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July 27, 2017

Questions and Answers Concerning Sleep and Anxiety Medications

By Dr. Richard Boyum, Ed.D. and Dr. Richard Kark, M.D.

Question: When people or students are having difficulty sleeping, when should they consider medication?

Answer: People or students should first try what are called sleep hygiene measures. Pamphlets on this are available from counselors and other health care providers, such as physicians. These measures include regular sleep routines, winding down, avoidance of caffeine and other stimulants, relaxation techniques, etc. Medication should be considered if sleep hygiene measures do not work and lack of sleep is causing daytime sleepiness or inattentiveness.

Question: What types of medications work?

Answer: These days basically three types of medications are prescribed. Most commonly used are the benzodiazepines or benzodiazepine-like medications. Some of these are marketed to help sleep and some are marketed to alleviate anxiety, but they work similarly. Some examples are brand names Ambien, Sonata, Halcion, Ativan and Xanax. The second most commonly used sleep aids are in the category of tricyclic antidepressants. These are a class of antidepressants which have been around a long time and which tend to cause drowsiness as well as help alleviate symptoms of depression. At low doses they are often used in combination with other antidepressants. A third sleep aid commonly used is Trazodone. It is a weak antidepressant which causes drowsiness and also is commonly combined with other antidepressant medications.

Question: How long are the sleep aids usually used?

Answer: Ideally they are used only temporarily. In the long run it is best to learn behavioral or sleep hygiene techniques to improve sleep habits. Sleep disturbances commonly improve when depression and anxiety are treated with other medications and with counseling. When the depression or anxiety improves the insomnia also usually improves. Temporary rather than chronic use is preferred because occasionally the medications used can be overused or become addictive.

Question:

Is addiction a problem?

Answer: Occasionally this can be a problem with chronic use and for those who have "addiction prone" personalities. Any patient who finds his or herself taking increasing doses to cause sleepiness should worry that this could be a problem. Fortunately true addiction to sleep medication these days is quite rare. In the past it was more common when barbiturates and other similar sedatives were used to aid sleep.

Question: Can a person consume alcohol when using these medications?

Answer: Combining alcohol especially with the benzodiazepine-type drugs can potentially be a problem. It can be a major problem with heavy alcohol use. Heavy use of both can lead to depression of the central nervous system to the point where breathing can stop. Lack of coordination and poor judgment and other problems occur at lower doses. Mixing alcohol with Trazodone and tricyclic antidepressants is less of a problem but still a concern. Zero or very minimal alcohol use is always the best policy when mixing alcohol with sleep medications. The best policy is to not use a sleep aid on the same night that you have been drinking alcohol.

Question: How should the sleep aids be taken in order to work and to help a student stay on task with their academics?

Answer: They basically should be taken at the lowest dose possible. Students should be aware that some of these medications could have lingering effects the next day. They can even interfere with memory. In that case either new medication should be tried or non-medication methods should be emphasized.

Question: When should a student consider medication for anxiety?

Answer: Basically, when a student becomes so anxious, worried or fearful that it interferes with reasonably normal functioning. Medication and/or counseling should be considered. Poor academic performance, poor personal relationships and certain physical symptoms may all necessitate treatment for anxiety if they cause significant dysfunction or distress. Physical symptoms of anxiety sometimes include frequent headaches, poor sleeping, easily upset stomach, heart pounding, trouble breathing, etc.

Question: Can a student be on both an antidepressant and antianxiety medication at the same time?

Answer: The answer is yes and this is frequently done. The reason the combination is common is that certain antidepressant medications also treat anxiety. They tend to be safer, less addictive and have fewer side effects than antianxiety medications. Commonly the scenario is that an anxiety sufferer will be started on a SSRI antidepressant, such as Prozac, Zoloft, Paxil, or Celexa. These medications take several weeks before they start to alleviate symptoms of depression and/or anxiety. During this time antianxiety agents in the benzodiazepine class, such as Xanax, Ativan, or Valium are used to alleviate the anxiety symptoms until the slower acting medication "kicks in".

Question: How can medication help with panic attacks?

Answer: Panic attacks are a type of anxiety disorder. When medications are used there are two types to be considered. The first are again antidepressants, which tend also to help anxiety. Again the onset of these is delayed and some students need specific antianxiety agents. Sometimes those agents will be needed indefinitely but sometimes the antidepressants will make their use unnecessary.

Question: Is addiction a problem with these medications?

Answer: Addiction can occasionally be a problem with the benzodiazepine class of drugs, which includes Ativan, Xanax, Valium and others. Luckily addiction is quite unusual in those who are taking the medication to treat anxiety. To put this in perspective, some experts say that these medications are no more addictive than alcohol. Certainly alcohol can be addictive in certain people, as can benzodiazepine antianxiety medications. If someone finds themselves increasing the dose over what initially helped, this may mean they are developing what is called tolerance to the medication and that addiction may be developing.

Question: Do some people take heart or blood pressure medication for anxiety?

Answer: There is a class of medication called beta blockers. These medications were developed to treat high blood pressure and later they were discovered to help certain types of heart conditions. They do not alleviate anxiety per se, however, they can decrease some of the symptoms of anxiety including heart pounding and shakiness. Some students who develop these symptoms while they are trying to perform in front of a class or while taking a test will benefit by taking the beta blocker-type medication. These medications are especially helpful for students who are bothered mainly by the heart pounding and shaking and not so much the internal feeling of anxiety. If the latter is the more prominent component of the performance anxiety then traditional antianxiety agents such as the benzodiazepines are likely to be more helpful.

Question: Do you recommend counseling along with medication for anxiety?

Answer: Generally counseling is a good idea whenever possible. It is generally best to avoid medications. All medications have side effects and they may be dangerous when mixed with alcohol. Unfortunately Benzodiazepines also can affect memory, which certainly is a concern for students as well as others. Counseling can be helpful to discover the true causes of anxiety and to learn relaxation techniques and other ways to alleviate anxiety without medication. Significant depression also commonly co-exists this with anxiety and this should be ruled out with the help of a counselor or other clinician.

Question: What about the use of alcohol with these medications?

Answer: Significant alcohol use is never a good idea for those with sleep disturbances, anxiety disturbances or depression. Small amounts of alcohol are generally, but not always, ok when used with antidepressants. Using alcohol with benzodiazepine-type antianxiety medications is more problematic for reasons that have been stated above. Using alcohol with these medications again can suppress the central nervous system to the point where confusion and brain dysfunction are prominent, incoordination is significant and even breathing can be depressed occasionally to the point of death if alcohol use is excessive. Of course this problem is compounded if more than the recommended doses of the antianxiety medication are taken.

Question: As a physician in the University Health Service, how do you feel about the use of these medications?

Answer: My feeling is that in general sleep aid medications, antianxiety agents and antidepressants should only be used if truly necessary. Generally non-medication strategies are preferred. However, medications should be considered if a student's function has been impaired for a significant period of time and to a significant degree. Then they should be used with caution and under the guidance of the prescribing health care practitioner.