Why Your Insomnia Patients Aren’t Getting Better (And What You’re Missing)

Psychiatrist and sleep medicine physician Nishi Bhopal, MD explains why chronic insomnia can persist despite sleep hygiene, medications, supplements, melatonin, and even CBT-I, outlining three commonly missed issues in clinical practice: misunderstanding insomnia-related hyperarousal and the patient’s learned relationship with wakefulness at night, the counterproductive effect of trying to force sedation, and targeting the wrong perpetuating factors. Using the 3P model and a case of a 34-year-old tech worker with worsening insomnia, she emphasizes focusing on what perpetuates insomnia rather than what triggered it, introduces the CSH framework (circadian patterns, sleep drive, hyperarousal) to guide targeted, simplified interventions, and highlights how clinician communication and expectations can reduce anxiety and rebuild patient confidence.

00:00 Why Insomnia Persists
00:41 Clinician Frustration Points
01:29 Maria Case Introduction
02:31 Hyperarousal And Learned Wakefulness
03:03 Stop Forcing Sedation
03:59 3P Model And Perpetuating Cycle
04:51 CSH Framework Overview
06:01 Key Questions And Maria Treatment
07:08 High Achievers Still Stuck
08:04 Communication And Next Steps

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