Sleep is fundamental to our mental and physical health. It affects how we think, feel, concentrate, manage stress and connect with the people around us. Yet for many women, a good night's sleep can feel frustratingly out of reach.
Perhaps you lie awake long after going to bed, your mind replaying conversations and tomorrow's responsibilities. Perhaps you fall asleep quickly but wake repeatedly through the night, disturbed by hot flushes, anxiety or vivid nightmares. You may wake early, exhausted, knowing you need more sleep but unable to return to it. Over time, the effects can extend far beyond the bedroom, affecting mood, memory, relationships, work and your ability to cope with everyday life.
Insomnia is often treated as though it is simply a problem with sleep habits. In reality, persistent sleep difficulties can have many different causes, and several may be present at the same time. Trauma, anxiety, ADHD, autism, hormonal changes, physical health conditions and medication can all influence sleep in different ways.
At The Somerville Clinic, we believe that treating insomnia begins with understanding the woman experiencing it. Rather than focusing solely on getting more hours of sleep, we take a comprehensive approach to understanding what is disrupting sleep, how it is affecting mental health and which treatments are most likely to help.
Why is sleep so important for mental health?
Sleep and mental health are closely connected. During sleep, the brain carries out processes involved in memory, learning, emotional regulation and recovery. When sleep is consistently disrupted, everyday challenges can become much harder to manage.
You may notice that you feel more anxious, irritable or emotionally sensitive after a poor night's sleep. Concentration may become difficult, small problems may feel overwhelming, and tasks that would normally be manageable may require considerably more effort.
Sleep deprivation can also affect motivation, decision-making and the ability to regulate emotions. For women already managing anxiety, depression, ADHD, autism or the demands of caring for others, these effects can be particularly difficult.
The relationship works in both directions. Mental health difficulties can disrupt sleep, while ongoing insomnia can contribute to worsening mood and anxiety. This can create a cycle in which worry about sleeping makes it harder to fall asleep, and the resulting exhaustion makes the following day more difficult.
Insomnia is therefore not simply a symptom to overlook while treating another condition. It deserves careful assessment in its own right, alongside consideration of the wider psychological, hormonal and physical factors affecting a woman's wellbeing.
Understanding the causes of insomnia in women
There is rarely one explanation for every woman's sleep difficulties. Understanding the pattern of insomnia, when it began and what may be maintaining it is an important first step towards effective treatment.
1. Anxiety, stress and feeling overwhelmed
For many women, bedtime is the first opportunity in the day to stop and think. Unfortunately, it can also be the moment when worries that have been pushed aside become impossible to ignore.
You may find yourself mentally reviewing the day, anticipating tomorrow's demands, worrying about your health or relationships, or feeling unable to switch off. Physical tension, a racing heart and a heightened sense of alertness can make it difficult to settle.
Women who spend much of the day managing competing responsibilities may find that their minds become busiest when the external demands finally stop. Over time, the bed itself can become associated with frustration, worry and the expectation of another sleepless night.
Treatment may need to address both the insomnia and the anxiety or overwhelm contributing to it. This could involve cognitive behavioural therapy, practical strategies for managing stress, treatment for an anxiety disorder where appropriate, and specific interventions to change the patterns that keep insomnia going.
2. Trauma, PTSD and nightmares
Trauma can have a profound effect on sleep. For women who have experienced abuse, violence, loss or other frightening events, the nervous system may remain on high alert even when there is no immediate danger.
Post-traumatic stress disorder (PTSD) can be associated with difficulty falling asleep, repeated waking, nightmares, intrusive memories and fear of losing control while asleep. Some people become anxious about going to bed because they anticipate distressing dreams or feel vulnerable when they are not fully alert.
These difficulties are not simply a matter of needing to relax. They may reflect a learned response to danger that requires sensitive, trauma-informed care.
Treatment should consider both the sleep problem and the underlying trauma. Depending on the individual's circumstances, this may include evidence-based psychological treatment for PTSD, specific approaches to recurrent nightmares, and carefully tailored insomnia treatment. It is important that therapy feels safe and appropriately paced.
Where nightmares are prominent, it is useful to explore their frequency, content, associated distress and relationship to trauma, medication or other mental health symptoms. Not all nightmares indicate PTSD, and a thorough assessment can help clarify what is happening.
3. Perimenopause, menopause and hormonal changes
Hormonal changes can be a major contributor to sleep difficulties during midlife. Some women notice that their sleep becomes lighter or more fragmented during perimenopause, even if they have previously slept well.
Hot flushes and night sweats may cause repeated waking. Changes in mood, anxiety, joint discomfort and genitourinary symptoms can also interfere with sleep. In addition, some women experience changes in concentration or emotional regulation that make the daytime consequences of poor sleep more noticeable.
It can be difficult to separate the effects of menopause from insomnia, stress, ADHD or anxiety because symptoms may overlap. A woman who feels exhausted and forgetful may assume that her concentration problems are entirely hormonal, when several factors could be contributing.
Assessment should explore the timing of symptoms, menstrual changes, vasomotor symptoms, mood, other health conditions and current medication.
Treatment depends on the individual's symptoms and medical history. Menopause hormone therapy (HRT) may be appropriate for certain menopause-related symptoms, including hot flushes and night sweats, after an assessment of its benefits and risks. Menopause-specific cognitive behavioural therapy may also help some women with sleep problems associated with menopause symptoms. These approaches can be considered alongside insomnia-specific treatment rather than assuming that one option will address every difficulty.
4. ADHD, autism and neurodivergence
Sleep difficulties are common among people with ADHD and autistic people, although experiences vary considerably.
Women with ADHD may struggle to disengage from stimulating activities, lose track of time in the evening or find that their minds become particularly active when they try to sleep. Difficulties with routines, time management and transitioning between activities can make a consistent sleep schedule harder to maintain.
Autistic women may experience differences in sensory processing, a need for predictability, difficulty transitioning from one activity to another or heightened sensitivity to light, noise, temperature and other environmental factors. Anxiety and the effort involved in navigating demanding social environments may also affect sleep.
For some women, sleep difficulties have been present since childhood. Others notice changes when work, caring responsibilities, stress or hormonal transitions increase the demands on their coping strategies.
A helpful approach recognises that generic sleep advice may not be sufficient. It may be more effective to adapt the environment, reduce sensory triggers, build predictable routines, make transitions easier and consider whether ADHD medication or other treatments are influencing sleep.
Where insomnia is persistent, it should still be assessed and treated directly. Having ADHD or being autistic does not mean that poor sleep is inevitable or that every sleep difficulty has the same cause.
5. Physical health conditions, including restless legs
Not every sleep problem originates in mental health. Physical health conditions can interfere with falling asleep, staying asleep or feeling refreshed in the morning.
Restless legs syndrome (RLS) is one important example. It causes an urge to move the legs, often accompanied by uncomfortable sensations that begin or worsen during periods of rest and are particularly noticeable in the evening or at night. Moving the legs may provide temporary relief, but the symptoms can make settling to sleep extremely difficult.
RLS can sometimes be associated with low iron stores, certain medications and other medical conditions. Where suspected, a clinician can assess symptoms and decide whether blood tests or further investigation are appropriate.
Other conditions that may affect sleep include obstructive sleep apnoea, chronic pain, thyroid disorders, reflux, breathing difficulties and conditions that cause frequent urination at night. Sleep apnoea, for example, can lead to repeated interruptions in breathing and unrefreshing sleep, even when someone believes they have slept for a reasonable number of hours.
Persistent daytime sleepiness, loud snoring, witnessed pauses in breathing, unusual movements during sleep or uncomfortable sensations in the legs should prompt further assessment where appropriate.
A comprehensive approach means considering whether the problem is insomnia itself, another sleep disorder, a physical health condition or a combination of these.
6. Medication and its effects on sleep
Medication can improve health and wellbeing, but some medicines can also alter sleep. Others may help one problem while unintentionally worsening another.
Stimulant medication used for ADHD, for example, may affect sleep in some people, particularly if the dose, formulation or timing is not well suited to their needs. Some antidepressants and other medicines can also contribute to insomnia, vivid dreams, restlessness or changes in sleep patterns. Conversely, certain medicines may cause daytime drowsiness or improve sleep while being prescribed for another condition.
The relationship between medication and sleep is not always straightforward. A medicine may be an important part of treating an underlying condition, and stopping it abruptly could cause harm or worsen symptoms.
A medication review should consider when sleep difficulties began, any recent changes in treatment, the timing of doses, potential interactions and the balance between benefits and side effects.
Sometimes adjusting the timing or dose, changing a preparation or reviewing an alternative treatment can help. These decisions should be made with the prescribing clinician rather than by stopping medication independently.
7. Depression and other mental health conditions
Depression can affect sleep in different ways. Some women struggle to fall asleep, others wake repeatedly, and some wake much earlier than intended and cannot return to sleep. Others sleep for long periods but still feel exhausted.
Insomnia can also coexist with bipolar disorder, eating disorders and other mental health conditions. Changes in sleep may occasionally be an early sign of a change in mental state, making it important to consider the wider clinical picture.
A detailed assessment helps distinguish between difficulties caused by insomnia, sleep changes associated with another condition and situations in which several problems need to be treated together.
The aim is not to assume that every sleep problem is psychological. It is to understand how sleep, physical health and mental health interact for that particular woman.
How is insomnia assessed?
A good assessment looks beyond the question of how many hours you sleep.
It explores what happens at night, how you feel during the day and what may be contributing to the problem. Depending on your circumstances, this may include:
Your sleep pattern, including time taken to fall asleep, night-time waking and early morning waking.
How long the problem has been present and how it affects everyday functioning.
Anxiety, depression, trauma, nightmares and other mental health symptoms.
ADHD, autism, sensory sensitivities and the impact of daily routines.
Menstrual changes, perimenopause, menopause and other relevant hormonal symptoms.
Physical health conditions, pain, restless legs and possible sleep apnoea.
Current medication, supplements, caffeine, alcohol and other substances that may affect sleep.
Previous treatments, what you have tried and what helped or made things worse.
A sleep diary can be useful for identifying patterns and understanding the relationship between routines, symptoms and sleep. Further investigations, such as blood tests or assessment by a sleep specialist, may be appropriate when the history suggests an underlying medical condition or another sleep disorder.
Insomnia that occurs at least three nights a week for three months or longer, with consequences for daytime functioning, may meet the criteria for chronic insomnia disorder. However, significant sleep difficulties deserve attention even when they have not lasted this long.
The purpose of assessment is to build a clear, individualised picture and use that understanding to guide treatment.
Treatments for insomnia: what can help?
The most effective treatment depends on what is causing or maintaining the sleep problem. For many women, the best results come from combining practical changes with targeted treatment for underlying health conditions and, when appropriate, psychological therapy or medication.
1. Sleep hygiene and lifestyle changes
Sleep hygiene refers to habits and environmental factors that support sleep. These measures can be helpful, although they are not always enough to treat persistent insomnia on their own.
Useful approaches may include:
Keeping a consistent wake-up time. A regular morning routine can help strengthen the body's sleep-wake rhythm.
Creating a comfortable sleep environment. Consider temperature, light, noise, bedding and other sensory factors that may disturb you.
Allowing time to wind down. A predictable evening routine can help create a transition between daytime demands and sleep.
Reviewing caffeine and alcohol. Caffeine can interfere with sleep, while alcohol may make you sleepy initially but disrupt sleep later in the night.
Finding a manageable approach to exercise. Regular physical activity can support sleep and general wellbeing, with timing and intensity tailored to the individual.
Getting appropriate daylight exposure. Natural light during the day, particularly in the morning, can support the body's circadian rhythm.
Reducing pressure around sleep. Trying increasingly hard to force sleep can increase frustration and arousal.
These changes should be realistic and suited to your circumstances. For a woman managing ADHD, an autistic woman with sensory sensitivities or someone caring for young children, a rigid evening routine may be impractical. The goal is to identify achievable changes rather than create another set of expectations to feel guilty about.
2. Cognitive behavioural therapy for insomnia (CBT-I)
Cognitive behavioural therapy for insomnia, usually called CBT-I, is a structured treatment designed specifically for persistent insomnia. It is an important first-line treatment for chronic insomnia and addresses the thoughts, behaviours and patterns that can keep sleep difficulties going.
CBT-I is different from general advice about sleep hygiene. It may include several components:
Stimulus control: helping rebuild the association between bed and sleep rather than wakefulness, frustration or worry.
Sleep scheduling: adjusting time in bed to support a more consolidated sleep pattern, with guidance from a suitably trained clinician.
Cognitive techniques: exploring unhelpful beliefs and fears about sleep, such as the feeling that one bad night will make the following day impossible.
Relaxation strategies: learning ways to reduce physical tension and mental arousal.
Sleep education: understanding sleep processes and how insomnia can become self-perpetuating.
CBT-I can help women who have struggled with insomnia for months or years. It may also be adapted to take account of coexisting anxiety, ADHD, autism, menopause symptoms or other health conditions.
For women with trauma-related sleep difficulties, the approach needs to be sensitive to their history and symptoms. Some elements of standard CBT-I, particularly those involving changes to time in bed, may need careful individualisation.
CBT-I is not currently provided by the clinic however our clinicians are trained in this modality and can use its principles to support your care. We would signpost to other services where we feel this would be of benefit.
3. Treating the underlying cause
Sometimes the most important step is to identify and treat another condition that is disrupting sleep.
For example, a woman experiencing night sweats and repeated waking during perimenopause may benefit from an assessment of menopause symptoms and discussion of appropriate treatments. Someone with PTSD and recurrent nightmares may need trauma-focused psychological treatment and specific support for nightmares. A woman with restless legs may need investigation of iron status or other contributing factors.
Similarly, treating anxiety, depression or ADHD effectively may improve sleep, although the relationship between these conditions and insomnia needs to be considered individually.
Where there is a possibility of sleep apnoea or another sleep disorder, further assessment or referral may be necessary. Treating presumed insomnia without recognising a different sleep disorder can delay appropriate care.
This is why a comprehensive assessment is so important: the treatment should follow an understanding of the problem, rather than assuming that every woman needs the same intervention.
4. Medication for insomnia
Medication can have a role in treating insomnia, particularly when symptoms are severe, persistent or causing substantial distress. The choice of treatment should take account of the underlying cause, other health conditions, current medication, potential side effects and the individual's preferences.
Medication should generally complement, rather than automatically replace, appropriate behavioural treatment and management of underlying causes. There are several options which can be considered for patients depending on their profile including Daridorexant which is a prescription medicine that may be considered for some adults with long-term insomnia.
5. Reviewing treatment over time
Sleep is not static. A treatment that works well during one stage of life may need reviewing when circumstances change.
Perimenopause, changes in work or caring responsibilities, new health conditions, alterations to medication and changes in mental health can all affect sleep. Follow-up appointments provide an opportunity to assess progress, identify side effects, reconsider the diagnosis if necessary and adjust the treatment plan.
For some women, a relatively short period of targeted support may be sufficient. Others may need ongoing monitoring or coordination between clinicians with different areas of expertise.
The aim is to avoid leaving women to manage persistent insomnia alone after an initial consultation or prescription.
Our approach at The Somerville Clinic
At The Somerville Clinic, we recognise that insomnia can be both a symptom of wider difficulties and a significant problem in its own right. We believe women deserve care that takes their sleep seriously and considers the whole clinical picture.
Our approach is centred on assessment, understanding and individualised treatment, led by a psychiatrist with extensive medical training and experience in women's mental health.
Our aim is to help you understand your sleep difficulties, find the right treatment and improve your wellbeing in a way that is safe, thoughtful and tailored to you.
If insomnia is affecting your quality of life, contact The Somerville Clinic to discuss your concerns and explore what support may be appropriate.
Further information
This article is for general information and does not replace an individual clinical assessment or medical advice. Medication and treatment decisions should be made with an appropriately qualified healthcare professional, taking account of individual circumstances, risks and preferences.
