Why You Can't Sleep: Insomnia Explained by Psychiatrists

How Bad Is Your Insomnia? Start Here

Insomnia is one of the most common reasons people seek psychiatric care. Before diving into solutions, it helps to understand how sleep quality is actually measured. The standard tool used in clinical settings is the Pittsburgh Sleep Quality Index (PSQI), which evaluates sleep across seven categories.

The first is subjective sleep quality—how rested you feel overall. This matters more than it sounds. A patient may insist they didn't sleep a wink all night, while nursing staff observed them snoring soundly. Neither is wrong. That disconnect is called subjective insomnia, and the patient's perception of their own sleep is clinically significant regardless of what the data shows.

Next is sleep latency—how long it takes to fall asleep, and how often you struggle to do so. The PSQI asks: "How many minutes does it typically take you to fall asleep?" and "How often have you had trouble falling asleep?"

From there, the assessment looks at total sleep duration and sleep efficiency. Sleep efficiency is the ratio of actual sleep time to total time spent in bed. Lying in bed for 20 hours to get 8 hours of sleep is not good sleep—it's a problem.

The fifth category covers sleep disturbances: waking up to use the bathroom, trouble breathing, coughing, or any other factor that interrupts sleep. Then comes daytime dysfunction—how much your sleep problems are affecting your daily life. Interestingly, some people who sleep only four or five hours a night report no meaningful daytime impairment. Constitutionally, some people simply need less sleep, and if they're functioning well, that alone lowers the clinical severity score.

Finally, the PSQI asks about sleep medication use—including over-the-counter supplements, not just prescriptions. Frequency of use signals both the severity of the problem and the potential for dependence. The full index covers 19 items. Searching "Pittsburgh Sleep Quality Index" will bring up self-assessment versions you can take on your own.

Real-World Sleep Hygiene: What Actually Works

Before turning to medication, psychiatrists typically start with sleep hygiene—adjustments to your sleep environment and habits. These changes alone are enough to resolve insomnia in many cases.

One example: a husband noticed his wife was struggling to fall asleep—not getting to sleep until after 2 a.m. and then sleeping poorly on top of that. He decided to investigate. He took a nap earlier in the evening so he'd be alert, then lay down beside her when she went to bed at 11:30 p.m. and observed through the night.

Within 10 minutes, she reached for her phone. He took it away. She started tossing and turning, so he asked what she was thinking about. She said her mind was full of worries and random thoughts. He told her to stop trying to clear her head and instead picture the two of them walking through a sheep farm they'd visited together. She was asleep shortly after.

Later, a motorcycle passed outside and she started grinding her teeth. He closed every window in the house and set the air conditioner to a gentle 80°F. The teeth grinding stopped. About two hours in, she began dry coughing—he realized the AC had made the air too dry, so he draped a thin scarf loosely around her neck. The coughing stopped, and she slept soundly until 6:30 a.m. She told him it was the best sleep she'd had all year.

This story is a near-perfect illustration of sleep hygiene principles in action: no screens in bed, cognitive redirection away from anxious thoughts, and optimizing for sound, temperature, and humidity. Two months later, she was still sleeping well.

Common Questions About Sleep, Answered

Should you stay in bed or get up when you can't sleep?

Get up—after about 20 minutes. Your brain needs to associate your bed with sleep, not wakefulness. If you lie there awake, you're training your brain to link the two, which makes the problem worse over time. Get out of bed, keep the lights dim, and do something calm—read a physical book, listen to quiet music. When you feel drowsy again, go back to bed.

And no phones. The moment light hits your eyes, melatonin drops and your brain shifts into alert mode.

Does lying with your eyes closed count as rest?

Partially. Your brainwaves do shift toward a resting state, and some physical fatigue can ease. But you won't get the benefits that come with actual sleep: memory consolidation, hormonal regulation, immune system recovery. The difference is similar to a phone in power-saving mode versus actually charging. That said, if you're facing a sleepless night, accepting that "eyes closed, brain resting" is the best available option—rather than catastrophizing—tends to make things more manageable.

When is the best time to go to sleep?

Biologically, somewhere around 11 p.m. As daylight fades in the evening, your brain starts releasing melatonin, peaking about two hours later. That's your natural sleep window. The problem is that screens, streaming, and social media all work against that window by suppressing melatonin right when it should be peaking.

That said, if your natural rhythm runs later—say, 1 a.m. to 8 a.m.—and you feel rested and function well, there's no need to force an earlier schedule. Consistency matters more than the specific hour.

Is it more important to keep a consistent bedtime or wake time?

Wake time, without question. Falling asleep at a consistent hour is hard to control—even medication doesn't always nail it. But waking up at the same time every day, whatever it takes, anchors your circadian rhythm and gradually pulls your sleep onset earlier. Your wake time is the lever that moves everything else.

Are naps okay?

Yes, but keep them to 20–30 minutes. Sleeping longer than that depletes your sleep pressure—the biological drive that makes you feel tired enough to fall asleep at night. Napping too long or too late in the day makes it genuinely harder to fall asleep when you need to. The same logic applies to exercise: physical activity builds sleep pressure, which is part of why it helps. Just avoid intense workouts close to bedtime, since the nervous system needs time to wind down afterward.

What about catching up on sleep over the weekend?

It helps with fatigue recovery in the short term, but it disrupts your circadian rhythm. Sleeping in on Saturday and Sunday shifts your internal clock, making it harder to fall asleep Sunday night—and setting you up for a rough Monday. Keeping your sleep schedule as consistent as possible across the week, including weekends, is genuinely better for your long-term sleep health. Irregular sleep patterns have also been linked to increased symptoms of depression and anxiety.

When Does Insomnia Actually Require Medication?

The clinical threshold for an insomnia diagnosis is currently set at three or more months of sleep difficulties occurring at least three nights per week. If problems have been going on for about a month, starting with sleep hygiene adjustments makes sense. If things haven't improved after another one to two months, medication becomes worth considering—especially if anxiety or depression is also present.

One important nuance: if someone has started to dread going to bed—if sleep itself has become a source of anxiety—that's a signal to consider medication even before the three-month mark. Anxiety about sleep feeds insomnia in a self-reinforcing loop. Getting someone a positive experience of sleep, even with pharmacological help, can break that cycle and make it easier to taper off medication later.

For people with a history of mood disorders—depression or bipolar disorder—insomnia can be an early warning sign of relapse. That warrants an especially attentive response.

Medication, when used appropriately, isn't a crutch—it's a tool for restoring the experience of being able to sleep, which is often the first step toward sleeping without it.