Sleep is a "single-player experience." You have no idea how the person next to you sleeps, what they feel when they wake up, or whether your own fatigue is normal. Many of us cope with caffeine, alchohol, or supplements

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Meanwhile, patients with unrecognized sleep disorders cycle through clinics carrying diagnoses of treatment-resistant depression, anxiety, ADHD. Many get Seroquel for insomnia. Sleep may improve short-term, but the underlying disorder stays untreated.

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On this episode of Psychiatry Tomorrow, hosts Will Sauvé, MD, and Brittany Albright, MD, sat down with Avinesh Bhar, MD, a board-certified sleep and pulmonary physician who founded Sliiip, a telemedicine practice expanding access to sleep care. Dr. Bhar trained at Washington University under the neurology department—a distinction that shaped his approach—before launching his practice in 2020.

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Read on or listen to learn:

• Why psychiatrists are trained to sideline sleep complaints, and the patient harm that results
• How sleep apnea mimics anxiety, ADHD, and treatment-resistant depression
• The financial incentives that keep patients stuck in outdated testing models
• The question every clinician should ask: "Is insomnia the diagnosis or the symptom?"
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Why is sleep underemphasized in psychiatry?

Psychiatry training rarely equips clinicians to treat sleep with the same rigor as mood or psychosis, so sleep complaints are often managed superficially rather than as disorders in their own right.

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"In my training, you get taught very early on that if you allow your patient to talk about sleep, it'll turn into all you talk about, always and forever," Sauvé explains. "You're trying to do the 55-minute hour and it'll just overtake everything."

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The result: sleep becomes invisible.  Albright adds that patients often default to their psychiatrist to manage sleep issues, "but we are not well-equipped with our standard psychiatric residency training."

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"A lot of complaints we get from psych offices are, 'We normally send to the sleep doctor. They'll get a test that's negative. And then they send them back recommending Seroquel,'" Dr. Bhar says. "Anyone can tell you a test is negative. You don't need to be a sleep physician. The question is “yes, the test is negative; now what?"

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Why quality sleep care Is so hard to access

The U.S. has produced roughly 150 board-certified sleep medicine fellows per year for the last 12 years. This year marked the first class of 200. Many practicing sleep physicians were grandfathered in before 2011—and the science has accelerated significantly since then.

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The math doesn't work. Wait times stretch to 9–12 months. Even in major cities, a single sleep doctor may serve hundreds of thousands of patients. When you're the only option, there's no pressure to see patients quickly.

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"Healthcare is local," Bhar notes. "But maybe it shouldn't be. We're getting as many patients from big cities as from small towns, because there's still a monopoly. One sleep doctor for a million patients."

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Financial incentives compound the problem. Sleep physicians credentialed at local sleep labs get reimbursed roughly three times more for in-lab studies than for home sleep tests. "If I have a patient in front of me, how do I give them what they actually need and still serve my own needs?" Dr. Bhar asks. "That's the conflict."

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In-lab testing carries its own barriers. The "first night effect" skews results: patients wired up and videotaped in an unfamiliar room don't sleep normally. For patients with PTSD, anxiety, or psychosis, the environment can be actively harmful. Add high-deductible plans ($700–800 out of pocket), and many patients bail entirely.

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How do at-home diagnostics and treatment improve sleep care?

Home sleep testing correlates with in-lab results at over 90%. It allows multi-night testing, capturing a realistic baseline instead of a single stressful night. For patients who can't access a local sleep specialist or can't tolerate the lab environment, home sleep tests remove a major barrier.

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Telemedicine collapses shortages. Dr. Bhar founded Sliiip as a nationwide virtual sleep practice, offering insurance-covered consultations and home-based testing. Patients in underserved areas—or in major cities with 12-month waits—get the same access.

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"A lot of sleep can be handled easily by tele," Bhar says. "You need to be able to listen and care. You can manage a lot of that online."

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Why sleep apnea doesn't look like how you think

The stereotype is an overweight 65-year-old man, snoring on the couch. That's not the whole picture.

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Bhar diagnosed himself at 42. His symptoms: night sweats and morning anxiety. "I wasn't a loud snorer. I wasn't snoring, gasping—not the prototypical peacock model we have in our heads."

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Human skulls are now at their smallest in evolutionary history. Jawlines underdeveloped, tongues too large for the oral cavity. Sleep apnea is appearing earlier and in different presentations.

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Women often present with REM-dependent sleep apnea—breathing disruption that occurs specifically during REM sleep, when muscle tone is lowest. Because the standard AHI (apnea-hypopnea index) averages events across total sleep time, women can test below the diagnostic threshold while still experiencing significant dysfunction.

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"If you look at REM-specific data, they have positive results," Bhar explains. "Two to three in the morning is the bewitching hour. Track back to a 10pm bedtime—that's the third REM cycle. Your airway relaxes, collapses, you awaken with a stress response."

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The symptoms get misread: grinding teeth (often caused by airway instability), morning headaches, nighttime panic attacks. "Your mind's asleep, it's not anxious," Bhar says. "Unless you have a nightmare, that's the only reason to wake up in a panic. Otherwise, your airway's narrowing and your brain's waking you up to save your ass."

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When Is it an underlying sleep disorder, not depression, ADHD, or metabolic dysfunction?

Brittany sees the pattern constantly in her interventional psychiatry practice. "With almost every TRD patient, I refer them, and most of them are positive for obstructive sleep apnea. That's likely one of the contributing factors to their treatment resistance."

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The mechanism makes sense. If sleep apnea fragments sleep and triggers repeated stress responses overnight, patients wake with elevated baseline anxiety and impaired recovery. PHQ-9 scores stay elevated despite antidepressant optimization because the patient isn't sleeping—they're surviving.

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Over-the-counter fixes don't help either. Bhar suspects the recent studies linking melatonin to cardiovascular risk may reflect undiagnosed sleep apnea being masked rather than treated.

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ADHD gets tangled up the same way. Some patients arrive with longstanding diagnoses that don't fit—no clear childhood history, stimulants helping somewhat but not resolving the picture. Brittany sends them for sleep testing. "Lo and behold, they have sleep apnea. They get treated, and I've been able to remove the ADHD diagnosis and deprescribe stimulants."

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Bhar sees the same pattern in teenagers. Parents get diagnosed with sleep apnea, recognize the symptoms in their kids, and seek testing. Treating the underlying sleep disorder early—rather than defaulting to stimulants—can shift a young person's trajectory for decades.

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Metabolic overlap adds another layer. In Alrbright’s South Carolina practice, metabolic syndrome is more the rule than the exception among patients with major depressive disorder or PTSD. Sleep apnea, metabolic dysfunction, and psychiatric symptoms form a feedback loop, with causal arrows running both directions. Brittany uses a sleep apnea diagnosis as her "cheat code" for getting tirzepatide approved by insurance—particularly for patients with a BMI of 27–28 who wouldn't otherwise qualify.

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Even when patients on GLP-1s achieve dramatic weight loss, Bhar recommends follow-up sleep testing. Many abandon their CPAP assuming they're cured. They're often not; airway walls continue to soften with age, and the apnea can return.

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What about wearables like Oura Ring or Apple Watches?

Patients ask about Oura rings, Apple Watches, and Garmin devices constantly. Bhar's take: useful for trends, not diagnosis.

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Week-to-week comparisons can reveal patterns: remove caffeine for a week, track the difference. But a single bad night won't tell you why. Ironically alerts about sleep could make you more anxious about sleep, like performance anxiety to ‘just relax.’ And the "lack of deep sleep" alerts that send patients spiraling? Something is blocking that deep sleep. The wearable is showing a symptom, not a cause.

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"Lack of REM or deep sleep behooves an evaluation," Bhar says.

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If your Garmin judges you every morning, it might be worth finding out why.

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Is Insomnia the diagnosis or the symptom?

When asked what he'd add to every psychiatry residency with a magic wand, Dr. Bhar doesn't hesitate.

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"I would bring up this question: is insomnia the diagnosis or the symptom? When a patient uses the word 'insomnia,' untrained practitioners adopt it and run with it. But the patient's actually describing a symptom. And that symptom begs a workup."

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The DSM itself requires ruling out other contributing factors before diagnosing primary insomnia. Yet in practice, the word triggers treatment algorithms—start this medication or that one—rather than investigation.

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For psychiatrists looking to address sleep more effectively: the VA offers a free CBT-I app that outperforms many paid alternatives. It works best as an adjunct to evaluation rather than a standalone intervention. Multi-night home testing captures realistic baselines and avoids first-night effect artifacts, and it's far more accessible for patients with trauma histories, anxiety, or financial constraints.

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But the single most important shift is conceptual.

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"We have to pause and say: is insomnia the diagnosis, or is it the symptom?" Bhar says. "I think it's always a symptom first until proven otherwise."

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TL;DR

Sleep disorders hide behind psychiatric diagnoses. The U.S. trains too few sleep physicians. Financial incentives favor in-lab testing over accessible home alternatives. Sleep apnea presents differently than the stereotype—especially in women and younger patients—and mimics anxiety, ADHD, and treatment-resistant depression. Seroquel prescribed for sleep carries real TD risk. Melatonin may mask rather than solve problems. A sleep apnea diagnosis can unlock GLP-1 approval for borderline patients. Wearables show trends, not causes. The single most important question: is insomnia a diagnosis, or a symptom that demands investigation?

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About Dr. Avinesh Bhar

Dr. Avinesh Bhar is a board-certified pulmonary, critical care, and sleep medicine physician. He completed his pulmonary critical care fellowship at UT Memphis and his sleep medicine fellowship at Washington University in St. Louis, where training under the neurology department shaped his approach to sleep as more than a pulmonary subspecialty. After years in employed practice, he earned his MBA and founded Sliiip (sliiip.com), a telemedicine sleep practice designed to expand access to sleep care nationwide. Dr. Bhar manages sleep apnea, insomnia, restless legs syndrome, nightmare disorders, and other conditions through home-based testing and virtual consultations.

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Timestamped Show Notes:

[00:00:00] Introduction: Dr. Bhar's path from pulmonology to sleep medicine[02:19] Sleep as a "single-player experience" and why patients normalize dysfunction

[06:18] Psychiatry training teaches us to avoid deep sleep conversations

[07:09] Only 150 sleep physicians graduate annually; most were grandfathered in

[08:08] "The test is negative, now what?" The Seroquel referral loop

[09:22] Tardive dyskinesia case from quetiapine prescribed for sleep

[11:58] Financial conflicts in sleep medicine: in-lab vs. home testing

[14:05] Setting up virtual sleep medicine for accessibility

[16:44] Dr. Albright on 9-12 month waitlists and finding Dr. Bhar

[19:04] The deprescribing challenge: when patients don't want to stop meds

[21:43] Multi-night home testing vs. single-night in-lab studies

[22:53] Skulls at smallest size in evolution; REM-dependent sleep apnea in women

[24:06] The 2-3 AM wake-up: tracing the third REM cycle

[26:15] "Is insomnia a diagnosis or symptom?"

[27:01] Teeth grinding as a sign of sleep-disordered breathing

[28:13] Sleep apnea and addiction: the stimulant-alcohol cycle

[29:02] AI scoring trained on male patients; women get missed

[31:32] PTSD, metabolic syndrome, and sleep apnea overlap

[32:08] GLP-1s as "cheat code" for insurance approval

[34:07] Weight loss doesn't cure sleep apnea permanently

[35:38] Patients don't know what "well" feels like

[36:20] ADHD diagnosis removal after sleep apnea treatment

[38:09] Teenagers on stimulants: changing long-term trajectories

[38:54] Magic wand question: insomnia as diagnosis vs. symptom

[40:04] CBTI resources: the VA's free app

[43:45] Wearables: useful for trends, not diagnosis

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