What medications can help with sleep and anxiety?

Medications for Sleep and Anxiety

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for chronic insomnia, and when anxiety is comorbid, SSRIs like sertraline combined with CBT-I provide the most effective approach for addressing both conditions simultaneously. 1, 2, 3

First-Line Treatment Approach

Non-Pharmacological Treatment (Start Here)

• CBT-I is the gold standard first-line treatment for chronic insomnia before any medication is considered, demonstrating superior long-term efficacy compared to pharmacotherapy with minimal adverse effects 1, 2, 3
• CBT-I components include stimulus control therapy, sleep restriction, cognitive restructuring of maladaptive sleep thoughts, relaxation techniques, and sleep hygiene education 1, 3
• For anxiety disorders, CBT should be implemented concurrently with any pharmacological intervention 4, 5
• Sleep hygiene education alone is insufficient but should be combined with other behavioral techniques 2, 3

When Anxiety is the Primary Problem

• SSRIs (particularly sertraline) are first-line pharmacotherapy for anxiety disorders and do not worsen sleep architecture when combined with behavioral interventions 4, 6
• Sertraline addresses both anxiety and associated sleep disturbances without the dependency risks of benzodiazepines 4, 6
• Avoid benzodiazepines as first-line treatment due to dependency potential, cognitive impairment, falls (especially in older adults), and worsening of sleep architecture long-term 2, 4, 3

Second-Line Pharmacological Options for Insomnia

When CBT-I Alone is Insufficient

Use the lowest effective dose for the shortest duration (typically 4-5 weeks maximum) 2, 3

For Sleep Onset Difficulty:

• Zolpidem 5-10 mg (5 mg in elderly) at bedtime 2
• Zaleplon 10 mg at bedtime 2
• Ramelteon 8 mg at bedtime (melatonin receptor agonist with no abuse potential) 2
• Triazolam 0.25 mg (not first-line due to rebound anxiety risk) 2

For Sleep Maintenance Difficulty:

• Eszopiclone 2-3 mg at bedtime 2
• Temazepam 15 mg at bedtime 2
• Low-dose doxepin 3-6 mg (particularly effective for sleep maintenance) 2, 3
• Suvorexant (orexin receptor antagonist) 2

For Comorbid Depression/Anxiety with Insomnia:

• Mirtazapine 7.5-30 mg at bedtime (sedating antidepressant) 1, 3
• Trazodone 25-100 mg at bedtime (though not recommended by some guidelines as monotherapy for insomnia) 1, 2

Medications to AVOID

Not Recommended Due to Safety/Efficacy Concerns:

• Over-the-counter antihistamines (diphenhydramine) - lack of efficacy data, daytime sedation, delirium risk especially in elderly 2, 3
• Antipsychotics as first-line - problematic metabolic side effects outweigh benefits 2, 3
• Long-acting benzodiazepines - increased risks without clear benefit 2
• Herbal supplements (valerian) and melatonin - insufficient evidence of efficacy 2
• Barbiturates and chloral hydrate - outdated with significant safety concerns 2

Treatment Algorithm

Step 1: Initial Assessment and Non-Pharmacological Intervention

• Implement CBT-I for all patients with chronic insomnia (≥3 nights/week for ≥4 weeks) 1, 3
• Continue for at least 4-8 weeks to evaluate effectiveness 3
• If anxiety is prominent, consider SSRI (sertraline) alongside CBT-I 4, 6

Step 2: Add Pharmacotherapy if CBT-I Insufficient

• For isolated insomnia without anxiety: Select medication based on sleep pattern (onset vs. maintenance) 2, 3
• For insomnia with anxiety: Continue SSRI, add short-term sleep medication if needed (zolpidem, eszopiclone, or low-dose doxepin) 2, 4
• Start with lowest effective dose 2, 3
• Limit duration to 4-5 weeks when possible 2, 3

Step 3: Reassessment and Adjustment

• Monitor regularly for treatment response, adverse effects, and potential misuse 2, 3
• Taper medications when conditions allow to prevent discontinuation symptoms 2
• Continue behavioral techniques even when using medications 2, 3

Critical Pitfalls to Avoid

• Never use benzodiazepines (including lorazepam) as first-line treatment - they carry significant risks of dependence, withdrawal, cognitive impairment, and falls, particularly in older adults 2, 4, 3
• Do not continue pharmacotherapy long-term without periodic reassessment - insomnia medications are FDA-approved for short-term use only 2, 3
• Avoid using sedating agents without considering sleep onset vs. maintenance pattern - medication selection should match the specific sleep complaint 2
• Do not prescribe sleep medications without implementing behavioral interventions - combining approaches provides better outcomes than medication alone 1, 3
• Never abruptly discontinue sleep medications - taper gradually to avoid rebound insomnia, anxiety, irritability, and other withdrawal symptoms 2

Special Considerations

Older Adults:

• Start with half the standard dose (e.g., zolpidem 5 mg instead of 10 mg) 2
• Higher risk for adverse effects including falls, cognitive impairment, and delirium 1, 2
• Particularly avoid antihistamines and long-acting benzodiazepines 2, 3

Patients with Substance Use History:

• Avoid benzodiazepines entirely due to high abuse potential 3
• Consider ramelteon (no abuse potential) or low-dose doxepin 2, 3
• Emphasize CBT-I as primary intervention 3

Monitoring Parameters:

• Assess for residual daytime sedation, memory impairment, and behavioral abnormalities including "sleep driving" with benzodiazepine receptor agonists 3
• Monitor for drug interactions, particularly with CYP3A4 inhibitors/inducers 7
• Check for signs of medication misuse or escalating doses 3