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 or 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 found in cold medication, amphetamines used in ADHD), bronchodilators (eg, theophylline, albuterol), pain medication (eg, oxycodone), and antidepressants (eg, SSRIs).12 The 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.
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.3,8,12 Currently, the FDA has 11 approved drugs for the treatment of insomnia:
• Nonbenzodiazepines: eszopiclone, zolpidem, zolpidem ER, and zaleplon
• Benzodiazepines: estazolam, flurazepam, quazepam, temazepam, and triazolam
• A tricylic antidepressant: low-dose sinequan
• A 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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