When Anxiety and ADHD Are Actually a Sleep Problem: Two Case Studies
One patient thought her antidepressant had stopped working. Another was certain she had adult ADHD. Both had an unaddressed sleep pillar — and both improved without any change in medication.
"My Antidepressant Stopped Working"
Jennifer, a marketing director in her early 40s, came to me because her SSRI seemed to have stopped working after four years of reasonable response. Her previous psychiatrist wanted to augment with a second medication. She was reluctant.
Her symptoms had worsened at exactly the same moment she started a demanding new role. She was averaging five and a half hours of sleep on weeknights and trying to recover on weekends — a pattern researchers call social jet lag, which the body experiences as crossing several time zones twice weekly. She scrolled her phone in bed nightly; the blue light was suppressing melatonin by up to 90 minutes. She had a nightly glass of wine, fragmenting her REM.
Her antidepressant hadn't stopped working. Her sleep had deteriorated to the point that no antidepressant could compensate for what her brain wasn't getting at night. Within eight weeks of addressing sleep alone — consistent wake time, no screens after 9:30pm, eliminating the wine — her PHQ-9 dropped by a clinically meaningful margin. Within four months she felt like herself. No medication change.
"I Think I Have ADHD"
Patricia, a teacher in her early 50s, came to me convinced she had adult ADHD. She couldn't finish tasks, lost track of conversations mid-sentence, felt scattered in a way that was new and alarming. She had read extensively about ADHD in women.
What emerged was something more specific. Patricia had been in perimenopause for two years and was waking two to four times per night, taking 20–30 minutes to fall back asleep each time. She had normalized this so thoroughly that she hadn't mentioned it to any other doctor. Her words: "I assumed everyone slept like this."
A sleep study confirmed moderate obstructive sleep apnea — dramatically underdiagnosed in women, particularly in perimenopause. With CPAP, her cognitive symptoms improved substantially within three months. She never needed a stimulant. Patricia didn't have ADHD. She had an untreated first pillar.
The Question Both Stories Raise
How many people are being evaluated — or medicated — for conditions that have a significant, unaddressed sleep component underneath them? If your sleep hasn't been examined carefully, it deserves to be, before anything else is added or changed.
