What are the alternatives to benzodiazepines (BZDs) for treating anxiety and insomnia?

Alternatives to Benzodiazepines for Anxiety and Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for both anxiety and insomnia before considering any pharmacological alternatives to benzodiazepines. 1, 2

First-Line Non-Pharmacological Alternatives

• CBT-I is superior to pharmacotherapy in long-term outcomes for insomnia and has minimal adverse effects compared to medications 1
• Behavioral interventions that should be utilized as initial approaches include:
  • Stimulus control therapy 1
  • Sleep restriction therapy 1
  • Relaxation techniques 1
  • Multicomponent therapy (combination of behavioral techniques) 1
• Sleep hygiene education alone is insufficient but should be used in combination with other therapies 1

First-Line Pharmacological Alternatives for Insomnia

• Short-intermediate acting non-benzodiazepine benzodiazepine receptor agonists (BzRAs):
  • Zolpidem (10mg, 5mg in elderly) for both sleep onset and maintenance insomnia 2
  • Eszopiclone (2-3mg) for both sleep onset and maintenance insomnia 2
  • Zaleplon (10mg) for sleep onset insomnia 2
• Ramelteon (8mg), a melatonin receptor agonist, for sleep onset insomnia 2

Second-Line Pharmacological Alternatives

• Low-dose doxepin (3-6mg) for sleep maintenance insomnia 1, 2
• Sedating antidepressants when comorbid depression/anxiety is present:
  • Trazodone (though not recommended by some guidelines) 1, 3
  • Amitriptyline 1
  • Mirtazapine 1
• Suvorexant (orexin receptor antagonist) for sleep maintenance insomnia 2

First-Line Pharmacological Alternatives for Anxiety

• Selective Serotonin Reuptake Inhibitors (SSRIs):
  • Sertraline is particularly effective for generalized anxiety disorder with minimal drug interactions 4, 5
  • Other SSRIs like escitalopram or paroxetine 6
• Buspirone (not mentioned in the provided evidence but commonly used)

Not Recommended Alternatives

• Over-the-counter antihistamines (e.g., diphenhydramine) lack efficacy data and have safety concerns 1, 2
• Herbal supplements (e.g., valerian) and melatonin have insufficient evidence of efficacy 1, 2
• Older hypnotics including barbiturates and chloral hydrate 1, 2
• SNRIs like venlafaxine may increase blood pressure in patients with hypertension 6, 7

Treatment Algorithm for Insomnia

1. Start with CBT-I as first-line treatment 1
2. If pharmacotherapy is needed, select based on:
   • Symptom pattern (sleep onset vs. maintenance) 1
   • Patient factors (age, comorbidities) 1
   • Previous treatment responses 1
3. For sleep onset issues: consider zaleplon, ramelteon, or zolpidem 2
4. For sleep maintenance: consider eszopiclone, zolpidem, or low-dose doxepin 2
5. Monitor regularly for effectiveness and side effects 1
6. Use the lowest effective dose for the shortest duration possible 1

Treatment Algorithm for Anxiety

1. Start with CBT for anxiety as first-line treatment 4
2. If pharmacotherapy is needed, consider SSRIs like sertraline 4, 5
3. Monitor for effectiveness using standardized measures 4
4. Avoid benzodiazepines for long-term anxiety management 4

Important Clinical Considerations

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies 1, 2
• Medication should be tapered when conditions allow to prevent discontinuation symptoms 1, 5
• Patients should be educated about treatment goals, safety concerns, and potential side effects 1
• Regular follow-up is essential to assess effectiveness, side effects, and need for medication adjustments 1

Common Pitfalls to Avoid

• Using sedating agents without considering their specific effects on sleep onset versus maintenance 2
• Failing to consider drug interactions and contraindications 1
• Using over-the-counter sleep aids with limited efficacy data 1, 2
• Continuing pharmacotherapy long-term without periodic reassessment 1
• Prescribing SNRIs like venlafaxine to patients with hypertension 6, 7