What are the recommended short-term medications for anxiety and sleep disturbances?

From the Guidelines

For short-term anxiety and sleep disturbances, benzodiazepines and Z-drugs are commonly recommended, with a preference for Z-drugs due to their lower risk of dependence and withdrawal, as suggested by the most recent evidence 1.

Recommended Medications

• Benzodiazepines like lorazepam (0.5-2mg), alprazolam (0.25-0.5mg), or diazepam (2-10mg) can be taken as needed for anxiety.
• Z-drugs such as zolpidem (5-10mg), eszopiclone (1-3mg), or zaleplon (5-10mg) are specifically designed for sleep and have fewer morning hangover effects.

Key Considerations

• These medications should generally be limited to 2-4 weeks of use due to risks of dependence, tolerance, and withdrawal.
• For anxiety, taking the medication 30-60 minutes before anticipated stressful situations is effective; for sleep, taking it 30 minutes before bedtime is recommended.
• Side effects may include drowsiness, dizziness, and impaired coordination, so activities requiring alertness should be avoided while using these medications.

Evidence-Based Recommendations

• The 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines advise against the use of benzodiazepines or trazodone for treatment of chronic insomnia disorder due to their potential harms and adverse effects 1.
• A 2020 study published in The Lancet Psychiatry highlights the risks of dependence and withdrawal associated with benzodiazepines and Z-drugs, emphasizing the need for careful prescribing and monitoring 1.
• The American College of Physicians recommends the use of nonbenzodiazepine hypnotics, such as eszopiclone and zolpidem, for the treatment of insomnia disorder, but notes that the evidence for their effectiveness is limited to short-term studies 1.

From the FDA Drug Label

Alprazolam tablets are indicated for the management of anxiety disorder (a condition corresponding most closely to the APA Diagnostic and Statistical Manual [DSM-III-R] diagnosis of generalized anxiety disorder) or the short-term relief of symptoms of anxiety Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. Demonstrations of the effectiveness of alprazolam tablets by systematic clinical study are limited to 4 months duration for anxiety disorder and 4 to 10 weeks duration for panic disorder;

Short-term medications for anxiety and sleep disturbances include:

• Alprazolam (PO), which is indicated for the short-term relief of symptoms of anxiety, including anxiety or tension associated with the stress of everyday life. Key points:
• Alprazolam is effective for short-term use (up to 4 months for anxiety disorder and 4 to 10 weeks for panic disorder) 2.
• The medication should be periodically reassessed for usefulness in individual patients.

From the Research

Short-Term Medications for Anxiety and Sleep Disturbances

• Benzodiazepines are commonly prescribed for rapid relief of anxiety and insomnia symptoms, but they are linked to various adverse effects 3
• Non-benzodiazepine hypnotics, such as zolpidem, are often used as adjunctive treatment for insomnia, but they also have potential side effects, including an increased risk of falls and hip fractures 4
• Zolpidem has been associated with complex behaviors, such as sleepwalking, hallucinations, and increased suicidality, and its use should be decided on a case-by-case basis 4

Alternatives to Benzodiazepines

• Antidepressants are often favored over benzodiazepines for the treatment of anxiety disorders, but they can also cause disturbing adverse events and discontinuation symptoms 5
• Cognitive behavioral therapy for insomnia (CBT-I) is a recommended frontline sleep intervention, which can be used in conjunction with non-benzodiazepines or antidepressants 6
• Lifestyle and sleep interventions, such as sleep hygiene education, can also be effective in enhancing sleep in individuals experiencing anxiety 6

Guidance on Using Benzodiazepines

• Benzodiazepines should only be prescribed for short-term use, and treatment longer than 4 weeks should only be offered to patients who have maximally improved at 4 weeks 5
• The role of benzodiazepines in anxiety disorders should be reassessed, considering their efficacy, adverse effects, and potential for dependence and abuse 7