Managing Insomnia in Patients Being Treated for ADHD
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for insomnia in patients with ADHD, followed by melatonin if needed, before considering other pharmacological interventions. 1, 2
Understanding Insomnia in ADHD
Insomnia is a common complication in ADHD treatment, particularly with stimulant medications which can cause delayed sleep onset. While non-stimulants may cause daytime sleepiness instead, sleep problems occur across all age groups with preschoolers and adolescents being more vulnerable to adverse sleep effects 2.
Treatment Algorithm
Step 1: Sleep Hygiene Optimization
- Maintain a regular sleep-wake schedule
- Avoid heavy meals and alcohol
- Create a sleep-conducive environment (dark, quiet, comfortable)
- Exercise regularly but not close to bedtime 1
- Consider adjusting ADHD medication timing (earlier administration of stimulants) 2
Step 2: Implement CBT-I Components
- Sleep hygiene education
- Stimulus control
- Sleep restriction
- Cognitive restructuring
- Relaxation techniques 1
Step 3: Consider Melatonin
- If sleep hygiene and CBT-I are insufficient, add melatonin (5mg)
- Research shows combined sleep hygiene and melatonin is safe and effective for initial insomnia in ADHD patients taking stimulants, with an effect size of 1.7 and mean decrease in initial insomnia of 60 minutes 3
Step 4: Consider Other Pharmacological Options
If the above measures fail, consider:
For sleep onset insomnia:
- Ramelteon 8mg
- Low-dose zolpidem 5-10mg (use lower dose in elderly)
For sleep maintenance insomnia:
- Low-dose doxepin 3-6mg
- Eszopiclone 1-3mg (lower dose in elderly)
- Suvorexant 10-20mg 1
Special Considerations
Light Therapy
- Morning light therapy has shown significant effects in adults with ADHD and sleep problems 4
Medication Adjustments
- Consider changing stimulant dose schedules or formulations
- For patients with significant sleep issues, switching to non-stimulant ADHD medications may be beneficial 2
Avoid or Use with Caution
- Benzodiazepines should be avoided due to risk of cognitive impairment and potential for worsening depression 1
- Doxylamine is not recommended due to poor efficacy and potential side effects 1
- Avoid alcohol use with sleep medications due to additive CNS depressant effects 1
Monitoring and Follow-up
- Use standardized measures like the Insomnia Severity Index (ISI) to track progress
- Schedule follow-up within 7-10 days of initiating treatment 1
- Monitor for resolution of sleep problems, which often improve over time with continued ADHD treatment 2
Common Pitfalls to Avoid
- Treating insomnia without addressing the timing of ADHD medications
- Relying solely on medications without implementing behavioral interventions
- Failing to recognize that most medication-induced sleep effects are mild and improve over time 2
- Not considering comorbid conditions that may contribute to sleep problems
The combination of sleep hygiene interventions and melatonin has demonstrated effectiveness specifically in ADHD patients with insomnia, making this approach particularly valuable in this population 3, 5. Systematic reviews support the use of sleep hygiene interventions to improve sleep quality in children with ADHD and sleep disturbance 5.