In many countries the drug treatment of both anxiety and insomnia still largely revolves around the use of the benzodiazepines. Nevertheless, controversy and disagreement still rage about the risk–benefit ratio of compounds in this area. Short-term use in both indications is well established, with a favourable database as a rationale for this approach. However, long-term use is still only researched in a limited way. While both the efficacy and safety of long-term use remain unclear, acceptance of current guidelines limiting the use of benzodiazepines seems wise. The advent of the SSRIs as anxiolytics has driven a wedge between the treatment methods for anxiety and insomnia. Anxiety can be treated just as effectively with an SSRI (and probably, pregabalin) as with a benzodiazepine, and more safely. The treatment of insomnia still relies on the benzodiazepines until the risk–benefit ratio of newer drugs such as the melatonin-related compounds becomes clear. Nevertheless, in the author's opinion the most important outstanding issue is the relationship between drug and non-drug treatments. The management of anxiety disorders and of insomnia is complex and is hampered by a dearth of information concerning the relative merits of various treatment modalities. Much research is also needed on the optimum strategies for combining all the therapies available to us, and on identifying predictors of response. Developments in the neuropharmacology of insomnia hold out the promise of new compounds with novel and perhaps more effective modes of action. With respect to anxiety disorders, a major shift of emphasis has followed the demonstration of the efficacy of the SSRIs.
Chapter. 6268 words. Illustrated.
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