Clinical Pharmacology and Therapeutics

106 HYPNOTICS AND ANXIOLYTICS
INSOMNIA
ANXIETY
Underlying
cause?
Underlying
cause?
Yes
No
No
Yes
Treat underlying
cause (Physical/
Psychological)
Treat underlying
cause (Physical/
Psychological)
Chronic/
long-term
cause?
Chronic/
long-term
cause?
Yes
No
No
Yes
Non-pharmacological
methods/
behavioural
therapies
Non-pharmacological
methods/
behavioural
therapies
No
No
Severe
and/or
disabling?
Severe
and/or
disabling?
Yes
Yes
First line
Benzodiazepine
Alternative (elderly)
Clomethiazole
Second line
Zopiclone, zolpidem, zaleplon
First line
Benzodiazepine
Second line (where sedation
is to be avoided)
Buspirone
Figure 18.1: Decision tree/flow chart for the management of insomnia and anxiety.
• depression;
• anxiety.
Much chronic insomnia is due to dependence on hypnotic
drugs. In addition, external factors such as noise, snoring partner
and an uncomfortable bed may be relevant.
Drug therapy is inappropriate in individuals who need little
sleep. Shortened sleep time is common in the elderly, and
patients with dementia often have a very disturbed sleep pattern.
• Hypnotics should be considered if insomnia is severe and
causing intolerable distress. They should be used for short
periods (two to four weeks at most) and, if possible, taken
intermittently. On withdrawal the dose and frequency of
use should be tailed off gradually.
• Benzodiazepines are currently the hypnotics of choice, but
may fail in the elderly, and alternatives such as
clomethiazole can be helpful. There is currently no evidence
of superiority for the newer ‘non-benzodiazepine’
hypnotics that act nonetheless on benzodiazepine
receptors (see below).
• Prescribing more than one hypnotic at a time is not
recommended, and there is no pharmacological rationale
for doing this.
• Drugs of other types may be needed when insomnia
complicates psychiatric illness. Sleep disturbances
accompanying depressive illness usually respond to
sedative antidepressives, such as amitriptyline.
Antipsychotics, such as chlorpromazine, may help to
settle patients suffering from dementia who have
nocturnal restlessness.
• Hypnotics should not be routinely given to hospital
patients or in any other situation, except where
specifically indicated and for short-term use only.
• Whenever possible, non-pharmacological methods such
as relaxation techniques, meditation, cognitive therapy,
controlled breathing or mantras should be used. Some
people experience sleepiness after a warm bath and/or
sexual activity. A milk-based drink before bed can promote
sleep, but may cause nocturia and, in the long run, weight
gain. Caffeine-containing beverages should be avoided,