What medications are used to treat insomnia associated with anxiety disorder?

From the Guidelines

Eszopiclone (1-3mg) at bedtime is a recommended treatment for insomnia related to anxiety, as it has been shown to improve sleep onset and sleep maintenance insomnia in adults, according to the American Academy of Sleep Medicine clinical practice guideline 1. When considering treatment options for insomnia related to anxiety, it's essential to weigh the benefits and risks of each medication.

• Benzodiazepines like temazepam (15-30mg) can help with both anxiety and sleep, but their use should be limited to 2-4 weeks due to dependency concerns.
• Non-benzodiazepine sleep medications such as zolpidem (5-10mg) and zaleplon (5-20mg) are also effective options with fewer morning hangover effects.
• Antidepressants like doxepin (3-6mg) can address both anxiety and sleep issues, but their use may be limited by side effects. The most recent and highest quality study, published in 2020, advises against the use of benzodiazepines, trazodone, antihistamines, and antipsychotics for the treatment of chronic insomnia disorder due to their adverse effect profiles and limited benefits 1. In clinical practice, the treatment of insomnia related to anxiety should prioritize medications with a favorable risk-benefit profile, such as eszopiclone, and combine them with good sleep hygiene practices and cognitive behavioral therapy for insomnia (CBT-I) for a comprehensive approach. Key considerations include:
• Treatment duration and potential for dependency
• Side effect profiles and potential for adverse events
• Individual patient needs and medical history
• Combination with non-pharmacological therapies for optimal outcomes.

From the FDA Drug Label

5.3 Need to Evaluate for Comorbid Diagnoses Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated.

Medications to treat insomnia related to anxiety are not directly mentioned in the label. However, it is stated that sleep disturbances may be a manifestation of a psychiatric disorder, and zolpidem can be used to treat insomnia.

• Zolpidem may be considered for the treatment of insomnia, but it is crucial to evaluate the patient for comorbid diagnoses, including anxiety disorders, before initiating treatment.
• The label does not provide specific guidance on the treatment of insomnia related to anxiety, but it emphasizes the importance of careful evaluation and consideration of underlying psychiatric or medical illnesses. 2

From the Research

Medications for Insomnia Related to Anxiety

Medications for insomnia related to anxiety include:

• Controlled-release melatonin and doxepin, which are recommended as first-line agents in older adults 3
• The so-called z-drugs (zolpidem, eszopiclone, and zaleplon), which should be reserved for use if the first-line agents are ineffective 3
• Low-dose doxepin and the z-drugs, which can be considered for those who have difficulty staying asleep 3
• Suvorexant, a dual orexin receptor antagonist, which can be recommended for sleep maintenance insomnia 4
• Ramelteon, a melatonergic agonist, which can be recommended for sleep onset insomnia 4

Non-Recommended Medications

The following medications are not recommended for insomnia related to anxiety:

• Benzodiazepines, due to their high abuse potential and the availability of better alternatives 3, 5
• Sedating antihistamines, antiepileptics, and atypical antipsychotics, unless they are used primarily to treat another condition 3

Important Considerations

• The use of benzodiazepines and z-drugs should be limited to ≤4 weeks due to the risk of tolerance, dependence, and misuse 5
• The long-term use of benzodiazepines is associated with multiple consequences, including dependence and an increased risk of opioid use disorder 5
• Cognitive behavioral therapy for insomnia (CBT-i) is a recommended first-line treatment for chronic insomnia, with clinically meaningful effect sizes and no reported adverse outcomes 6