What are the treatment options for exacerbated anxiety and insomnia?

From the Guidelines

For worsened anxiety and insomnia, cognitive behavioral therapy for insomnia (CBT-I) should be considered as the first-line treatment, as it has been shown to improve global outcomes, sleep onset latency, and wake after sleep onset, with moderate-quality evidence supporting its effectiveness 1.

Treatment Options

When considering medication, a shared decision-making approach should be used to discuss the benefits, harms, and costs of short-term use of medications, as recommended by the American College of Physicians 1.

• For anxiety, selective serotonin reuptake inhibitors (SSRIs) like sertraline or escitalopram can be effective, but may take 2-4 weeks to reach full effect.
• For immediate anxiety relief, benzodiazepines like lorazepam or clonazepam can be used short-term, but their use should be limited due to dependency risks.
• For insomnia, non-benzodiazepine sleep aids like zolpidem or eszopiclone can be considered for short periods, or trazodone, which helps with both sleep and anxiety with less dependency risk.

Cognitive Behavioral Therapy

CBT-I can be performed in primary care and has various delivery methods, including individual or group therapy, telephone- or Web-based modules, or self-help books 1.

• The therapy consists of a combination of treatments, including cognitive therapy around sleep, behavioral interventions, and education on sleep hygiene.
• Stimulus control, relaxation training, and sleep restriction are also effective therapies for chronic insomnia, as outlined in the clinical guideline for the evaluation and management of chronic insomnia in adults 1.

Medication

When medication is necessary, the choice of drug should be based on the patient's response to the first treatment, with consideration of factors such as treatment history, coexisting conditions, and specific side effect profiles 1.

• Sedating low-dose antidepressants like trazodone, mirtazapine, or doxepin may be considered for patients with comorbid depression or treatment failures, but their efficacy as sleep aids is relatively weak.
• Mirtazapine is useful for patients with both anxiety and insomnia, as it improves sleep at lower doses and addresses anxiety at higher doses.

Conclusion is not allowed, so the answer just ends here.

From the Research

Treatment Options for Worsened Anxiety and Insomnia

• Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for anxiety disorders, including generalized anxiety disorder, social anxiety disorder, and panic disorder 2, 3, 4, 5
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are also effective for anxiety disorders, with some studies suggesting they may have greater efficacy than SSRIs at higher doses 6, 4
• Benzodiazepines may be used as a first-line treatment for panic disorder, but their use is often limited due to the risk of dependence and withdrawal 5
• Other treatment options for anxiety disorders include tricyclic antidepressants, monoamine oxidase inhibitors, and mirtazapine, although the evidence base for these medications is limited 5
• Cognitive-behavioral therapy (CBT) is a highly effective treatment for anxiety disorders, including panic disorder, and is often used in combination with medication 5

Medication-Specific Considerations

• Venlafaxine, a SNRI, is approved for the treatment of generalized anxiety disorder, social anxiety disorder, and panic disorder, and may have an ascending dose-antidepressant response curve 6
• Duloxetine, another SNRI, is approved for the treatment of major depressive disorder, generalized anxiety disorder, and fibromyalgia, and has a more balanced profile of binding to serotonin and norepinephrine transporters 6
• Milnacipran, a SNRI, is approved for the treatment of fibromyalgia and has a favorable pharmacokinetic profile, but may cause dose-dependent adverse effects such as dysuria and blood pressure elevation 6
• Levomilnacipran, the levorotary enantiomer of milnacipran, has a similar pharmacological profile to milnacipran but may have milder side effects within the approved dosing range 6

Considerations for Long-Term Treatment

• Long-term use of SSRIs may increase the risk of tachyphylaxis and discontinuation syndrome, and patients should be periodically monitored to reassess the risk-benefit ratio of remaining on the medication 2
• The decision to continue or discontinue an SSRI should be an active one, involving both the patient and prescriber, and should be revisited periodically 2
• Patients who remain on SSRIs for the long-term should have periodic monitoring to assess the safety, tolerability, and efficacy of the medication 2