Psychiatric and Sleep Disorders

Topic IV: Psychiatric Disorders and Sleep
Introduction
Antidepressants have efficacy in depressive and anxiety disorders, however patients should be offered nonpharmacologic therapy as well (including psychotherapy and other modalities). Antidepressants are also utilized off-label for many indications.
Each antidepressant has a response rate of 60-80%, and there is no strong evidence that any one antidepressant is superior to any other. Choice of antidepressant may be based on additional indications, side effect profiles, characteristics of each medication (see Table 38-4), and considerations of interactions with a patient's overall medication profile. Patients who do not respond to the initial medication choice may be tried on other antidepressants within the same class or medications from other classes. Drugs from different classes may be combined to augment the therapeutic effect (STAR-D Optimization)
Medically or physically complicated/fragile patients (elderly, pregnant, lactating, multiple comorbidities) should be evaluated carefully for side effects and tolerances to antidepressant medications.
Benzodiazepine medications are recommended for acute issues of anxiety and sleep. They are useful for acute somatic symptoms of anxiety and choice of benzodiazepine may be based on pharmacokinetic properties (Table 40-4).
Patients with insomnia should be looked at for other conditions such as narcolepsy, restless legs syndrome, or obstructive sleep apnea and treated accordingly. Other medications (including OTC meds/supplements and dietary components such as caffeine) causing difficulty sleeping should be examined for necessity, dose, and timing before a sedative medication is added.
In addition to short acting benzodiazepines and “Z-hypnotics” (zolpidem, eszopiclone, or zaleplon), other medications may be exploited for their sedating effects if utilized for additional indications (dosing may manipulated to improve a patient's sleep while using these agents for other purposes).
Primary care practitioners often find themselves at the front line of treating mild to moderate psychiatric problems including depression, anxiety, and insomnia. Medications can be very useful to control symptoms in these conditions, hopefully while the patient works on their issues with therapy and supportive non-pharmacologic treatments. Patients may need to try several different antidepressants during the course of their therapy - medications with different mechanisms of action and different side effect profiles may be considered as per the patient's preferences.
Antidepressant drugs have a variety of potentially dangerous side effects (including cardiac, blood pressure and seizure risk) and drug interactions (including food-drug interactions), especially with older antidepressants.- May not apply to all members of a particular drug class. Medically or physically fragile patients should have their entire medication list carefully evaluated when an antidepressant drug is added.
Benzodiazepines are very effective for acute anxiety conditions and the physical symptoms of anxiety, however these drugs have the potential to be abused by the patient or others. They can also be dangerous if combined with other sedating drugs (notably alcohol). Benzodiazepines should not be utilized for chronic control of anxiety. Benzodiazepines are also useful for acute insomnia, as are similar medications that work on the same receptors but are not “traditional” benzodiazepines (zolpidem/Ambien, zaleplon/Sonata, Eszopiclone/Lunesta) - although all medications with this mechanism can have some residual "hang-over" effects, and some have been implicated cases of anterograde amnesia. Over the counter products advertised as sleep aids are usually first generation antihistamines which produce significant anticholinergic effects (part of which is responsible for the sleep-inducing effect). These medications are useful for the occasional problem but generally have too many side effects for longer term use of continued problems. The anticholinergic effects of these drugs can be a problem in many conditions as well (elderly patients, those with dry mouth, urinary retention, constipation, etc.).
As in all diseases - the practitioner should focus on the cause of the problem. However with depression, anxiety, and insomnia - we may often forget that these issues may be symptoms of a problem (not only medical but psychosocial) and mistakenly focus on the symptoms only. It is best to consider medications for these conditions as only part of the toolbox necessary for successful treatment.