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. 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
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 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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