Treating Co-Morbid Sleep Problems with Psychiatric Disorders


For sleep problems in ADHD, a brief behavioral sleep intervention may be more effective, according to the first randomized controlled trial of the use of such an approach in children with ADHD.7 In addition to a sleep behavior management plan tailored to the child’s sleep difficulties, the approach teaches relaxation techniques to manage anxiety.

The “intervention improved not only sleep but ADHD symptoms, behavior, quality of life and daily functioning, such as getting ready for school and completing homework,” and teachers reported improved classroom behavior, study co-author Harriet Hiscock, MD, a researcher and pediatrician at Murdoch Childrens Research Institute in Melbourne, Australia, told Psychiatry Advisor.

Findings also support a non-pharmaceutical option for insomnia that co-occurs with various mental disorders: Cognitive-behavioral therapy for insomnia (CBT-I), which is recommended as the first line of treatment for primary insomnia. A 2012 review by University of Pennsylvania researchers concluded CBT-I is at least equally effective to common sleep medications, and that its effects may last longer.8 A study from the April 2014 issue of International Review of Psychiatry investigated the use of CBT-I in patients with depression, anxiety, PTSD, and substance-use disorders.9 The approach was found to be highly effective in reducing sleep problems, and it significantly reduced psychological symptoms.

The authors of the 2014 study believe there is enough evidence for clinicians to implement CBT-I into their practices, and there are several manuals available that detail how to use the intervention. The components most supported by research are: Stimulus control therapy to weaken associations of the bedroom with poor sleep; sleep restriction to limit time awake in bed that can worsen anxiety; relaxation training; and cognitive therapy to reduce maladaptive thoughts about sleep.

While sleep hygiene advice is often included in CBT-I, it is not considered an adequate treatment approach by itself. Study co-author Daniel Taylor, PhD, a professor and director of the Insomnia Research Laboratory at the University of North Texas, likens it to dental hygiene.

“It might be helpful to prevent a problem, but once the problem has started it is of little use. One issue is that people often mistake stimulus control for sleep hygiene,” he told Psychiatry Advisor

The former includes behaviors like not using the bedroom for any activities other than sleep or sex, while the latter includes habits like avoiding heavy meals, exercise, coffee and alcohol too soon before bed. “People with chronic insomnia have already tried all of the sleep hygiene tactics,” says Taylor. Adding CBT-I to treatment for co-occurring mental disorder could help improve patients’ sleep and psychological symptoms simultaneously.

Tori Rodriguez, MA, LPC, is a psychotherapist and freelancer writer based in Atlanta.


  1. Centers for Disease Control and Prevention. Insufficient Sleep Is a Public Health Epidemic. Retrieved March 4, 2015 from
  2. National Institutes of Health: National Heart, Lung, and Blood Institute. How Much Sleep Is Enough? Retrieved March 4, 2015 from
  3. National Alliance on Mental Illness. Mental Illnesses: Insomnia. Retrieved March 4, 2015 from
  4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 2013; 5th ed. Washington, DC.
  5. Tkachenko O, et al. Sleep difficulties are associated with increased symptoms of psychopathology. Experimental Brain Research. 2014; 232:1567-1574.
  6. McHugh RK, et al. Changes in sleep disruption in the treatment of co-occurring posttraumatic stress disorder and substance use disorders. Journal of Traumatic Stress; 2014; 27(1): 82-89.
  7. Hiscock H, et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ; 2015; 350:h68.
  8. Mitchell MD, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice; 2012; 13:40.
  9. Taylor DJ and Pruiksma KE. Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: A systematic review. International Review of Psychiatry; 2014; 26(2): 205–213.