What treatment approach should be used for a patient presenting with symptoms of anxiety, depression, and insomnia?

Treatment Approach for Anxiety, Depression, and Insomnia

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) combined with an antidepressant that has favorable sleep-promoting properties, specifically mirtazapine 15-30 mg at bedtime, as this addresses all three symptom domains simultaneously. 1, 2, 3

Primary Treatment Algorithm

First-Line: CBT-I as Foundation

• CBT-I must be the cornerstone of treatment even when depression and anxiety are present, as it provides superior long-term efficacy compared to pharmacotherapy alone and addresses the perpetuating factors of insomnia 1, 2
• Implement sleep restriction therapy: limit time in bed to match actual total sleep time, maintaining sleep efficiency >85-90%, with weekly adjustments of 15-20 minutes based on sleep logs 1, 2
• Apply stimulus control: use bed only for sleep and sex; leave bedroom if unable to sleep within 15-20 minutes to break the conditioned arousal association 1, 2
• Include cognitive restructuring to address dysfunctional beliefs about sleep (e.g., "I can't sleep without medication," "My life will be ruined if I can't sleep") and catastrophic thinking about sleep loss 1, 2
• Provide sleep hygiene education: regular sleep-wake schedule, avoid caffeine/alcohol/nicotine before bed, optimize sleep environment 1, 2

Concurrent Pharmacotherapy Selection

For the antidepressant component, choose based on this hierarchy:

1. Mirtazapine 15-30 mg at bedtime (preferred first choice):

   • Blocks 5-HT2 receptors, directly improving sleep efficiency and architecture 2, 3
   • Produces significant shortening of sleep-onset latency and increases total sleep time 3
   • Addresses depression at full therapeutic doses (not undertreating like low-dose trazodone) 2, 3
   • Caveat: Associated with weight gain; counsel patients proactively 1

2. Trazodone 150-300 mg at bedtime (alternative if mirtazapine not tolerated):

   • Full antidepressant doses have 5-HT2 blocking properties 2
   • Minimal anticholinergic activity compared to tricyclics 1
   • Critical pitfall to avoid: Do NOT use low-dose trazodone (50-150 mg) as monotherapy—this undertreats the depression 1, 2

3. SSRIs (sertraline, escitalopram) ONLY if combined with specific insomnia management:

   • SSRIs stimulate 5-HT2 receptors, which can worsen insomnia and disrupt sleep architecture 3
   • If choosing an SSRI, you MUST address sleep-disrupting effects with either CBT-I or adjunctive short-term hypnotic 2, 3
   • Do NOT prescribe SSRIs/SNRIs without addressing their sleep-disrupting effects 2

Adjunctive Short-Term Pharmacotherapy for Insomnia (If Needed)

Only add if CBT-I plus appropriate antidepressant selection is insufficient after 2-4 weeks:

• Zolpidem 10 mg or eszopiclone 2-3 mg at bedtime for short-term use (weeks, not months) 1, 2
• Low-dose doxepin 3-6 mg specifically for sleep maintenance insomnia 1, 2
• Ramelteon for sleep onset insomnia 1
• Time-limit all hypnotics and reassess periodically—avoid long-term use without concurrent behavioral interventions 2

Managing Anxiety Component

• CBT-I itself improves anxiety symptoms in 40-50% of cases where insomnia is comorbid with anxiety 4, 5
• Mirtazapine or trazodone address anxiety through improved sleep and direct anxiolytic effects 6, 3
• If anxiety persists after 4-8 weeks, consider adding:
  • Cognitive behavioral therapy specifically for anxiety (combination treatment superior to either alone) 7
  • SSRI (sertraline, escitalopram) at therapeutic doses, but remember to manage sleep-disrupting effects 7
  • Avoid benzodiazepines for routine use—not recommended as first-line for anxiety disorders 7

Critical Clinical Pitfalls to Avoid

• Never use low-dose sedating antidepressants (trazodone 50 mg, mirtazapine 7.5 mg) as monotherapy—this undertreats depression 1, 2
• Never prescribe multiple sedating agents simultaneously (e.g., mirtazapine + zolpidem + benzodiazepine)—increases fall risk, cognitive impairment, and complex sleep behaviors 2
• Never treat insomnia with hypnotics alone without addressing underlying depression/anxiety—insomnia increases risk of episode recurrence and poor treatment response if left as residual symptom 5
• Never assume insomnia will resolve with antidepressant alone if using SSRIs/SNRIs—these worsen sleep architecture and require specific insomnia management 3

Expected Timeline and Monitoring

• CBT-I benefits emerge within 4-6 weeks, with continued improvement over 8-12 weeks 1
• Mirtazapine's sleep effects are immediate (within days), while antidepressant effects require 2-4 weeks 3
• Assess response at 4 weeks and 8 weeks using standardized measures for depression, anxiety, and insomnia severity 2
• If inadequate improvement after 8 weeks despite good adherence, add individual CBT for anxiety/depression rather than increasing medication doses 2

Special Population Considerations

• Elderly patients: Use lower medication doses; avoid benzodiazepines due to fall risk 2
• Patients with substance abuse history: Avoid benzodiazepines entirely 2
• Patients with bipolar disorder risk: Screen carefully before initiating antidepressants; use caution with sleep restriction therapy due to seizure risk 1, 2, 8

Maintenance and Duration

• Continue antidepressant for 6-12 months minimum after remission to prevent recurrence 1, 7
• CBT-I provides durable benefits that persist after treatment ends, unlike pharmacotherapy 1
• Taper hypnotics after 2-4 weeks once CBT-I and antidepressant effects are established 2