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.

Combination therapy

Is a combination of pharmacotherapy and nonpharmacotherapy more effective than either alone in the treatment of anxiety disorders with insomnia? Combination therapy has not been addressed in studies of this particular patient population. Furthermore, the question has been minimally addressed even in the treatment of insomnia per se. Study findings suggest only modest differences in outcomes with a combination of therapies. Similar results were seen in a study that compared CBT with CBT plus zolpidem(Drug information on zolpidem). The 6-week acute study demonstrated a 60% response rate and a 40% remission rate; the group with the combination treatment did have a significant increase in sleep time of 15 minutes, but the researchers question the clinical significance of this isolated finding.²⁹

Summary

Anxiety disorders with comorbid insomnia are highly prevalent with potential negative consequences. Therefore, assess for insomnia with self-rating scales and careful clinical interviews. When appropriate, refer patients for polysomnography.

Insomnia should be treated aggressively with pharmacotherapy, nonpharmacotherapy (particularly CBT-I), or a combination. Some of the hypnotic treatments actually appear to facilitate successful therapy for the anxiety disorder.

Benzodiazepines and nonbenzodiazepines have a number of adverse effects and can lead to abuse and dependence. Patients with an anxiety disorder may be particularly vulnerable, especially those with a history of alcohol(Drug information on alcohol) and drug abuse. Treatment with benzodiazepine and nonbenzodiazepine hypnotics needs to be reassessed monthly. Alternatively, ramelteon, low-dose sinequan, and CBT-I should be considered because they have minimal adverse effects and no risk of abuse.

Successful treatment of insomnia is an important goal in patients with anxiety disorders. Both pharmacological and nonpharmacological interventions have response rates of approximately 60%.

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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,

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Treatment of Insomnia in Anxiety Disorders

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