Insomnia is a common symptom in anxiety disorders, in fact it is a criteria for several DSM-IV Anxiety Disorders. It is important to inquire about sleep disturbance as part of the assessment for anxiety disorders, especially because there is clear evidence that the presence of insomnia in anxiety disorders is associated with increased morbidity. It is important to carefully assess for medical problems that could be causing or contributing to the insomnia, as well as side effects (from prescribed medications, alcohol and illegal drug use, and caffeine) that could be a contributing factor. It is also important to ask about sleep hygiene.
Treatment of insomnia related to anxiety includes pharmacological and non-pharmacological approaches. For most patients with co-morbid anxiety and insomnia, one should consider treating the insomnia separately, as treatment for anxiety traditionally with an SSRI or other antidepressant medication can take a few weeks to be effective. Several studies have shown that treating the insomnia concurrently helps improve the response of the anxiety disorder.
Currently, the FDA has several approved drugs for the treatment of insomnia: nonbenzodiazepines including eszopiclone (Lunesta), zolpidem (Ambien), zolpidem ER (Ambien ER), and zaleplon (Sonata); benzodiazepines including estazolam (Pro Som), flurazepam (Dalmane), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion); a tricylic antidepressant low-dose sinequan (Doxepin); an orexin inhibitor (Belsomra or suvorexant) and a melatonin agonist: ramelteon (Rozerem).
Both nonbenzodiazepines and benzodiazepines are associated with adverse effects that include fatigue, dizziness, ataxia, and the development of dependence and tolerance with long-term use. Belsomra also shares some of these concerns. If there is concern about alcohol or other substance abuse, consider ramelteon or low-dose sinequan to avoid potential issues of abuse and addiction.
Long-term use of nonbenzodiazepines or benzodiazepines needs to be reassessed monthly. Short-acting benzodiazepines like Xanax and Ativan are not effective medications for insomnia, particularly if sleep maintenance is an issue. Non-FDA approved options for insomnia include: Melatonin, Benadryl and Trazodone. Even though they are not FDA approved, they are good first line options because they can be used on a more long-term basis if needed.
Non-pharmacological approaches to treat insomnia related to anxiety are also well-studied. Cognitive behavioral therapy for insomnia (CBT-I) is a well studied therapy approach to treating insomnia but it is underutilized. Components of CBT-I include stimulus control, sleep hygiene, sleep restriction, relaxation techniques, and cognitive therapy. If one cannot find a therapist to help a patient with CBT-I, there are self-help books offering CBT-I that are also available, including “The Insomnia Answer” by Paul Glovinsky and Art Spielman and “Quiet Your Mind and Get to Sleep” by Colleen E. Carney and Rachel Manber.
Consider referral to a sleep specialist if treatment is not working and/or if a specific sleep disorder, like obstructive sleep apnea, periodic limb movements, narcolepsy or rapid eye movement behavior disorder, is suspected.
The goal of this article is to reiterate the importance of assessing for and potentially treating sleep disturbance that is related to anxiety. The treatment for insomnia specifically can help to see better outcomes for the treatment of the anxiety disorder as a whole.
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