What medications are recommended for treating insomnia and anxiety?

Treatment of Insomnia and Anxiety

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for patients with both insomnia and anxiety, with pharmacological options added only when necessary. 1

First-Line Treatment: CBT-I

CBT-I is strongly recommended as the initial treatment for all adults with chronic insomnia disorder, with moderate-quality evidence showing improvement in:

• Global sleep outcomes
• Sleep efficiency
• Sleep quality
• Overall functioning

CBT-I components include:

• Sleep restriction therapy
• Stimulus control
• Cognitive therapy targeting dysfunctional beliefs about sleep
• Sleep hygiene education
• Relaxation techniques

Research shows that CBT-I is not only effective for insomnia but also equally effective in reducing anxiety symptoms compared to anxiety-focused treatments 2. This makes it an ideal first-line approach for comorbid insomnia and anxiety.

Pharmacological Options for Insomnia with Anxiety

When CBT-I alone is insufficient, pharmacological treatment may be added using a shared decision-making approach. The following medications are recommended based on symptom presentation:

For Sleep Onset Insomnia:

• Zolpidem: 10mg for adults, 5mg for elderly
• Zaleplon: 10mg
• Ramelteon: 8mg (well-tolerated with low abuse potential)

For Sleep Maintenance Insomnia:

• Doxepin (3-6mg): Effective for sleep maintenance with modest improvement in sleep onset
• Eszopiclone: 2-3mg (1mg for elderly patients)
• Temazepam: 15mg
• Suvorexant: 10-20mg

Important Considerations for Medication Selection

1. Safety profile:

   • Ramelteon has a favorable safety profile with low abuse potential
   • Low-dose eszopiclone (1mg) is preferred for elderly patients with fall risk
   • Avoid benzodiazepines in patients with conditions that may worsen with cognitive impairment

2. Duration of treatment:

   • Use the lowest effective dose for the shortest duration
   • Schedule follow-up within 7-10 days to evaluate response

3. Discontinuation:

   • Gradual tapering is recommended when discontinuing medications to prevent withdrawal symptoms

Treatment Algorithm

1. Start with CBT-I for all patients with insomnia and anxiety
2. Assess response after 4-6 weeks
3. If inadequate response, add appropriate medication based on:
   • Primary symptom (sleep onset vs. maintenance)
   • Patient age and comorbidities
   • Risk of side effects and drug interactions
4. Monitor and adjust treatment:
   • Evaluate efficacy and side effects
   • Consider tapering medication once stable improvement is achieved
   • Continue CBT-I techniques long-term

Cautions and Pitfalls

• Benzodiazepines should be avoided in patients with certain conditions due to risk of cognitive impairment and potential for worsening depression 1
• Higher doses of eszopiclone may increase risk of next-day impairment affecting driving and activities requiring alertness
• Doxylamine is not recommended due to poor efficacy and potential side effects, particularly in older adults
• Antidepressants (like trazodone) are often prescribed off-label for insomnia despite limited efficacy data 3
• When discontinuing medications, gradual tapering is essential to prevent withdrawal symptoms and rebound insomnia

Special Considerations for Anxiety

While treating insomnia in patients with anxiety:

• CBT-I has been shown to reduce both insomnia and anxiety symptoms 2, 4
• Sleep problems may persist after anxiety treatment, suggesting that CBT-I may be warranted during or after CBT for anxiety 5
• For patients with severe anxiety symptoms, addressing both conditions simultaneously may be necessary