What treatment options are available for a 17-year-old with Attention Deficit Hyperactivity Disorder (ADHD) experiencing insomnia, who has had adverse effects from trazodone (triazolopyridine) and mirtazapine (Remeron), specifically daytime fatigue?

Management of Sleep Disturbances in a 17-Year-Old with ADHD

For a 17-year-old with ADHD experiencing sleep maintenance insomnia who has experienced daytime fatigue with trazodone and mirtazapine, cognitive behavioral therapy for insomnia (CBT-I) should be initiated as first-line treatment, with melatonin as a safer pharmacological alternative if needed. 1

Non-Pharmacological Approaches (First-Line)

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• Implement a comprehensive CBT-I program including:
  • Sleep consolidation/restriction
  • Stimulus control (using bed only for sleep)
  • Regular sleep schedule
  • Sleep hygiene education
  • Relaxation techniques
  • Cognitive restructuring to address anxiety about sleep

Sleep Hygiene Modifications

• Maintain consistent sleep-wake schedule (even on weekends)
• Limit daytime napping
• Ensure comfortable sleep environment (dark, quiet, cool)
• Avoid caffeine, alcohol, and electronic devices before bedtime
• Regular physical activity (but not within 2 hours of bedtime)

Pharmacological Options (Second-Line)

Melatonin

• Consider low-dose melatonin (1-3mg) 1-2 hours before bedtime
• Advantages:
  • Safer alternative to prescription medications
  • Small but consistent effects on sleep latency
  • Lower risk of daytime sedation compared to trazodone/mirtazapine 1

ADHD Medication Adjustments

• Consider timing of ADHD medications, as stimulants can contribute to sleep difficulties 2
• Options include:
  • Earlier administration of last stimulant dose
  • Switching to a shorter-acting formulation for afternoon dose
  • Exploring non-stimulant options like guanfacine or clonidine that may actually help with sleep 3

Alternative Medications if Needed

• Low-dose doxepin (3-6mg) - has less daytime sedation than trazodone/mirtazapine
• Ramelteon (8mg) - melatonin receptor agonist with minimal daytime effects
• Avoid benzodiazepines and antihistamines due to risk of dependence and anticholinergic effects 1

Special Considerations for ADHD and Sleep

1. Medication Interactions: Stimulant ADHD medications commonly cause delayed sleep onset/insomnia, while non-stimulants like guanfacine may cause daytime sleepiness but can improve nighttime sleep 2

2. Timing Considerations: The patient's sleepiness pattern with trazodone and mirtazapine suggests sensitivity to sedating medications, which can interfere with daytime functioning and learning 4, 5

3. Monitoring: If initiating any medication, start at the lowest effective dose and reassess within 2-4 weeks for:

   • Improvement in sleep maintenance
   • Daytime alertness and functioning
   • Side effects, particularly daytime sedation
   • Impact on ADHD symptoms 1

4. Alpha-2 Agonist Option: Consider guanfacine as it may address both ADHD symptoms and sleep disturbances with "around-the-clock" effects, making it a potential first-line option for ADHD patients with comorbid sleep disorders 3

Pitfalls to Avoid

• Using sedating medications at too high a dose or administering them too late in the evening can worsen daytime functioning 5
• Methylphenidate can cause increased sleepiness a few hours after administration, which may impact learning 6
• Long-term use of sleep medications is generally not recommended; aim for the shortest duration necessary 1
• Trazodone, while effective for sleep maintenance, is associated with cognitive and motor impairments that may be problematic for a teenager with ADHD 4

If sleep disturbances persist despite these interventions, consider referral to a sleep specialist, particularly if sleep-disordered breathing is suspected.