Still Unable to Sleep on a Sleeping Pill Plus Antidepressants, Dizzy on Standing and Feeling Low: Causes to Review With Your Psychiatrist, Why Not to Stop Medicines on Your Own, and Evidence-Based CBT-I and Breathing

From our readers: several medicines, still no sleep, and dizzy when walking

A member of a panic disorder support group shared that she had struggled to sleep for about a year despite taking a sleeping pill together with several antidepressant tablets.
She described migraine headaches, breathlessness, feeling faint when she got up to walk, and days when her mood suddenly dropped. In the comments, someone suggested stopping the medicines if they were not working.

Short answer: medicines that are not yet working are a signal to review them with your psychiatrist, not a signal to stop them yourself. Dizziness on standing calls for a lying-and-standing blood pressure check, and chronic insomnia responds to CBT-I even while you take medicines.
If your main problem is a racing mind at bedtime, see
Insomnia and Overthinking: CBT-I

1. Why several medicines may still not bring sleep

Direct answer: medicine is rarely the only issue. Chronic insomnia in panic disorder and depression usually has overlapping causes: an aroused brain, the type and timing of medicines, tolerance to sleeping pills, and other sleep disorders. The European guideline recommends a sleep study when insomnia does not respond to treatment.
(Riemann 2023)

An over-aroused brain (hyperarousal)

A 2023 review concluded that people with chronic insomnia show high-frequency brain waves during sleep, frequent brief awakenings and more sleep-related worry,
while evidence for heart rate or autonomic changes remains inconclusive
(Dressle 2023).
This state responds to treatment that changes thoughts and sleep behaviour, not simply to more medicine.

Medicine type and timing affect sleep

Some antidepressants are activating, such as fluoxetine and venlafaxine, and can make sleep harder at first, while sedating ones such as trazodone, mirtazapine and doxepin bring sleep quickly but may cause oversedation over time.
The effect depends on dose, timing and duration. Some antidepressants can also worsen restless legs, nightmares, or sleep apnoea through weight gain
(Wichniak 2017).

Sleeping pills work best short term

The European guideline limits benzodiazepines and Z-drugs to short-term use of up to 4 weeks and makes CBT-I the first-line treatment
(Riemann 2023).
A Cochrane review of 23 trials with 2,806 participants found that low-dose trazodone and doxepin slightly improved sleep quality in the short term, with no evidence for amitriptyline
(Everitt 2018).

Table: why sleep may still fail on medicines

Use this to prepare for your psychiatrist, not to adjust medicines yourself.

2. Feeling faint when you get up: check lying and standing blood pressure

Direct answer: in someone taking several psychiatric medicines, dizziness on standing should first raise the question of medicine-related orthostatic hypotension, then fast breathing during anxiety, eating little and drinking too little.

What orthostatic hypotension is

The international definition is a fall of at least 20 mmHg in systolic or at least 10 mmHg in diastolic blood pressure within 3 minutes of standing
(Freeman 2011).
Medicines are a common cause, and a medication review is the first step of care
(Rivasi 2020).

Which psychiatric medicines can lower blood pressure

SSRIs have little effect on blood pressure, while tricyclics, trazodone and MAOIs can cause orthostatic hypotension, and mirtazapine rarely does
(Calvi 2021).
Among 123 older adults, trazodone users had a larger drop on standing and fainted or fell in 58.3% vs 21.2%
(Rivasi 2025).
These figures come from older adults, so for other ages they serve only as a caution.

Fast breathing during anxiety also causes dizziness

Many people with panic disorder breathe fast enough to lower carbon dioxide in the blood, causing light-headedness and tingling in the fingers or around the mouth.
A trial in 41 people found that 4 weeks of breathing training with a carbon dioxide monitor brought levels back to normal and reduced panic symptoms
(Meuret 2010).

How to check at home

• Lie flat for 5 minutes, then measure blood pressure and pulse
• Stand up and measure again at 1 and 3 minutes, with someone beside you
• If systolic falls by 20 or more, diastolic by 10 mmHg or more, or you feel faint during the test, write it down and show your doctor
• Until your appointment, get up slowly, sit on the edge of the bed before standing, and drink enough fluids unless your doctor has restricted them
• If you faint or nearly fall often, avoid heights and driving until you have been checked

3. The medicines are not working: should you stop them yourself?

Direct answer: do not stop medicines abruptly on your own. Medicines that are not yet working should be reviewed with your psychiatrist, who may adjust the dose or timing, switch, or taper gradually.

How common antidepressant discontinuation symptoms are

A meta-analysis of 79 studies with 21,002 patients found at least one discontinuation symptom in 31% after stopping an antidepressant and 17% after stopping placebo.
Severe symptoms occurred in 2.8% vs 0.6%. The authors estimated that about 15%, or 1 in 6–7 people, have symptoms truly caused by the drug
(Henssler 2024).
Symptoms include dizziness, nausea, insomnia, irritability and brief electric-shock sensations.

Relapse after stopping

In a trial of 478 patients who felt well enough to stop, depression returned within 52 weeks in 56% of those tapered off versus 39% of those who continued
(Lewis 2021).
People who still have symptoms may get worse if they stop on their own.

Benzodiazepine sleeping pills must be reduced slowly

After long-term benzodiazepine use, stopping suddenly can cause rebound insomnia, anxiety, tremor and, in some people, seizures, so the dose should be reduced gradually under medical supervision
(Soyka 2017).

Table: stopping abruptly vs a planned taper

Generic drug names and drug classes, for education only.

What has been studied about tapering

Guidelines often taper antidepressants over 2–4 weeks, yet some people still have withdrawal symptoms. A 2019 review proposed tapering slowly over months, with smaller reductions as the dose gets lower
(Horowitz 2019).
Any such plan must be made with the prescribing doctor.

4. Preparing for your psychiatrist, CBT-I, and breathing with evidence behind it

Direct answer: bring your medicine and sleep details for a review, ask for CBT-I, which is first-line even with depression or panic, and use slow exhale-focused breathing as a support.

What to bring

• Every medicine, or photos of the labels, with the doses and times you actually take them
• A 2-week sleep diary: bedtime, time asleep, night waking, wake time and naps
• Lying and standing blood pressure readings, and when the dizziness happens
• How often you get headaches, and which painkillers you use
• Snoring, breathing pauses, leg jerks or restless legs at night
• Any thoughts of self-harm, stated plainly

CBT-I works even while you take medicines

A meta-analysis of 37 trials in people with psychiatric or medical conditions found insomnia remission in 36.0% vs 16.9%, with larger benefits for the other condition in psychiatric groups
(Wu 2015).
In a trial of 150 people with depression taking antidepressants, 7 sessions of CBT-I reduced insomnia severity more than a control therapy,
and depression remission was 44% vs 36%, a difference that was not statistically significant
(Manber 2016).
The American Academy of Sleep Medicine gives multicomponent CBT-I a strong recommendation and advises against sleep hygiene alone
(Edinger 2021).

Core CBT-I steps

• Get up at the same time every day, including weekends, and go to bed only when sleepy
• If you cannot sleep for about 20 minutes, get up, do something quiet in dim light, and return when sleepy
• Use the bed only for sleep; no phone in bed
• Limit time in bed to roughly the time you actually sleep, under a therapist’s guidance
• Write down worries in the early evening rather than thinking them through in bed
• No coffee after noon, and no alcohol as a sleep aid

Which breathing has evidence

A review of 15 studies found that slow breathing below 10 breaths per minute increased heart rate variability and reduced anxiety
(Zaccaro 2018).
A randomised trial of 5 minutes of daily breathwork for 1 month found that exhale-focused cyclic sighing improved mood and lowered breathing rate more than mindfulness meditation;
box breathing was also one of the tested exercises
(Balban 2023).

• If you feel faint, sit or lie down first; do not keep walking
• Breathe in through the nose, take a second short sip of air to fill the lungs, then breathe out slowly through the mouth, longer than the in-breath
• Practise 5 minutes a day when you are not panicking, so it comes easily when needed
• If your fingers or lips tingle, you are breathing too fast; slow down

5. When mood drops during sleepless nights: a safety plan and using your coverage

Direct answer: chronic insomnia makes low mood more likely and is linked to suicidal thoughts. Write a safety plan in advance and tell your psychiatrist every time.

Sleep and thoughts of self-harm

A meta-analysis covering 147,753 participants found insomnia and nightmares to be risk factors for suicidal thoughts and behaviours, even after accounting for depression
(Pigeon 2012).
Treating sleep is part of caring for mood.

A short safety plan

• Write your own warning signs, such as a sharp drop in mood, crying that will not stop, or recurring thoughts of death
• Write what helps you get through, such as a warm shower, a walk, or calling someone
• Name 2–3 people you can call, and let them know you might
• In Thailand the mental health hotline 1323 is open 24 hours; for emergencies call 1669
• If you worry about taking too much medicine, ask someone at home to keep it and hand out each dose

Using your health coverage in Thailand

• Psychiatric care and medicines are covered under the Universal Coverage scheme and Social Security at your registered hospital; ask 1330 or 1506
• Ask whether your hospital has a clinical psychologist or a CBT-I clinic; the European guideline also endorses digital CBT-I
• If your next appointment is far away but you are getting worse, call the hospital to ask for an earlier visit

Table: comparing approaches for insomnia with panic and depression

Generic drug names and drug classes only. Medicines must be started and adjusted under medical supervision.

Common beliefs vs the evidence

If the medicine does not work, just stop it

Not advisable. Stopping abruptly risks withdrawal symptoms and relapse; medicines that are not working should be reviewed with your doctor.

If you cannot sleep, take an extra sleeping pill

Not advisable. Adding pills yourself risks next-day drowsiness, falls, and slowed breathing when combined with other medicines or alcohol.

Insomnia means you are not trying hard enough

False. An over-aroused brain is a measurable mechanism, and it responds to CBT-I.

Box breathing fixes every kind of dizziness

False. Breathing helps symptoms from fast breathing but does not fix drug-related low blood pressure, which needs a medication review.

Once on antidepressants you are hooked for life

Antidepressants do not cause craving like addictive drugs, but the body adapts to them, so they need a gradual taper when it is time to stop.

Dizziness is just panic and needs no checks

Do not assume this. Lying and standing blood pressure, anaemia and the heart should be checked as your doctor sees fit.

Frequently asked questions (FAQ)

Why can I still not sleep on a sleeping pill plus antidepressants?

There are usually several overlapping causes, such as a chronically aroused brain and racing thoughts, an activating antidepressant taken in the evening, tolerance to long-used sleeping pills, or another sleep disorder such as restless legs or sleep apnoea. Your psychiatrist should review the type, dose and timing of each medicine rather than you adding more.

What can cause feeling faint when I get up to walk?

It may be orthostatic hypotension, which some antidepressants, sleeping pills, eating little and drinking too little can cause, or fast breathing during anxiety. To tell them apart, measure blood pressure lying down and again 1 and 3 minutes after standing. A systolic fall of 20 or a diastolic fall of 10 mmHg or more counts as orthostatic hypotension.

If the medicine feels useless, should I stop it myself?

Do not stop abruptly on your own. About 31% of people have at least one discontinuation symptom after stopping an antidepressant, and among people who stopped even after feeling better, depression returned in 56% versus 39% of those who continued. Long-used benzodiazepine sleeping pills also carry a seizure risk if stopped suddenly. Book your psychiatrist to adjust or taper gradually.

What are antidepressant discontinuation symptoms, and how dangerous are they?

Symptoms include dizziness, nausea, insomnia, irritability, brief electric-shock sensations and flu-like feelings. Most are mild and severe symptoms occur in about 2.8%, but they make it hard to tell withdrawal from relapse, so taper according to your doctor’s plan.

Does CBT-I help if I am already taking medicines?

Yes. CBT-I is the first-line treatment for chronic insomnia, including in people with depression or anxiety. A meta-analysis of 37 trials found insomnia remission in 36.0% versus 16.9% with control, and it can be combined with antidepressants.

Which breathing helps with palpitations and air hunger?

Slow breathing with a long exhale, such as breathing in through the nose, taking a second short sip of air, then breathing out slowly through the mouth for 5 minutes a day, improved mood and lowered breathing rate in a one-month trial. Box breathing also works, but it does not fix dizziness from low blood pressure.

What should I do if I feel very low or think about dying during sleepless nights?

Disturbed sleep is linked to roughly 2–3 times more suicidal thoughts and behaviours. If you are thinking about dying or planning to harm yourself, call 1323 or 1669 in Thailand, or go to the emergency department now, and ask someone close to stay with you.

What should I bring to my next psychiatrist appointment?

Bring every medicine or photos of the labels, a 2-week sleep diary, the times you take each medicine, when the dizziness happens, lying and standing blood pressure readings if you have them, and say plainly if you have thoughts of self-harm, so your doctor can review medicines and refer you for CBT-I.

Scientific mechanism

An over-aroused brain: in chronic insomnia the brain shows high-frequency activity during sleep, repeated brief awakenings, and sleep worry that feeds itself,
so the bed becomes a cue for wakefulness. CBT-I breaks this loop by re-linking the bed with sleep and building sleep drive
(Dressle 2023).

Medicines and blood pressure: some drug classes block alpha-1 receptors that tighten blood vessels when you stand, so blood pools in the legs, pressure falls, and the brain briefly receives less blood, causing faintness
(Calvi 2021).

Fast breathing: anxious fast breathing lowers blood carbon dioxide and slightly narrows brain blood vessels, causing light-headedness and tingling; slow breathing brings levels back toward normal
(Meuret 2010).

Withdrawal: with long antidepressant use the nervous system adapts to the drug; reducing too fast changes the system faster than it can readjust, causing withdrawal symptoms.
Small, gradual reductions let changes at the receptor happen step by step
(Horowitz 2019).

Compiled and reviewed by Asst. Prof. Dr. Norawit Raatpiboon

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