Insomnia older agents

Answer Because of sertraline s favorable side effect profile and no need for dietary restrictions, it probably should be chosen over the older agents (TCAs and MAOIs). She should be warned about nausea and possibly loose stools, anorgasmia, and insomnia before she begins therapy. It also should be explained that the medication will take at least 2 weeks to begin working and that a complete trial of the medication to assess its efficacy will take 4 to 6 weeks. Since this is her first episode of depression, she should take the medication for 6 to 12 months after her symptoms have remitted before considering discontinuation of drug therapy. 

Note Benzodiazepines have only a limited capacity to produce profound and potentially fatal CNS depression. Although coma may be produced at very high doses, benzodiazepines cannot induce a state of surgical anesthesia by themselves and are virtually incapable of causing fatal respiratory depression or cardiovascular collapse unless other CNS depressants also are present. Because of this measure of safety, benzodiazepines have substantially replaced older agents for the treatment of insomnia or anxiety. 

Older agents such as barbiturates, glutethimide, and meprobamate should be avoided for the management of insomnia they have high abuse potential and are dangerous in overdose. 

Nonbenzodiazepine sedative-hypnotics. The non-BZD hypnotic zolpidem (Ambien) is a newer sleeping agent that is thought to work on more specific subdivisions of the GABA receptor complex than, for example, some of the older benzodiazepine agents. It is indicated for short-term insomnia and is generally limited to seven to 10 days of use. 

A review of published studies of zaleplon has shown that it has a quick onset of action and undergoes rapid elimination, which results in an arguably better safety profile than previously available agents (10). In addition, rebound insomnia and other withdrawal effects have not been demonstrated with zaleplon, and it is well tolerated in both young and older patients. These characteristics may be advantageous for patients who should not receive benzodiazepines. 

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