What medications are effective for treating anxiety and insomnia?

Medications for Anxiety and Insomnia

For patients with anxiety and insomnia, first-line pharmacological treatment should include SSRIs or SNRIs for anxiety, while insomnia can be treated with eszopiclone, zolpidem, or suvorexant depending on whether sleep onset or maintenance is the primary issue. 1

First-Line Approach

For Anxiety:

• SSRIs (Selective Serotonin Reuptake Inhibitors)

  • Effective for anxiety disorders with fewer side effects than older medications
  • Examples: sertraline, fluoxetine, escitalopram
  • Sertraline has demonstrated efficacy across a broad spectrum of depression and anxiety 2

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

  • Effective for anxiety with an ascending dose-response curve
  • Examples: venlafaxine, duloxetine
  • Venlafaxine shows greater efficacy at higher doses and is approved for generalized anxiety disorder, social anxiety disorder, and panic disorder 3

For Insomnia:

Sleep Onset Insomnia:

• Zolpidem (10 mg): Effective for sleep onset and maintenance insomnia 1

  • Caution: Risk of next-day psychomotor impairment, especially if taken with less than 7-8 hours of sleep remaining 4
  • Avoid in patients with respiratory depression or severe hepatic impairment

• Zaleplon (10 mg): Specifically recommended for sleep onset insomnia 1

• Ramelteon (8 mg): Recommended for sleep onset insomnia with fewer next-day effects 1, 5

  • Good option for patients concerned about dependence potential

Sleep Maintenance Insomnia:

• Suvorexant: Orexin receptor antagonist effective for sleep maintenance 1

  • Moderate-quality evidence shows improved treatment response and sleep outcomes

• Eszopiclone (2-3 mg): Effective for both sleep onset and maintenance insomnia 1

• Doxepin (3-6 mg): Specifically recommended for sleep maintenance insomnia 1

Important Considerations and Cautions

Medications Not Recommended for Insomnia:

• Trazodone: Despite common use, guidelines suggest against using trazodone for insomnia 1

  • Increased risk of serotonin syndrome when combined with other serotonergic drugs 6
  • Risk of cardiac arrhythmias, especially when combined with other QT-prolonging medications

• Over-the-counter options not recommended by guidelines 1:

  • Diphenhydramine
  • Melatonin
  • L-tryptophan
  • Valerian

Drug Interactions and Special Populations:

• Avoid combining sedative-hypnotics with:

  • Alcohol or other CNS depressants (increased sedation) 4
  • CYP3A4 inhibitors (may increase drug levels)

• Use caution in:

  • Elderly patients (higher fall risk)
  • Patients with respiratory conditions (risk of respiratory depression) 4
  • Hepatic impairment (altered drug metabolism)

Treatment Algorithm

1. Assess primary symptom:

   • If anxiety predominates → Start with SSRI/SNRI
   • If insomnia predominates → Start with appropriate sleep medication based on type of insomnia

2. For comorbid anxiety and insomnia:

   • Begin with SSRI/SNRI for anxiety
   • Add appropriate sleep medication if insomnia persists after 2-4 weeks
   • Monitor for improvement in both conditions, as treating anxiety often improves insomnia 7, 8

3. Monitoring and follow-up:

   • Assess for adverse effects, particularly next-day impairment with sleep medications
   • Evaluate for improvement in both anxiety and insomnia symptoms
   • Consider dose adjustments based on response and tolerability

Clinical Pearls

• Insomnia is often comorbid with anxiety and depression, with 40% of patients with anxiety/depression reporting significant insomnia 7
• Treatment of underlying anxiety/depression can improve insomnia symptoms, though may not change total sleep time 7
• Short-term use of sleep medications is recommended (4-5 weeks) as FDA has only approved pharmacologic therapy for short-term use 1
• Consider cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment for chronic insomnia before or alongside pharmacotherapy 1