What medication is recommended for a patient with anxiety and insomnia?

From the Guidelines

For patients with anxiety and insomnia, a combination approach is often most effective, starting with cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment, as recommended by the American College of Physicians 1.

Treatment Approach

• First-line medications for anxiety include SSRIs like sertraline (starting at 25-50mg daily, increasing to 50-200mg as needed) or escitalopram (5-20mg daily), which take 2-4 weeks to reach full effectiveness but provide sustainable anxiety relief.
• For immediate anxiety relief while waiting for SSRIs to work, short-term benzodiazepines like lorazepam (0.5-2mg as needed) can be used, but should be limited to 2-4 weeks due to dependence risk.
• For insomnia, non-benzodiazepine sleep aids like zolpidem (5-10mg at bedtime) or eszopiclone (1-3mg at bedtime) are effective for short-term use, as suggested by the American Academy of Sleep Medicine 1.
• Alternatively, suvorexant, an orexin receptor antagonist, can be considered for sleep maintenance insomnia, as recommended by the American Academy of Sleep Medicine 1.

Key Considerations

• Cognitive behavioral therapy should accompany medication treatment for both conditions.
• Patients should be monitored for side effects, particularly when starting SSRIs, which may initially worsen anxiety or sleep disturbances.
• Treatment should be individualized based on symptom severity, comorbidities, and previous medication responses.
• The American College of Physicians recommends a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1.

From the FDA Drug Label

Anxiety and Insomnia — In US placebo–controlled clinical trials for major depressive disorder, 12% to 16% of patients treated with Prozac and 7% to 9% of patients treated with placebo reported anxiety, nervousness, or insomnia. In US placebo–controlled clinical trials for OCD, insomnia was reported in 28% of patients treated with Prozac and in 22% of patients treated with placebo Anxiety was reported in 14% of patients treated with Prozac and in 7% of patients treated with placebo.

The medication fluoxetine (PO) may be used to treat patients with anxiety and insomnia, but it can also cause these symptoms as adverse events. The decision to use fluoxetine should be made with caution, considering the potential benefits and risks, including the possibility of worsening anxiety and insomnia in some patients 2.

• Key considerations:
  • Anxiety and insomnia are common adverse events associated with fluoxetine treatment
  • Fluoxetine may be effective in treating anxiety and insomnia in some patients, but it can also exacerbate these symptoms
  • Close monitoring of the patient's response to treatment is necessary to minimize the risk of adverse events.

From the Research

Medication Options for Anxiety and Insomnia

• The treatment of insomnia and anxiety can be complex, as these conditions often co-occur and have a reciprocal relationship 3.
• Cognitive behavioral therapy for insomnia (CBT-I) is considered the preferred treatment approach for insomnia due to its efficacy, safety, and durability of benefit 4.
• However, pharmaceutical treatments are also widely used for insomnia symptoms, and the choice of medication may depend on the presence of accompanying symptoms such as anxiety 5.

Pharmacological Management of Insomnia and Anxiety

• Second-generation antidepressants (SGAs) are often used to treat depression, anxiety, and insomnia, but the evidence guiding their selection based on accompanying symptoms is limited 5.
• Some studies suggest that SGAs such as selective serotonin reuptake inhibitors (SSRIs) may be effective in treating anxiety and insomnia, but the strength of the evidence is often moderate or low 5.
• Newer hypnotics have been shown to have a better safety profile and longer-term efficacy compared to older medications, but the decision to use long-term hypnotics should be individualized and balance the potential risks and benefits 6.

Considerations for Treatment

• The treatment of insomnia and anxiety should take into account the complex interrelationship between these conditions, and targeted therapeutic attention may be necessary to achieve optimal outcomes 3, 7.
• Non-benzodiazepines, antidepressants, lifestyle and sleep interventions, and cognitive behavioral therapy for insomnia may be considered as frontline sleep interventions for individuals experiencing anxiety 7.
• Novel non-invasive brain stimulation techniques may also be explored as a potential therapeutic target for reducing anxiety and improving sleep 7.