Treatments for Anxiety and Insomnia

Drugs for Anxiety and Insomnia

Introduction to Drug Classes

  • Benzodiazepines: Primarily for short-term use due to dependence risks.

  • Antidepressants: Often used due to shared neurotransmitters and comorbidity with anxiety.

  • Miscellaneous Anxiolytics: Anti-anxiety medications.

  • Barbiturates: Rarely used due to significant risks.

Understanding Anxiety: Definitions and Disorders

  • Anxiety (Medical Diagnosis):

    • Emotional response or behavior in the presence of stress.

    • Distinguished from typical situational stress (e.g., exams, public speaking).

    • Defined when tension or apprehension is above and beyond expected levels.

    • May lack an identifiable trigger.

    • Requires a negative effect on quality of life or measurable inability to function normally to be a medical diagnosis/disorder.

  • Situational Anxiety:

    • Presents due to a temporary stressor or situation, with an identified trigger.

    • Examples: moving, loss, starting school.

    • Can sometimes be motivating or stimulating but can impair daily function.

  • Generalized Anxiety Disorder (GAD): Prolonged anxiety for at least 6 months, difficult to control.

  • Obsessive Compulsive Disorder (OCD):

    • Caused by intrusive thoughts leading to repetitive thoughts, possibly behaviors.

    • Impacts daily function (e.g., repetitive hand washing).

    • Diagnosis can exist with intrusive thoughts alone, without the overt behavior.

  • Phobias: Fears disproportional to typical or expected reactions.

  • Panic Attack:

    • Sudden episode of intense anxiety or fear.

    • Includes physical symptoms: chest pain, diaphoresis (sweating), shortness of breath, feeling faint, sensation of impending death.

    • No actual threat identified; not a normal response to actual danger.

    • Triggers the autonomic nervous system's ("ANS") fight-or-flight response, similar to actual danger.

  • Panic Disorder: Frequent or recurrent panic attacks, leading to fear of unexpected attacks.

  • Post-Traumatic Stress Disorder (PTSD):

    • Result of experiencing a traumatic event (single or prolonged).

    • Symptoms include physical body symptoms and reliving trauma through dissociations or flashbacks.

    • Like other disorders, it impairs daily life function.

  • Social Anxiety:

    • Increased or excessive anxiety in social settings, related to fear or discomfort of social interactions.

    • May involve excessive worry about being judged.

  • Agoraphobia: Irrational fear of specific situations or places (e.g., crowds).

    • Social anxiety and agoraphobia are distinct but not mutually exclusive.

Insomnia and Sleep Disorders

  • Rebound Insomnia:

    • Occurs when individuals stop using insomnia medications for sleep.

    • The resulting insomnia is worse than the initial insomnia that prompted medication use.

    • Increases anxiety.

    • Reason why sleep aids are not recommended for long-term use: medications override the inherent sleep drive, which is difficult to restore.

General Drug Types for Anxiety and Insomnia Symptoms

  • Anxiolytics: Drugs that help decrease anxiety.

  • Antidepressants: Often used because neurotransmitters involved in depression (Norepinephrine, Serotonin) are also linked to anxiety symptoms.

  • Sedatives: Depress central nervous system ("CNS") responses.

  • Hypnotics: Higher doses of sedatives used to induce sleep.

  • Sedative-Hypnotics: Can be used for both anxiety and sleep, especially for individuals whose sleep is negatively impacted by anxiety.

  • "Tranquilizer": An antiquated term, no longer common in medical context.

Limitations of Medications and Holistic Approaches

  • Medications for anxiety do not cure it; they decrease symptoms and improve function.

  • Holistic, Long-Term Approach: Understanding anxiety, identifying triggers, and developing healthy coping mechanisms.

  • This approach often combines pharmacologic and non-pharmacologic interventions, or non-pharmacologic strategies alone.

  • Non-Pharmacologic Strategies (Examples):

    • Cognitive Behavioral Therapy ("CBT").

    • Other counseling/psychotherapy techniques.

    • Biofeedback.

    • Meditation or mindfulness training and exercises.

  • Rationale for Pharmacologic Intervention:

    • When stress is overwhelming and outpaces coping ability, leading to anxiety symptoms.

    • Medication can reduce the overwhelm to allow individuals to learn and implement coping strategies (e.g., learning geometry amidst chaos analogy).

    • Used when anxiety level negatively impacts daily functioning.

Other Therapeutic Classes for Anxiety Symptoms

  • Antidepressants and CNS depressants (already discussed).

  • Anti-seizure medications: Sometimes used.

  • Anti-psychotic medications: Sometimes used.

  • Anti-hypertensive drugs & Anti-dysrhythmic medications: May be ordered (discussion reserved for cardiovascular section).

Herbal Preparations

  • Used to promote sleep and/or induce calm.

  • Examples: Melatonin, Valerian root, Kava.

  • Importance: Be aware of significant interactions with prescribed medications.

  • Melatonin Specifics:

    • Current studies suggest short-term use (
      \le 3 months) is safe for adults.

    • Analog prescription drugs should not be used concurrently.

    • Not approved for use in children.

    • Considered relatively safe in appropriate doses for children, but these are significantly lower than adult doses.

    • Not recommended for children under 5 years due to developing circadian rhythms; underlying cause of poor sleep in this age group is crucial to identify.

Connections: Anxiety, Insomnia, and Depression

  • Clear connection between anxiety and insomnia, and anxiety and depression.

  • "Chicken or the Egg" question: Does anxiety cause insomnia, or does lack of sleep cause anxiety?

  • Sleep Hygiene:

    • Should be evaluated before initiating any sleep medication.

    • Interventions (if indicated) should be implemented to promote better sleep routines before and during medication use to reduce reliance.

    • Techniques: Preparing for bed, no screen time (for at least 30 minutes, some suggest hours), darkening the room, creating a quiet and calm environment.

  • Over-the-Counter ("OTC") Sleep Medications:

    • Common for self-medication due to anxiety about lack of sleep.

    • Diphenhydramine (Benadryl):

      • Often induces drowsiness in adults.

      • Chronic use can lead to rebound insomnia.

      • Causes daytime drowsiness.

      • Not recommended for chronic use due to negative effects on wakefulness.

      • Pharmacologic Tidbit in Kids: Can cause a reverse (activating) effect; should not be used as a sleep aid in children.

Critical Pre-Medication Assessment for Sleep Disorders

  • Rule out underlying physiological conditions (e.g., sleep apnea) before initiating pharmacologic treatment, especially if medication further suppresses the CNS and could cause respiratory depression.

  • Failure to address core problems can lead to severe adverse effects.

  • Potential Assessments: Sleep study, Electroencephalogram ("EEG").

Specific Drug Classes and Prototype Drugs

Antidepressants

  • Comorbidity: High comorbidity between anxiety and depression (many with depression have anxiety, and vice-versa).

  • Neurotransmitter Theory: Same primary neurotransmitters (Norepinephrine, Serotonin) play a role.

  • Goal (Anxiety Treatment): Reduce overwhelm and negative thoughts, thereby reducing anxiety. Allows patients to learn skills to manage ANS (fight-or-flight) reactions.

  • Drug Classes:

    • Tricyclic Antidepressants ("TCAs").

    • Selective Serotonin Reuptake Inhibitors ("SSRIs").

    • Serotonin-Norepinephrine Reuptake Inhibitors ("SNRIs").

    • Monoamine Oxidase Inhibitors ("MAOIs").

    • Atypical Antipsychotics (less common for anxiety, but may be used in comorbidity).

  • Most Typical for GAD: The SSRI drug class.

    • Prototype SSRI: Lexapro (Escitalopram) or Citalopram (the transcript mentions Tala Prem for Lexapro; which is Citalopram, another SSRI).

    • Other Important SSRIs: Sertraline (Zoloft), Fluoxetine (Prozac).

    • Mechanism of action is generally similar across drugs in the same class.

Benzodiazepines

  • Prototype Drug: Lorazepam (Ativan).

  • Classification: Controlled drugs, Schedule IV.

  • Historical Use: Previously widely prescribed for anxiety and insomnia; now less so due to dependence issues.

  • Current Use: Limited to very short-term, situational use (e.g., intense phobia of flying).

  • Mechanism of Action: Enhance the effects of Gamma-aminobutyric acid ("GABA"), the most abundant inhibitory neurotransmitter, at its receptor sites.

    • Results in: sedating, relaxing, sleep-inducing, anxiety-reducing, and anticonvulsant effects.

  • Duration: Helpful for short-term use (up to 2 weeks).

  • Risks with Longer-Term/Chronic Use:

    • Dependence, tolerance, withdrawal symptoms.

    • Abrupt withdrawal from chronic use can lead to: seizures, delirium tremens, and even death.

    • Withdrawal from alcohol and benzodiazepines are two situations where withdrawal can be fatal.

    • Long-term users must be tapered off slowly.

  • Rare Adverse Effects:

    • Paradoxical Stimulation: Increased agitation or panic.

    • In Elderly Patients: Increased risk of short- and long-term adverse effects, paradoxical stimulation, aggression, suicidal ideation, and worsening dementia.

      • Considered inappropriate for elderly population due to decreased kidney/liver function affecting metabolism and memory issues.

  • Reversal Agent/Antidote: Flumazenil (a benzodiazepine antagonist).

    • Crucial to know antidotes.

    • Consider benzodiazepine's half-life: if longer than Flumazenil's, re-dosing of antidote and close monitoring are necessary.

  • Variations and Therapeutic Uses:

    • Same action and side effect profile, but onset and duration of action vary.

    • Lorazepam (Ativan): Pre-anesthetic agent, stopping status epilepticus, alcohol withdrawal (due to impact on GABA receptors, similar to alcohol).

    • Diazepam (Valium): Anticonvulsant properties, used for seizure disorders and status epilepticus.

    • Midazolam (Versed): Often for minor procedures, conscious to moderate sedation, pre-anesthetic. Causes inability to create memory (amnesia), which is why it exacerbates dementia in elderly.

Barbiturates

  • Current Use: Rarely used for anxiety or insomnia due to availability of safer options.

  • Primary Use: Anesthetic agents.

  • Not First or Second-Line: No longer a primary choice for anxiety or insomnia.

  • High Risks:

    • High risk of physical and psychological dependence.

    • Significantly depress the CNS at all levels.

    • Withdrawal is extreme and can be fatal.

    • Tolerance develops quickly.

    • Cross-tolerance with other CNS depressants (e.g., opioids).

Miscellaneous Anxiolytics / Insomnia-Specific Medications

  • Valproate (Depakote): An anti-seizure medication, sometimes used for anxiety.

  • Propranolol: A beta-blocker (beta-adrenergic antagonist), blocks the fight-or-flight response (referencing ANS lecture).

  • Insomnia-Specific Medications (e.g., "Z-drugs"):

    • Prototype: Zolpidem (Ambien).

    • Other Examples: Zaleplon (Sonata), Eszopiclone (Lunesta).

    • Current Use: Still used, but less frequently due to side effect profiles.

    • Rebound Insomnia: A significant problem with chronic use.

    • Administration: Must be taken when sleep is imminent due to a very short onset of action.

    • Safety Concerns: Patients may be active but not aware (

    • dissociated behaviors), leading to: sleepwalking, sleep-eating, sleep-driving.

      • Crucial patient education is required: take medication only when in bed and prepared to sleep (
        20-30 minutes before).

Conclusion and Key Takeaways

  • Many medications for anxiety and insomnia have varied uses.

  • Be highly aware of side effects and safety concerns related to CNS depression.

  • Education is required to minimize dependence, especially for controlled substances.

  • Non-pharmacologic techniques should be:

    • Attempted initially for both anxiety (if overwhelm is manageable) and insomnia.

    • Considered as adjuncts to drug therapy in both situations.