They tend to be the first line choice for multiple anxiety disorders and depression. These include fluoxetine (aka Prozac), paroxetine (aka Paxil), sertraline (aka Zoloft), fluvoxamine (aka Luvox), citalopram (aka Celexa), and escitalopram (aka Lexapro). In our experience, those relying on medications only may be more likely to experience tolerance to medications over time. The decision of which medicine should be tried should always be made after a complete in person evaluation, which this blog is not meant to supplant. Keep in mind that while medicines can be helpful for many, it is important to always stress the need for a holistic treatment plan including (but not limited to) psychotherapy, exercise, nutrition, mindfulness training, work life balance, social support, and so on. ![]() The topics we are going to touch on in this post are: 1) which classes are useful for which types of anxiety disorders, 2) general pros and cons of each class, and 3) basic mechanisms of action of each group. Obviously, the point of this post is breadth rather than depth, and there is so much more to say about any one of the categories mentioned here - but we hope that this will provide a helpful overview for patients and will help them feel more prepared when walking into a prescriber’s office. Moreover, some evidence suggests that tolerance may develop to the sedating effects of histamine H1 blockade as quickly as in four nights.One thing that’s not clear to most patients is that there is a huge number of different medications that can be used to treat anxiety. 47 Whether using lower doses of these agents would carry a lower risk profile is unknown at this time. 1 All antidepressants have an FDA-issued black box warning regarding increased risks of suicidal thinking and behavior (i.e., suicidality) in young adults ages 18 to 24 during initial treatment (generally the first one to two months). Nonetheless, antidepressants carry their own potentially significant adverse effects that need to be weighed against these potential benefits. 46 The less stringent regulation surrounding antidepressants makes them an attractive option in those individuals residing in long-term care facilities. Furthermore, long-term care facilities are required to report and monitor the use of benzodiazepines and sedative drugs however, these requirements do not apply to antidepressants. Reasons postulated for the common practice of off-label use of antidepressants in insomnia, despite insufficient evidence, include unscheduled drug status, lower risks of abuse and dependence, lack of prescribing restrictions, availability as generic agents and reduced performance-impairing effects. 39 Subsequent controlled studies systematically assessed significantly lower doses of doxepin for its effects on sleep. One of the earlier doxepin studies for primary insomnia in adults utilized 25–50mg for 4 weeks, improving TST in 20 adults. 28 There have been several clinical trials confirming the efficacy of doxepin 1–6mg/day in adult 33–35and elderly 36–38 patients with primary chronic insomnia. 32 It is highly specific for the H1 receptor at lower doses. Doxepin 3–6mg is specifically approved for the treatment of insomnia characterized by difficulties with sleep maintenance. ![]() Generics of some of these higher strengths are also available. This product is marketed in lower dosage strengths (3 and 6mg non-scored tablets) compared to the product strengths originally marketed for MDD in 1969 (i.e., 10, 25, 50, 75, 100, 150mg capsules 10mg/mL oral concentrate) such as Sinequan (Pfizer). 19, 20ĭoxepin, approved under the trade name Silenor (Somaxon Pharmaceuticals) in March 2010, is the only antidepressant currently approved for insomnia. In healthy volunteers, mirtazapine increased sleep efficiency (SE), enhanced sleep continuity, decreased SL and reduced the frequency of awakening without any apparent decreases in the percentage of time spent in REM sleep. All clinical trials assessing the role of mirtazapine on sleep parameters have been conducted either in healthy volunteers or in patients with co-morbid conditions, primarily depression. 14 To the best of our knowledge, there is no research evaluating the use of mirtazapine in primary insomnia. ![]() It is hypothesized that the action of mirtazapine on 5HT2 and H1 contribute to its highly sedating activity. Mirtazapine is a novel antidepressant, which acts as a potent inhibitor of 5HT2 and 5HT3, central α2-adrenergic and histamine H1 receptors. 18 As an antidepressant it is used at doses ranging from 15–45 mg/d, however, it is unclear if these doses are appropriate in the treatment of insomnia. Mirtazapine is commercially available under the trade name Remeron and was FDA approved solely for MDD in 1996.
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