening for enrollment again soon. Join the waitlist here.

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

References:
(1) Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2024 Jan 1;20(1):121-125. doi: 10.5664/jcsm.10898. PMID: 37904574; PMCID: PMC10758561.

Depression and Sleep

Posted on March 9, 2026 by IntraBalance - Sleep Health

It’s pitch black outside, and I’m standing in the shower trying to find the energy to face the day.

I’d come off a weekend call, and between the sound of the water hitting the tiles and the thought of 6am rounds, I found myself sobbing.

It was the kind of crying that sneaks up on you without warning. All I wanted was to crawl back into bed and hide.
That was my Internal Medicine intern year in Detroit, Michigan.

My mom had called at some point during those months to check in.

“How are you doing?” she asked.

“I hate this,” I told her.

As a normally quite positive person, it was unlike me, but honest.
The chronic sleep deprivation wasn’t just making me tired, it was rearranging things in my brain.

I was ruminating, emotional, negative, exhausted, and a little lost inside my own head. I didn’t have language for it at the time. I just thought something was wrong with me because it seemed like everyone else was thriving.
Then vacation came, and I slept. Like long and deep sleeps. And the fog lifted so quickly, that I remember thinking, “I feel like myself again.”

I see this in my patients frequently as well, with a combination of disrupted sleep and low mood.

One feeds the other and it can be hard to know which came first.
I sat down with Amit Chopra MD — psychiatrist and sleep specialist at Massachusetts General Hospital, Assistant Professor at Harvard Medical School, and co-author of Management of Sleep Disorders in Psychiatry published by Oxford University Press, to dig into exactly that relationship.

What looks like treatment-resistant depression may actually be undiagnosed sleep apnea. Dr. Chopra explains the presentation most physicians miss — particularly in women.
Insomnia is an independent risk factor for suicidality, even when you control for depression severity. We get into the specific features that should raise your concern.
CBT-I isn’t just for sleep. It has measurable antidepressant effects and can even prevent depression onset in vulnerable patients. Dr. Chopra explains why it belongs in your treatment toolkit.
The sleep-depression relationship is bidirectional, and the direction matters clinically. We break down what that means for your treatment plans.
Untreated insomnia increases depression recurrence risk by 3-6x. Treating the mood disorder without addressing the sleep may be setting your patients up to relapse.

Watch the interview here and claim your CME credit using the Learner+ link below.

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

Hypnosis for Insomnia

Posted on February 17, 2026 by IntraBalance - Sleep Health

Does Clinical Hypnosis Work For Insomnia?

I deleted Instagram from my phone last week.
I noticed that I was doomscrolling far longer than I’d like to admit, and my nervous system was paying the price.

The irony wasn’t lost on me, as this is a conversation I have with patients nearly every day, especially those struggling with anxiety or insomnia.

In fact, scrolling social media has been compared to a form of hypnosis, inducing a trance-like state. (1)

The word hypnosis is derived from the Greek hypnos, meaning “sleep,” after Hypnos, the Greek god of sleep.

The American Psychological Association defines hypnosis as a “state of consciousness involving focused attention and reduced peripheral awareness characterised by an enhanced capacity for response to suggestion”, but that definition is still debated.

Hypnosis can also be understood as a state of deep relaxation and focused concentration, not unlike certain meditative states.
In terms of therapeutic uses of hypnosis, there is some evidence for insomnia. A few studies suggest it may increase slow-wave sleep (2), though more research is needed.

This week, we’re talking about hypnosis with pediatrician Nadia Sarwar MD.

She’s certified in clinical hypnosis and on faculty at the National Pediatric Hypnosis Training Institute. She also runs a private practice providing clinical hypnosis to children and families.

(By the way, these are the kinds of applied, case-based discussions we have inside The Clinical Sleep Kit (CSK) program, where Dr. Sarwar also joins us as guest faculty.)

In this interview, Dr. Sarwar shares:

Whether hypnosis is evidence-based
The difference between clinical hypnosis and hypnotherapy
How hypnosis can support sleep and what her clinical process looks like (some of this surprised me)
Who is and isn’t a good candidate
A case example of a 6-year-old with insomnia
How clinicians can get trained
And more

If you’re curious about the kinds of interdisciplinary perspectives we explore in CSK, stay tuned. Registration opens again later this month.

Click here to watch the interview and claim your CME credit.

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

P.S. Many clinicians use this CME as a starting point, then continue refining and applying sleep medicine concepts through live, case-based discussion and training inside The Clinical Sleep Kit program.

References:
(1) Olson JA, Stendel M, Veissière S. Hypnotised by Your Phone? Smartphone Addiction Correlates With Hypnotisability. Front Psychiatry. 2020 Jun 25;11:578. doi: 10.3389/fpsyt.2020.00578. PMID: 32670109; PMCID: PMC7330005.

(2) Baselgia S, Rasch B. Hypnotic suggestions in the modulation of sleep. Int Rev Neurobiol. 2025;184:151-178. doi: 10.1016/bs.irn.2025.04.015. Epub 2025 Apr 25. PMID: 41161943.