What medications can help with anxiety that contributes to insomnia?

Medications for Anxiety with Insomnia

For anxiety that contributes to insomnia, benzodiazepine receptor agonists (BzRAs) like zolpidem, eszopiclone, and zaleplon are the recommended first-line pharmacological treatments, with sedating antidepressants as second-line options. 1

First-Line Pharmacological Options

• Short to intermediate-acting benzodiazepine receptor agonists (BzRAs) are recommended as the initial pharmacological treatment for insomnia with anxiety 1
• Non-benzodiazepine options (Z-drugs) are preferred over traditional benzodiazepines due to their better safety profile and less disruption of sleep architecture 2:
  • Zolpidem (5-10 mg): Primarily for sleep onset insomnia; short to intermediate-acting 1
  • Eszopiclone (1-3 mg): Effective for both sleep onset and maintenance insomnia; intermediate-acting 1
  • Zaleplon (5-10 mg): Best for sleep onset difficulties; shortest-acting option 1
• Ramelteon (8 mg), a melatonin receptor agonist, is another first-line option particularly for sleep onset insomnia without the controlled substance risks 1

Second-Line Options

• Sedating antidepressants are recommended when first-line treatments fail or when comorbid depression exists 1:
  • Trazodone (25-100 mg): Though widely prescribed off-label, evidence for efficacy is limited 3
  • Mirtazapine (7.5-15 mg): Sedating at lower doses 1
  • Doxepin (3-6 mg): Particularly effective for sleep maintenance insomnia 1, 3
  • Amitriptyline (10-25 mg): Has significant anticholinergic side effects 1

Traditional Benzodiazepines

• While effective, traditional benzodiazepines have more concerns regarding tolerance, dependence, and side effects 1, 4, 5:
  • Temazepam (7.5-30 mg): Short to intermediate-acting 1
  • Lorazepam (0.5-2 mg): Intermediate-acting; may cause daytime anxiety 4, 6
  • Alprazolam (0.25-0.5 mg): Rapid tolerance development and rebound insomnia upon discontinuation 5

Important Clinical Considerations

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered first-line treatment before or alongside pharmacotherapy 1, 7
• When insomnia is comorbid with anxiety or depression, the insomnia should be treated directly rather than assuming it will resolve when the psychiatric condition improves 8
• All medications should be used at the lowest effective dose and for the shortest duration possible 1
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for pharmacotherapy 1

Special Populations

• For elderly patients, use reduced doses (e.g., zolpidem 5 mg) due to increased sensitivity to side effects 1, 7
• For patients with substance use history, non-benzodiazepine options may have lower abuse potential than traditional benzodiazepines 7, 2

Common Pitfalls to Avoid

• Avoid long-term use of any hypnotic medication without regular reassessment 1
• Do not use atypical antipsychotics (e.g., olanzapine, quetiapine) as first-line treatments for insomnia due to their significant side effect profiles 1, 7
• Over-the-counter sleep aids and herbal supplements are not recommended for chronic insomnia due to lack of efficacy and safety data 1, 3
• Avoid abrupt discontinuation of benzodiazepines or Z-drugs after prolonged use due to risk of rebound insomnia and withdrawal symptoms 1, 5