What is the best treatment approach for an elderly female with severe anxiety, depression, and insomnia?

Treatment of Severe Anxiety, Depression, and Insomnia in Elderly Females

Start with cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, followed by an SSRI (preferably sertraline or escitalopram) to address the depression and anxiety, recognizing that the SSRI may initially worsen insomnia but will ultimately improve all three conditions when combined with CBT-I. 1, 2

Initial Treatment Approach

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

The American College of Physicians and American Geriatrics Society mandate CBT-I as the initial intervention for chronic insomnia in older adults, with effects sustained for up to 2 years and superior long-term outcomes compared to medications alone. 1, 2, 3

CBT-I should include these specific components:

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time (sleep compression is better tolerated than immediate restriction in elderly patients) 2
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep/wake times 2
• Sleep hygiene modifications: Avoid caffeine/nicotine/alcohol in evening, ensure bedroom is cool/dark/quiet, avoid heavy exercise within 2 hours of bedtime 2, 3
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing 2, 3
• Cognitive restructuring: Address anxiety about sleep and maladaptive beliefs 2

Second-Line: Add SSRI for Depression and Anxiety

Once CBT-I is initiated, add an SSRI to address the severe depression and anxiety:

Sertraline is the preferred SSRI for elderly patients with comorbid anxiety and depression due to its superior efficacy for anxiety symptoms, low drug interaction potential (critical in elderly on multiple medications), and no required dosage adjustment based on age alone. 1, 4, 5

• Start sertraline at 25 mg daily (half the standard starting dose) to minimize initial anxiety exacerbation, then titrate to 50-200 mg/day as tolerated 4, 5
• Alternative option: Escitalopram 5-10 mg daily (shown effective when augmented with CBT for generalized anxiety disorder in older adults) 6
• Critical warning: SSRIs including sertraline can cause or worsen insomnia initially, which is why concurrent CBT-I is essential 2, 3

Medication Selection Rationale

The American College of Physicians guideline establishes that second-generation antidepressants show no difference in efficacy for treating accompanying anxiety and insomnia in depression, but sertraline demonstrated better efficacy for managing psychomotor agitation and anxiety compared to other SSRIs 1. Sertraline's low cytochrome P450 interaction potential is particularly advantageous in elderly patients who typically take multiple medications 4, 5.

When to Add Hypnotic Medication

Only consider adding a hypnotic if CBT-I combined with SSRI therapy has been unsuccessful after adequate trial (at least 4-6 weeks). 1, 2

If pharmacotherapy for insomnia becomes necessary:

• For sleep onset insomnia: Ramelteon or short-acting Z-drugs (zolpidem) 2
• For sleep maintenance insomnia: Suvorexant or low-dose doxepin 2
• For both onset and maintenance: Eszopiclone or extended-release zolpidem 2
• Start at the lowest available dose due to reduced drug clearance and increased sensitivity in elderly 2, 3
• Limit to short-term use whenever possible 1, 2

Critical Pitfalls to Avoid

Avoid benzodiazepines as first-line agents in older adults due to high risk of falls, cognitive impairment, and dependence. 2, 3

Additional medications to avoid:

• Over-the-counter antihistamines (diphenhydramine): Unfavorable risk-benefit profile in elderly 2
• Sedating antidepressants as monotherapy for insomnia (trazodone, mirtazapine, amitriptyline): Only use when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia and risks outweigh benefits 2
• Antipsychotics and anticonvulsants: Unfavorable risk-benefit profiles for primary insomnia 2

Do not prescribe long-term hypnotic pharmacotherapy without concurrent CBT-I trials whenever possible. 2

Monitoring and Follow-Up

• Assess treatment response every few weeks initially using sleep diaries and standardized scales (Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire) 1, 6
• Once stable, reassess every 6 months as relapse rate for insomnia is high 1
• Monitor for SSRI adverse effects: dry mouth, headache, diarrhea, nausea, initial insomnia worsening, somnolence, dizziness 4, 5
• If single treatment or combination is ineffective, consider other behavioral therapies, alternative pharmacological agents, or reevaluation for occult comorbid disorders 1

Expected Outcomes

The combination of CBT-I with antidepressant medication leads to:

• Increased response rates on worry reduction measures in the short-term 6
• Sustained remission that may allow discontinuation of long-term pharmacotherapy for many individuals 6
• Prevention of relapse when either medication or CBT is continued 6
• Improved quality of life and cognitive functioning compared to tricyclic antidepressants 5

This sequenced approach—CBT-I first, then SSRI, then hypnotic only if needed—maximizes long-term outcomes while minimizing medication-related risks in elderly patients. 1, 2, 6