Treatment of Insomnia in Anxiety Disorders

By Gregory M. Asnis, MD, Elishka Caneva, MD, and Margaret A. Henderson, MD | January 5, 2012

Dr Asnis is Professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine and Director of the Anxiety and Depression Clinic of Montefiore Medical Center, Bronx, NY; Dr Caneva is a Psychiatry Fellow at the Anxiety and Depression Clinic of Montefiore Medical Center; Dr Henderson is Research Coordinator at the Anxiety and Depression Clinic of Montefiore Medical Center. Dr Asnis is Consultant for Bristol-Myers Squibb and has received grants in the past year from Forest Pharmaceuticals, Lilly, Otsuka, and Pfizer. Drs Caneva and Henderson report no conflicts of interest concerning the subject matter of this article.

Before beginning treatment of anxiety disorder–associated insomnia symptoms, rule out any concurrent medical illness, medication treatment, or substance use that might be inducing or worsening insomnia. Many medical illnesses, such as cardiovascular disorders (eg, congestive heart failure), pulmonary disorders (eg, emphysema), endocrinopathies (eg, thyroid disorders), GI disorders (eg, acid reflux), and neurological disorders (eg, pain syndromes), are associated with insomnia.¹²

Carefully assess the use of medications for medical and psychiatric disorders that may be implicated in insomnia as well as caffeine(Drug information on caffeine) or alcohol(Drug information on alcohol) use. Even small amounts of the latter have been associated with increased nighttime awakenings.

One should be highly suspicious of alcohol or substance use or abuse in patients with anxiety disorders because these are frequently comorbid.⁴ Various medications are associated with insomnia, including psychostimulants (eg, ephedrine(Drug information on ephedrine) found in cold medication, amphetamines used in ADHD), bronchodilators (eg, theophylline(Drug information on theophylline), albuterol), pain medication (eg, oxycodone(Drug information on oxycodone)), and antidepressants (eg, SSRIs).¹²The latter category is particularly important because many antidepressants are FDA-approved and are prescribed for anxiety disorders.

Before providing any significant intervention for insomnia, a careful evaluation regarding behaviors that might contribute to insomnia should be made. Daytime naps, late nighttime snacks or meals, watching television in bed, nighttime exercise, or excessive light or loudness in the bedroom should be identified and modified. Eliminating these behaviors can lead to significant sleep improvements. A 13-item self-rating questionnaire by Mastin and colleagues¹⁷ can help elicit sleep hygiene information.

Pharmacological options

The treatment of insomnia in patients with anxiety disorders is, for the most part, the same as the treatment of insomnia per se: pharmacological, nonpharmacological, or a combination of the two.

The primary treatment of insomnia is pharmacological because of the rapid onset of action (eg, hypnotics are usually effective within days to 1 week of use). The most common nonpharmacotherapy, cognitive-behavioral therapy for insomnia (CBT-I) takes considerably longer.^3,8,12Currently, the FDA has 11 approved drugs for the treatment of insomnia:

• Nonbenzodiazepines: eszopiclone, zolpidem(Drug information on zolpidem), zolpidem ER, and zaleplon(Drug information on zaleplon)

• Benzodiazepines: estazolam, flurazepam(Drug information on flurazepam), quazepam, temazepam, and triazolam

• A tricylic antidepressant: low-dose sinequan

• A melatonin(Drug information on melatonin) agonist: ramelteon

In recent years, nonbenzodiazepines have become the most recommended of the approved hypnotics. (There has been less and less reliance on benzodiazepines.) Not only are nonbenzodiazepines effective in treating insomnia (equivalent to the benzodiazepines), but there is a notion that they are safer than benzodiazepines.^3,12

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by Chevies Newman | September 18, 2012 8:42 AM EDT

Sorry, this is a passionate topic: At home sleep testing is available, easy to administer and reimbursable. A full poly sonogram is not needed by most, you need to know if they have apnea. If not snoring loudly, waking up in a pool of sweat, etc, remember about 1-2% of people have it while 40-50% snore. If they have comorbid anxiety, good luck with the mask. If it helps them with compliance, a low dose benzo is worth the risk.
If there is no apnea and a person cannot sleep on 10 mg Ambien and 2 my clonazepam, I start looking at bipolar spectrum. In this case seroquel will get the job done. I'm not sure the 60% number is accurate if someone is actively managed. Last point is that you may need to nail the daytime fatigue; Modafanil or it's more potent cousin may help some to sleep better at night by helping the circadian rythm disturbance. Of course this is in combination and using a dimensional approach.

by Chevies Newman | September 18, 2012 8:29 AM EDT

Most insomnia is nightime hyperarousal as a result of anxiety. Certainly benzodiazepines can be abused, but this is generally by those who have a history of abuse. Anxiety has two main medical treatments, benzodiazepines and ssri/snri's. Zolpidem may be helpful for some, that's great. A long standing history of anxiety plus zolpidem can result in a bad experience; it turns off the ignition without turning off the engine. Sleep related Bruxism, night terrors in children, REM sleep disorder- clonazepam. Certainly tolerance can develop. When part of a comprehensive plan, including Other treatment of mood and anxiety, a long acting benzodiazepine for sleep is more helpful than not for most who suffer. According to Steven Stahl, only 30% of people treated for mood or depression get complete remission with one drug; what's left, insomnia, daytime fatigue and pain out of proportion to tissue damage. Zolpidem has very little sedative capacity. It doesn't help relieve muscle spasm. If concerned, use a combination, say 5 mg Ambien with 1 mg clonazepam. It works better than the cr in my experience. There are differences between abuse, dependence and addiction. To be dependant on a benzo for sleep is not
addiction. Many are dependant on Meds for blood pressure, no qualms about it. Anxiety is usually a chronic problem requiring chronic treatment. Using benzodiazepines judiciously, at night for sleep, is reasonable and will
be more efficacious if part of a regimen. Most will not abuse the drug and the part of the issue with anxiety may
be a problem in the receptor; too few or otherwise not functioning properly. After stabilization, monthly reassessment will leave many people undertreated. These schedule 4 medications, for most, do not require monthly assessment. Mr Dym, you may have bipolar depression; there are many medications available, make sure the psychiatrist is exploring these.

by Michael Dym | August 19, 2012 4:29 PM EDT

I have suffered chronic insomnia for many years. Unfortunately a therapist I had seen for many years only prescribed klonipin(that was also encouraged by the sleep specialist I saw at the time) , which was the only drug that helped to get me 5 hours of sleep, at which point I would down coffee in the AM, and function........Unfortunately 2. 5 years ago, the klonipin stopped working, and then mood disorder exploded, as well as severe depression and worsening daily panic attacks and anxiety......Unfortunately medications have yet to help the depression and the sleep/anxiety remain awfu.......I feel like I am dying and I am a medical professional who has no gas left in the tank. The behavioral stuff has not worked for the sleep,

Treatment of Insomnia in Anxiety Disorders

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