Medication Recommendations for Sleep Disturbances in Patients with Anxiety Disorder, Addiction Tendency, and Family History of Glaucoma
Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as the first-line treatment for sleep disturbances in this patient, avoiding medications that could worsen glaucoma risk or lead to dependence. 1
First-Line Treatment: Non-Pharmacological Approach
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- Recommended as first-line treatment with high-quality evidence 1
- Components include:
- Sleep restriction therapy: Limiting time in bed to match actual sleep time
- Stimulus control: Associating bedroom only with sleep and sex
- Cognitive restructuring: Addressing negative thoughts about sleep
- Sleep hygiene education: Maintaining consistent sleep schedule, limiting daytime naps
- Relaxation techniques: Progressive muscle relaxation, guided imagery, diaphragmatic breathing
Additional Non-Pharmacological Approaches
- Regular physical activity (e.g., walking, Tai Chi) can improve sleep quality 1
- Consistent sleep-wake schedule
- Creating a comfortable sleep environment (quiet, dark, comfortable temperature)
- Limiting caffeine, alcohol, and nicotine, especially in the evening
Second-Line Treatment: Pharmacological Options
If CBT-I is insufficient after 4 weeks of consistent practice, consider limited medication options:
Recommended Medications
Low-dose doxepin (3-6mg)
- Effective for sleep maintenance 1
- Does not cause dependence
- No contraindication for glaucoma
Ramelteon (8mg)
- For sleep onset difficulties 1
- No addiction potential
- No contraindication for glaucoma
Medications to Avoid
Contraindicated Due to Glaucoma Risk
- Phentermine - Explicitly contraindicated in glaucoma 2
- Tricyclic antidepressants (except low-dose doxepin) - May worsen glaucoma
Contraindicated Due to Addiction Risk
- Benzodiazepines - High risk of dependence, tolerance, and withdrawal 1, 3
- Z-drugs (zolpidem, eszopiclone) - Risk of dependence and cognitive impairment 1
Use with Caution
- Trazodone - While sometimes used for insomnia, it has potential for side effects including dizziness and can interact with many medications 4
- SSRIs/SNRIs - While helpful for anxiety, they may worsen insomnia in some patients 5
Monitoring and Follow-Up
- Schedule follow-up within 7-10 days of initiating any medication 1
- Use the Insomnia Severity Index (ISI) to track progress 1
- Reassess every 4-6 weeks using standardized measures 1
- Monitor for:
- Treatment response
- Side effects
- Signs of dependence
- Changes in anxiety symptoms
- Any visual symptoms that could indicate glaucoma development
Special Considerations
Anxiety Management
- Anxiety itself can worsen glaucoma progression through increased intraocular pressure fluctuations and disc hemorrhage 6
- Consider addressing the underlying anxiety disorder with psychotherapy and/or appropriate medication
Glaucoma Risk
- Family history of glaucoma requires vigilance
- Regular eye examinations are recommended 2
- Patients considering any eye procedures should inform ophthalmologists about all medications 2
Addiction Risk
- Avoid medications with high dependence potential
- Consider using medications with no or minimal addiction potential
- If medication is needed, use the lowest effective dose for the shortest duration
Treatment Algorithm
- Start with comprehensive CBT-I (4-8 sessions)
- If insufficient response after 4 weeks:
- For sleep onset difficulties: Add ramelteon 8mg
- For sleep maintenance difficulties: Add low-dose doxepin 3mg
- If still insufficient:
- Consider referral to sleep specialist for further evaluation
- Consider polysomnography if sleep-disordered breathing is suspected
By following this approach, you can effectively manage sleep disturbances while minimizing risks related to glaucoma and addiction potential.