A Textbook of Clinical Pharmacology and Therapeutics

• depression;


• anxiety.

Much chronic insomnia is due to dependence on hypnotic
drugs. In addition, external factors such as noise, snoring part-
ner 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
  clomethiazolecan 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,
  
  
  
  

106 HYPNOTICS AND ANXIOLYTICS

INSOMNIA ANXIETY

Underlying

cause?

Chronic/

long-term

cause?

Severe

and/or

disabling?

Treat underlying

cause (Physical/

Psychological)

Non-pharmacological

methods/

behavioural

therapies

First line

Benzodiazepine

Alternative (elderly)

Clomethiazole

Second line

Zopiclone, zolpidem, zaleplon

Ye s

Ye s

No

No

No

Ye s

Underlying

cause?

Chronic/

long-term

cause?

Severe

and/or

disabling?

Treat underlying

cause (Physical/

Psychological)

Non-pharmacological

methods/

behavioural

therapies

First line

Benzodiazepine

Second line (where sedation

is to be avoided)

Buspirone

Ye s

Ye s

No

No

No

Ye s

Figure 18.1:Decision tree/flow chart for the management of insomnia and anxiety.