Therapeutics - Anxiety/Insomnia

what are the symptoms of GAD

-feeling nervous, anxious, frightened, worried, or on edge

-feeling panic or being frightened

-avoiding situations that make you anxious

why are antidepressants the drugs of choice for GAD

-tolerable side effects

-no risk for dependency

-efficacy in common comorbid conditions (MDD, panic disorder, OCD, SAD)

what antidepressants are used first line for the treatment of GAD

SSRIs or SNRIs

what medications are recommended for GAD if first-line treatment fails

-try a different SSRI or SNRI

-if that doesn't work, try another or switch to imipramine, buspirone, or pregablin

-if none of those work, try augmentation with a second-gen antipsychotic, another antidepressant, benzo, or psychotherapy

what is the MOA of benzos

enhance the transmission of GABA through interaction with the GABAa receptor complex

what is the MOA of buspirone

5-HT1a partial agonist (exerts its anxiolytic effects by reducing presynaptic 5-HT firing)

how does buspirone differ from the benzos

does not have abuse potential, cause withdrawal symptoms, or potentiate alcohol and sedative-hypnotic effects

what are the common side effects of benzos

CNS depressant effects (drowsiness, sedation, psychomotor impairment, ataxia) and cognitive effects (poor recall, anterograde amnesia)

which benzos are preferred for patients with reduced hepatic function secondary to aging or disease

lorazepam and oxazepam

how can someone improve their sleep hygiene

-keep a regular sleep schedule

-exercise frequently but not immediately before bedtime

-avoid alcohol and stimulants (caffeine, nicotine) in the last afternoon and evening

-maintain a comfortable sleeping environment that is dark, quiet, and free of intrusions

-avoid consuming large quantities of foods or liquids immediately before bedtime

how can someone improve their stimulus control

-go to bed only when sleepy

-avoid daytime naps

-if you cannot sleep within approximately 20 minutes, get out of bed and go to another room (only return to your bed when you feel the need to sleep)

-bed is for sleep and intimacy only (not eating or watching TV)

-wake up at the same time each day

what is the parent half life of eszopiclone

6 hours

what is the parent half life of temazepam

10-15 hours

what is the parent half life of zaleplon

1 hour

what is the parent half life of zolpidem

2-2.6 hours

what is the parent half life of zolpidem CR

2.8 hours

what are the most common adverse effects associated with benzos and non-benzo receptor agonists

-residual sedation into the waking hours after sleep

-grogginess

-psychomotor impairment

what are the antidepressant prescribed for insomnia

trazodone, amitriptyline, mirtazapine, and doxepin

what is the MOA of of ramelteon

melatonin receptor agonist

what is the MOA of suvorexant and lemborexant

orexin receptor antagonist (turn off wakefulness mechanisms instaed of stimulating pathways that induce sleepiness)