Prescription for Anxiety or Insomnia
For anxiety, initiate alprazolam 0.25-0.5 mg three times daily, titrating cautiously to a maximum of 4 mg/day in divided doses; for insomnia, prescribe zolpidem 10 mg at bedtime (5 mg for elderly patients) as first-line pharmacotherapy, with cognitive behavioral therapy for insomnia (CBT-I) strongly recommended as the preferred initial treatment approach. 1, 2, 3
Insomnia Management
First-Line Treatment Approach
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended initial treatment before initiating pharmacotherapy, particularly in patients with cardiovascular disease or when long-term management is anticipated 3
- CBT-I includes stimulus control, sleep restriction, relaxation training, cognitive therapy, and paradoxical intention techniques 3
- Sleep restriction therapy initially limits time in bed to match total sleep time from baseline sleep logs, maintaining >85% sleep efficiency 3
Pharmacological Options for Insomnia
Short-to-intermediate acting benzodiazepine receptor agonists (first-line):
- Zolpidem 10 mg at bedtime (5 mg for elderly or debilitated patients) for sleep-onset insomnia; short-to-intermediate acting with proven efficacy in both transient and chronic insomnia 3, 2
- Eszopiclone 2-3 mg at bedtime (1 mg for elderly; maximum 2 mg in hepatic impairment) for sleep-onset and maintenance insomnia; no short-term usage restriction 3
- Zaleplon 10 mg at bedtime (maximum 20 mg) primarily for sleep-onset insomnia; shortest-acting option 3
- Temazepam for intermediate-duration action 3
Alternative agents if initial BzRA unsuccessful:
- Ramelteon 8 mg at bedtime works through melatonin receptors rather than GABA pathways, with no risk of dependence or abuse and minimal impact on mood stability 4
Sedating antidepressants (when comorbid depression/anxiety present or after BzRA failure):
- Trazodone (starting 25 mg daily, maximum 200-400 mg in divided doses) has little anticholinergic activity; use with caution in patients with premature ventricular contractions 3
- Low-dose doxepin 3-6 mg is FDA-approved for sleep maintenance insomnia with minimal risk of triggering mania in bipolar patients 4
- Mirtazapine (starting 125 mg twice daily) offers appetite stimulation and sleep benefits but is associated with weight gain; safe in cardiovascular disease 3
- Amitriptyline and trimipramine have more anticholinergic effects 3
Critical Prescribing Considerations for Insomnia
- Benzodiazepines and Z-drugs should be prescribed with extreme caution as approximately 50% of patients dispensed these medications continue treatment for at least 12 months, leading to tolerance, dependence, and withdrawal symptoms 3
- Hypnotics like zolpidem and eszopiclone may cause cognitive impairment and increase fall risk, particularly in elderly patients 3
- Over-the-counter antihistamines and melatonin are NOT recommended due to relative lack of efficacy and safety data 3, 4
- Barbiturates, barbiturate-type drugs, and chloral hydrate are NOT recommended 3
Long-Term Management
- Follow patients every few weeks initially to assess effectiveness, side effects, and need for ongoing medication 3
- Employ the lowest effective maintenance dosage and taper when conditions allow 3
- Medication tapering should be gradual: decrease by no more than 0.5 mg every 3 days; some patients require slower reduction 1
- Long-term administration may be nightly, intermittent (three nights per week), or as-needed 3
Anxiety Management
Generalized Anxiety Disorder
Alprazolam dosing (FDA-approved):
- Initiate at 0.25-0.5 mg three times daily 1
- Increase at 3-4 day intervals to achieve maximum therapeutic effect, up to maximum 4 mg/day in divided doses 1
- The lowest possible effective dose should be employed with frequent reassessment of continued treatment need 1
- Gradual discontinuation is mandatory: decrease by no more than 0.5 mg every 3 days to avoid withdrawal symptoms 1
Alternative anxiolytic options:
- SSRIs (particularly sertraline) are well-studied and safe in patients with coronary heart disease and heart failure, with lower QTc prolongation risk than citalopram or escitalopram 3
- Buspirone 5 mg twice daily (maximum 20 mg three times daily) is useful for mild-to-moderate agitation but may take 2-4 weeks to become effective 3
Panic Disorder
- Treatment may require doses of alprazolam greater than 4 mg daily; mean effective dosage is approximately 5-6 mg/day 1
- Initiate at 0.5 mg three times daily, increasing at 3-4 day intervals in increments of no more than 1 mg/day 1
- Distribute administration times evenly throughout waking hours on a three or four times daily schedule to lessen interdose symptoms 1
- Some patients may require up to 10 mg/day for successful response 1
Comorbid Anxiety and Insomnia
When insomnia and anxiety coexist, both conditions require direct treatment:
- Insomnia should be treated distinctly from comorbid anxiety, not merely as a symptom of the anxiety disorder 5
- The relationship is bidirectional: anxiety contributes to arousal that interferes with sleep, while insomnia exacerbates emotional dysregulation and amplifies worry 6
- CBT-I has been effective in improving both sleep and reducing anxiety severity, even without directly targeting anxiety 6
- Anxiolytic benzodiazepines are effective for insomnia associated with mild-to-moderate generalized anxiety disorder 7, 8
Medications to Avoid
- Monoamine oxidase inhibitors and tricyclic antidepressants have significant cardiovascular side effects including hypertension, hypotension, and arrhythmias 3
- Gabapentin and pregabalin require renal dose adjustment and carry risk of fluid retention, weight gain, and heart failure exacerbation 3
- NSAIDs should be avoided due to cardiovascular toxicity, renal toxicity, and increased bleeding risk 3
- Full-dose sedating antidepressants should be avoided in patients with suspected bipolar disorder as they may trigger manic symptoms 4
Patient Education Requirements
All prescriptions must be accompanied by education regarding: