Insomnia: sleep evaluation and treatment by video in Puerto Rico

Insomnia is a common sleep disorder: you struggle to fall asleep, wake up at night and cannot get back to sleep, or wake too early without feeling rested. It is more common in women and in older adults.

It can be short-term, lasting days or weeks, often from stress or a change in routine; or chronic, when it happens 3 or more nights a week for more than 3 months. Adults need 7 to 9 hours of sleep a night.

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A doctor visit has the same price for every age, with no membership. You pay by card when you request the visit, and you get a full refund if the clinic can’t see you. We do not bill insurance; the lab and the pharmacy charge separately. See all prices. The service is run by The Health Initiative, a nonprofit.

The most common signs are:

• Trouble falling asleep
• Waking up at night and not getting back to sleep
• Waking up too early
• Waking up tired, as if you had not slept
• Daytime sleepiness, trouble concentrating or irritability

Often there is more than one cause:

• Stress and worry: work, school, family, money or a loss. Worrying about not sleeping makes it worse too.
• Habits: irregular schedules, long naps, screens in bed, too little exercise, and caffeine, nicotine or alcohol.
• Your surroundings: noise, light or a hot room; in Puerto Rico, a hot night with no power and no fan is enough to keep you up.
• Shift work or travel across time zones.
• Health conditions: sleep apnea, thyroid problems, reflux, allergies, pain such as arthritis, an enlarged prostate, menopause, depression or anxiety.
• Medicines taken for other conditions.

In the long run, lifestyle and sleep-habit changes work best. Try this:

• Go to bed and get up at the same time every day, weekends included.
• Use your bed only for sleep: if you cannot fall asleep, get up, do something calm in dim light and go back when you feel sleepy.
• Keep the room cool, dark and quiet.
• Avoid caffeine, nicotine and alcohol near bedtime, and heavy late dinners.
• Exercise during the day and limit afternoon naps.
• Keep your phone and screens out of bed.
• Keep a sleep diary: when you went to bed, how long it took to fall asleep and how you felt the next day.

Cognitive behavioral therapy for insomnia (CBT-I). It is a 6- to 8-week program that helps you ease anxiety about sleep, learn to relax and reset your schedule so your bed means sleep again. The American College of Physicians (ACP) recommends it as the first treatment for chronic insomnia. If it suits you, we refer you.

In the United States and Puerto Rico, melatonin is sold as a dietary supplement, not a medicine, so the FDA regulates it less strictly. According to the NCCIH (NIH), it may help with jet lag after travel, but guidelines from the American Academy of Sleep Medicine (2017) and the ACP (2016) did not find enough evidence to recommend it for chronic insomnia.

The label is not always what is in the bottle: in a 2023 study cited by the NCCIH, 22 of 25 melatonin gummy products held a different amount than labeled, from 74% to 347% of the stated dose.

Watch out for children. The CDC estimated about 11,000 emergency department visits from 2019 to 2022 for children 5 and younger who ate melatonin unsupervised, often gummies. Store it out of reach and ask before giving it to a child.

If you are pregnant, take other medicines or have used it for weeks, tell the doctor: it is part of your sleep evaluation.

Many over-the-counter sleeping pills contain antihistamines, which make you drowsy but are not safe for everyone: they can leave you groggy the next day, and older adults need to be more careful with them. Ask before using them, especially if you take other medicines.

There are also prescription medicines for insomnia. None of them replaces sleep habits or therapy, and each has risks weighed against its benefits. After evaluating you, the doctor decides which treatment is appropriate and safe for you. If appropriate, the doctor prescribes and we send your prescription to your pharmacy.

A medicine sometimes prescribed for sleep is trazodone, an antidepressant that causes drowsiness. According to its FDA label, it is approved for depression, not insomnia, so using it for sleep is "off-label". The 2017 American Academy of Sleep Medicine (AASM) guideline suggests not using trazodone for chronic insomnia, and says everyone with chronic insomnia should first get cognitive behavioral therapy for insomnia (CBT-I).

Other antidepressants that cause drowsiness, such as mirtazapine and amitriptyline, are also sometimes used for sleep. They are not FDA-approved for insomnia either: using them for sleep is "off-label", and the doctor considers it only after evaluating you.

If you also have anxiety or depression along with poor sleep, tell the doctor: she evaluates your sleep and your mood in the same visit. See also online mental health care.

The doctor sees children of all ages by video; patients under 21 need a parent or legal guardian on camera for the whole visit, with ID. For children and teens, a set schedule and keeping screens out of the bedroom are the foundation. If your child snores loudly or stops breathing for moments during sleep, tell the doctor.

Insomnia is rarely an emergency, but some signs need help now. If you have thoughts of harming yourself, call or text 988 or call Línea PAS at 1-800-981-0023. In an emergency, call 911. See when to go to the ER.

• Thoughts of harming yourself or ending your life
• Chest pain or shortness of breath at night
• Falling asleep while driving or at dangerous moments
• Someone notices you stop breathing in your sleep and you are very sleepy during the day
• Confusion or major changes in behavior