The truth about benzodiazepines...
Benzodiazepines are the only genuinely effective medication class for the treatment of anxiety. They are safe, inexpensive and can be used on an as-needed basis.
Following is a concise but comprehensive account of benzodiazepines. It may take approximately forty minutes to read.
The information on this page is intended to help those with clinically significant anxiety, those who care for someone with anxiety in a professional or non-professional capacity and as a general source of information on anxiety and its treatment. The intention is not in any way, to promote benzodiazepines; it is simply to give an honest and open account of anxiety and its treatment with this medication class.
People that have a chronic anxiety disorder or an acute problem with anxiety, could reasonably expect to be treated correctly. However, when a person with a genuine complaint regarding anxiety consults a doctor and it is apparent that treatment with a medication is required, the most likely scenario is that they will not be treated properly. This may include being prescribed a medication whose effectiveness for anxiety has not been proven and/or being referred for psychological intervention that will likely be of limited benefit.
Benzodiazepines are the only truly effective medication for anxiety, yet doctors usually won't prescribe them as a matter of course. Currently (as a generalisation), there is a worldwide situation of safe, effective and inexpensive anxiety medication (benzodiazepines) being intentionally withheld by the medical profession. This has serious consequences for those suffering from anxiety and those who care about them.
Unfortunately, the medical and psychiatric professions as a generalisation, have reached a point of being completely dysfunctional regarding the treatment of anxiety. Doctors worldwide are generally reluctant to prescribe benzodiazepines, which are the only truly effective medication for anxiety.
A situation in which patients are being routinely denied suitable and safe medication would not be tolerated or permitted for the majority of other medical or psychiatric conditions. For people with problematic anxiety however, this situation is a common and unfortunate reality.
When anxiety is problematic, it can have a profoundly negative effect on a person's life because of the way they -
FEEL - Physical symptoms of anxiety can include a tight, unpleasant feeling in the throat and chest, fast heartbeat, abdominal distress, sweating and blushing etc.
THINK - Excessive worry is the hallmark feature of Generalised Anxiety Disorder. This can be intrusive and debilitating and can make it difficult for a person to lead a 'normal' life. For example, they can take too long to perform tasks due to constant rumination caused by worry. This may be problematic in regards to employment and other endeavours. A constant state of high anxiety can lead to depression, which brings with it a second raft of mental-health issues and challenges.
Anxiety can be prompted by an environmental trigger or the person can be genetically prone to being excessively fearful -
Situational anxiety - A person can have anxiety because of an actual threat in their lives, for instance, loss of a job or bullying. Once the anxiety-provoking trigger ceases, the anxiety dissipates and finishes.
Constitutional anxiety - A person can have anxiety when there is no actual, immediate threat in their lives. These people tend to be born with this inclination to be fearful. The anxiety will be with them for life.
A mixture of Situational and Constitutional anxiety - A person with a naturally fearful personality can become more anxious because of an environmental cause of anxiety (stressor) such as loss of a job or bereavement.
Benzodiazepines are the prototypical anxiolytics, meaning they are the original and best anti-anxiety medication. They are in fact, the only medication class that is truly effective for anxiety. They were introduced in the 1960's and largely replaced the barbiturates in this area of medicine. No better medication for anxiety has been produced since. The most well-known of the group is Diazepam (Valium).
They are believed to exert their effects by influencing the action of the brain's most prevalent inhibitory neurotransmitter, GABA (Gamma-amino-butyric-acid). An inhibitory neurotransmitter is a chemical compound whose action is to prevent a nerve impulse in the brain and elsewhere. So in very basic terms, benzodiazepines encourage the action of GABA and thereby contribute to an inhibitory effect on neurons (nerve cells) in the brain.
At the correct dose, benzodiazepines initiate an inhibitory effect that reduces and controls the fear reaction (anxiety) whilst still allowing the person to function normally. Anxiety could be described as the body's alarm system, whose job is to assist in surviving a situation of threat. Apart from anti-anxiety effects, benzodiazepines have three other valuable properties: sedative/hypnotic (sleep inducing), anti-convulsant and muscle relaxant.
Benzodiazepines for anxiety is possibly the simplest, safest and most effective medical intervention for a mental-health condition.
At the correct dose, the benzodiazepines used to treat anxiety alleviate anxiety and worry -
without inducing euphoria (feeling high) or disinhibition (acting without concern for social restraints)
without inducing problematic levels of sedation
without having to be taken on a regular basis (they can be taken 'as needed') and
with a minimal side-effect profile. Benzodiazepines are proven from decades of use to be very safe. They are free of the troublesome side-effects that come with drugs that act on the serotonin and histamine receptor systems for example.
Benzodiazepines give people the ability to be in control of their anxiety. For people with problematic anxiety, this medication group can reduce anxiety and worry to levels that allow a much more enjoyable and productive life.
Many variants evolved as companies developed and marketed their own slightly differing version of the basic structure. Following is a list of commonly utilised benzodiazepines whose effectiveness is well proven. There is no inference that variants not on the list are not effective.
Diazepam - Possibly the most well-known benzodiazepine, with three active metabolites: nordiazepam, temazepam and oxazepam.
Oxazepam - A product of the metabolism of diazepam, with no active metabolites and which is often prescribed for Generalised Anxiety Disorder
Temazepam - A product of the metabolism of diazepam and often prescribed for insomnia
Alprazolam - A rapidly-acting variant commonly prescribed for Panic Disorder
Midazolam - An essential medication for use in medicine, commonly utilised in anaesthesia before a surgical procedure
Benzodiazepines are not a cure for anxiety. As a medication, they are not perfect. They merely control the symptoms of anxiety. Whilst they are unsurpassed as a medication for treating the symptoms of anxiety, their use is a balance between relief from anxiety and sedation. They work by inhibiting activity in areas of the brain that initiate worry and they counter the effects of 'excess' adrenaline. So, as a medication that inhibits activity in the central nervous system, they have the capacity to induce sedation.
Sedation is a side effect found in many medications: it is not a side effect peculiar to benzodiazepines. As with any medication, the amount taken determines the balance between desired and undesired effects. A dosage level can be found where relief from anxiety is achieved with little or no noticeable sedation. Once the right balance between alleviating symptoms of anxiety and sedation is found, they can deliver a much better life for an anxious person.
It is important for people taking benzodiazepines for the first time to realise that they are not a cure for anxiety. The medication treats the symptoms only. If you have a constitutional or innate anxiety condition and you stop taking the medication, the intensity of symptoms of the original untreated anxiety will return. This can be confused with symptoms of physical withdrawal.
In a manner of speaking however, benzodiazepines do provide a 'cure' for one aspect of anxiety. This is the fear of anxiety itself. People with anxiety can become 'anxious about anxiety'. People know that a certain situation such as a meeting or public speaking engagement will provoke anxiety. They can become anxious in anticipation of the event. When the person has access to benzodiazepines however, they know that relief will be at hand if required. This knowledge has a valuable comforting effect.
An honest and evidence-based discussion on the use of benzodiazepines to treat anxiety on a continual and long-term basis would involve the following points -
They are the only truly effective medication for the treatment of anxiety. They act on the correct neurotransmitter system and have been proven over a period of decades to be effective.
They have extremely low or zero toxicity. The medication class is well known to be safe and well tolerated.
They have no arbitrary dose and can be taken as-needed in a dosage tailored to the effective treatment of symptoms only. This makes them valuable as a medication that does not arbitrarily cause neuroadaptation (physical dependency, 'addiction'), as do anti-depressants.
They are inexpensive, as they are out of patent and able to be supplied as a generic drug type.
Benzodiazepines are widely claimed to be a medication that should be used on a short-term basis only, due to a percieved risk of physical dependency. The same sources claiming this promote anti-depressants, primarlily SSRIs, as the first-line treatment for anxiety; a medication class for which physical dependency is normal.
So obviously, physical dependency is not a genuine nor valid reason for sufferers of anxiety to be denied the best treatment for their condition (benzodiazepines) on a long-term basis.
If you go to a doctor with a complaint about anxiety (certainly in Australia and by all accounts elsewhere in the world), there is an extremely high probability that initially, you will not be treated properly. If it is obvious that you would benefit from pharmacotherapy (being treated with a medication), it is likely the following will happen -
1. If a medication is prescribed, the medication will most likely not be a benzodiazepine and therefore will not be truly effective for anxiety
2. You will be referred for psychological intervention
3. You will be prescribed a medication whose effectiveness for anxiety has not been proven and also referred for psychological intervention
The medications recommended as 'first-line' treatment for anxiety in Australia and elsewhere are the SSRIs. The Selective Serotonin Reuptake Inhibitors are marketed as anti-depressants with the theory being that increased levels of the neurotransmitter serotonin help depression. Common sense would suggest that a serotonin-boosting drug inherently does not operate to counter the constant 'fight or flight' adrenaline-related overload that characterises serious levels of anxiety.
They also have the potential for many more side effects than benzodiazepines. The following list contains side effects described as common, with 1% or more of people affected: "nausea, agitation, insomnia (sleep problems), drowsiness, tremor (shaking), dry mouth, diarrhoea, dizziness, headache, sweating, weakness, anxiety, weight gain or loss, sexual dysfunction, runny nose, myalgia (muscle pain) and rash". (1)
SSRIs have to be taken regularly to maintain the physical dependence (brain adjustment) that they induce and also therefore, to avoid withdrawal symptoms. This is tiresome and costly. They commonly have to be 'tapered down' if the patient wishes to cease using them in order to keep withdrawal symptoms to a minimum.
An article addressing cessation of anti-depressants lists "symptoms associated with withdrawal from selective serotonin reuptake inhibitors" as belonging to the following categories: "[g]astrointestinal, general somatic distress, sleep disturbance, affective symptoms, problems with balance, and sensory abnormalities". (2) Importantly, SSRIs are not effective on an 'as-needed basis' as are benzodiazepines.
There are a number of other medications prescribed for anxiety whose effectiveness has not been proven and that have many unwanted side effects. These include SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors), anti-psychotics, MAOIs (MonoAmine Oxidase Inhibitors) and Beta Blockers etc.
One of the most ironic and concerning consequences of the maligning of the benzodiazepines is the prescription of anti-psychotics rather than the administering of a safe, 'clean' and uncomplicated benzodiazepine. Doctors that submit to pressure not to prescribe benzodiazepines sometimes resort to prescribing anti-psychotics in the hope that they treat anxiety and as a sedative for insomnia for example.
The anti-psychotics are 'complicated' medications designed to treat disorders such as schizophrenia and have the potential for serious side-effects. The use of these medications for the treatment of anxiety over and above the benzodiazepines is one of the more disturbing trends in medicine.
Non-medication interventions for anxiety can of course, be of value. Cognitive behaviour therapy for example, can help people make changes that are helpful. If however, changes in thoughts and behaviour are not successful in adequately reducing the adrenaline overload of chronic anxiety, then medication is entirely appropriate.
Cognitive behaviour therapy will be of little assistance if a person has a constitutional anxiety that cannot be eased by psychological intervention. Counselling and other psychological interventions will also be of limited benefit if the cause of anxiety is environmental and cannot be removed easily. In these cases, medication can be the difference between continual suffering or the chance of a reasonable life.
So, benzodiazepines are the most effective medication for the treatment of anxiety. Why then, are they prescribed reluctantly or not at all?
There are obviously some reasons why an effective and safe medication would be aggressively portrayed as being problematic and routinely substituted with other medications. A situation whereby people are being denied proper treatment for what can be a serious and debilitating condition (anxiety), is worthy of discussion.
The pharmaceutical industry. Benzodiazepines are problematic for some in the pharmaceutical industry from two main perspectives. Firstly, the original benzodiazepines are long out of patent. The development of a new medication requires immense amounts of money and entails substantial risk. The primary mechanism that allows companies to recoup development costs and maximise income from a product is the patent system. It allows a retail price that is unaffected by competition. As they are no longer covered by patent, benzodiazepines can no longer deliver the 'rivers of gold' that medications under patent protection can.
Secondly, no better medication for the treatment of anxiety has been produced. Benzodiazepines are effective and safe, with a minimal side-effect profile. It is conceivable that a better treatment for anxiety will never eventuate.
Research and literature. It is almost inevitable that authors of research or literature that criticises or maligns benzodiazepines have at some stage and in some way, received some kind of reward from the pharmaceutical industry in particular. Payments offered by companies to researchers and medical personnel can of course, come with the expectation that the company's products are referred to in a positive light.
There are various methods employed by industry to promote products and influence the perception of those products that constitute the competition. It is common for medical personnel to be reimbursed for accommodation and travelling expenses by companies when they speak at conferences for example. When people receive money for promoting something when that activity would normally have been done on a voluntary basis, the payments are called 'honoraria'. There is often a list of 'honoraria' that an author has received at the end of research papers and other such literature.
Following are some themes which are utilised in maligning the benzodiazepines -
The maligning of benzodiazepines and the subsequent pressure on the medical profession to avoid their prescription, is apparently based largely on the 'potential' for physical dependence. That benzodiazepines are capable of inducing brain adjustment, is given as a reason for their avoidance. However, this is an obvious double standard which can be illustrated by the following points -
Benzodiazepines are commonly substituted with anti-depressants for the treatment of anxiety due to an apparent concern about physical dependence. However, it is completely normal for anti-depressants to cause physical dependence.
There has been a long-standing and concerted campaign to malign benzodiazepines based on an apparent concern about physical dependence. There is no such campaign to malign antidepressants, even though they as a matter of course, induce physical dependence.
There is a reluctance to prescribe benzodiazepines in large part due to an apparent concern about physical dependence. There is no reluctance to prescribe anti-depressants however, even though it is normal for them to induce physical dependence.
Benzodiazepines, like many other drugs, are capable of inducing physical dependence. If they are taken regularly in sufficiently large amounts, the brain will compensate to counteract their effects on the central nervous system and physical dependence will develop. Physical dependence is a completely normal consequence of the therapeutic administration of anti-depressants, but curiously, it attracts little comment and is not looked upon as a concern.
In regards to benzodiazepines however, the subject of physical dependence and 'addiction' attracts comment and insinuation bordering on hysteria. The unfounded allegation that benzodiazepines commonly induce physical dependence at genuine therapeutic doses has featured in the campaign to malign them. This has contributed to them being commonly substituted with medications that are not truly effective for anxiety and that are renowned for inducing physical dependence.
In terms of avoiding physical dependence, benzodiazepines are actually the ideal medication. Apart from being genuinely effective in treating the symptoms of anxiety, they are typically taken at low doses and often only 'as needed'. This means their actual potential for inducing physical dependence is low.
Anti-depressants however, are taken regularly and often in high doses. It is normal for them to take a period of time to become effective and for a withdrawal syndrome to take place on cessation of use or dose reduction. These are features indicative of neuroadaptation. This is the process that gives rise to physical dependence.
Simply put, it is a process of adjustment that the brain makes to counteract the effects of a substance on the central nervous system. When the brain is exposed to high levels of a substance for extended periods of time, it will make adjustments (neuroadaptation) to ensure the body maintains a 'steady state' of operation (homoeostasis). When the substance is removed suddenly or reduced in dose, a withdrawal syndrome can result.
Representation of neuronal junction (synapse)
Obviously, potential for physical dependence is not an actual justifiable concern held by many who discourage use of the benzodiazepines. It is quite simply an irrelevant double standard. If someone was to discourage benzodiazepines due to a concern about physical dependence, it would follow that there would be a number of other medications that they would also discourage the use of, including anti-depressants.
'Potential for abuse' is commonly cited as a reason for benzodiazepines being less desirable than other medications. It is however, less than valid when examined from two perspectives. Firstly, in therapeutic doses, benzodiazepines recommended for the treatment of anxiety do not induce euphoria. This is one of their great assets. It is therefore possible for a person to use the medication and not be exposed to a situation of 'feeling high' as occurs with alcohol.
Secondly, consider the situation of a person with clinically significant anxiety that has found the great value of this medication. They finally have a medication that assists them to live a much better life. Most likely, they are fully aware of the difficulty of getting a prescription. Why would they then jeopardise their prescription for such a valuable medication by using them for 'recreational' purposes? It is highly unlikely that an anxious person would risk their supply of the medication for the sake of a 'high'.
Possibly the most cynical method of maligning the medication is to infer that they have the potential to increase the 'risk of falls' amongst the elderly. The elderly inherently have an increased rate of falls. It is easy to allege 'increased risk' and another thing altogether to prove an actual increased rate of falls directly due to a medication.
Studies claiming to do this typically have flawed methodology such as subjects merely having a prescription for benzodiazepines; the subjects that had fallen were not actually tested to prove the presence of the medication. Studies are typically based on the 'meta-data' style of research rather than actual clinical, controlled methodology.
This aspect of human behaviour is fundamental to understanding the maligning of the benzodiazepines. It is a basic trait of human behaviour that people can sometimes apportion blame to something unrelated to an undesired event in their lives. This can be called 'scapegoating' and it is a common mechanism that people employ to cope with an undesirable situation. Laymen and professionals alike can fall prey to the phenomenon.
Consider a person with a constitutional (inherent or genetic) anxiety who has been prescribed benzodiazepines and who has subsequently discontinued the medication. The original level of anxiety has understandably returned. They have heard before or after stopping the medication about an alleged potential for physical dependence and therefore a withdrawal syndrome on discontinuation of therapeutic doses.
The person then incorrectly attributes the return of increased anxiety to a withdrawal syndrome caused by benzodiazepines, rather than the correct explanation which is the return of symptoms relating to the original untreated anxiety condition. They are preoccupied with apportioning blame rather than analysing the situation and accepting the true cause.
Doctors themselves can mistakenly attribute the return of anxiety to withdrawal from benzodiazepines. This situation leads to benzodiazepines commonly being blamed by patients and doctors alike for the return of symptoms of the original anxiety condition that they were initially used to successfully treat.
Following are some points regarding the reluctance of many in the medical profession to prescribe benzodiazepines -
Members of the medical profession can be as capable as anyone else of believing something which is actually untrue. They must rely on what they have been taught about the medication and what they hear from various sources. Many doctors and other medical personnel such as psychiatric nurses believe (incorrectly) that benzodiazepines commonly induce physical dependence at therapeutic doses.
They, along with many patients, can mistakenly attribute the return of anxiety symptoms on discontinuation of benzodiazepines to withdrawal from the medication. They may believe therefore that they will almost inevitably be required to manage a patient with physical dependence should they prescribe benzodiazepines and the person subsequently ceases the medication or reduces the dose. These incorrect beliefs can lead to the mindset that benzodiazepines are themselves a health concern and are to be avoided.
This situation is a disaster for people with problematic anxiety, as they are inevitably denied the only true pharmacological treatment for anxiety: benzodiazepines. Interestingly, it is to be noted that many in the medical profession who are reluctant to prescribe benzodiazepines due to an apparent concern about physical dependency, do not appear to display the same reluctance when prescribing substitute medications such as anti-depressants that induce physical dependency as a matter of course.
Doctors are subject to the influence of the pharmaceutical industry. It has substantial resources with which to influence members of the medical profession, professional bodies and government.
The prescribing of benzodiazepines has reached the stage of having the characteristics of a clandestine practice, with those prescribing the medication forced to feel 'naughty' or 'deviant', such is the pressure to avoid the medication class.
Doctors can be influenced by their own professional organisations. If their professional organisations advise them to discourage benzodiazepine use, this is what many doctors will do regardless of the ramifications for their patients or the rationale for the advice.
The maligning of benzodiazepines has effectively reached a point where many doctors feel the burden of peer pressure to avoid the medication class. There is a subset of doctors however, that acknowledge the value and effectiveness of benzodiazepines and will treat their patients with the medication class. These doctors presently appear to comprise a minority of medical practitioners.
The following information is based on the actual experience of an elderly woman with severe Generalised Anxiety in the state of Victoria, Australia from 2015 to 2017. Her anxiety was as severe as is possible with physical symptoms such as shaking to the degree that she could not hold a cup steady enough to allow drinking. She was effectively abandoned by the medical profession and quite likely would have died as a result of being too anxious to eat and drink had family members not advocated for her and obtained treatment with benzodiazepines.
If you care for and/or are concerned for the welfare of an aged person or someone similarly vulnerable and they require treatment for clinically significant anxiety, you need to be extremely wary. A scenario of truly hellish proportions can await those who do not have someone knowledgeable regarding the treatment of anxiety advocating for them. Expect that the person will not be given benzodiazepines and therefore will not be treated properly for anxiety.
The first warning sign can be the prescription of an anti-depressant, typically a serotonin-boosting drug. The rationale for this from medical personnel may be that the "anxiety is coming out of the depression". If the person has been known to be anxious without the usual signs of depression, this appraisal will likely be an excuse not to prescribe benzodiazepines. Be prepared for every excuse 'under the sun' to justify not treating the person with benzodiazepines.
If you are caring for someone who has severe anxiety and who cannot advocate for themselves, be prepared for the possibility of a grim and frustrating scenario: that the medical profession will stubbornly refuse to treat the person with benzodiazepines. There is an answer; you must put your demand that the person be treated in writing. Doctors have no justifiable medical or ethical reason to withhold treatment.
If the person continues to deteriorate due to anxiety, be extremely wary of the next step: the intervention of psychiatric services. This brings with it the distinct possibility of 'treatment' with Electro-Convulsive-Therapy (ECT). This 'treatment' modality remains highly controversial. It involves passing enough electricity through the brain under general anaesthetic that a grand-mal seizure results.
The procedure is often carried out multiple times. The idea that passing a large electric current through the brain produces a beneficial therapeutic effect has not been proven. Common sense would suggest it is nothing short of an archaic and brutalising procedure.
There is no place for ECT in the treatment of anxiety
It can produce a transient improvement of symptoms but this is likely to be the result of the placebo effect and short-term memory loss (which the procedure is renowned for causing). It is not a safe, effective nor humane treatment for anxiety. The 'treatment' of a person for anxiety with ECT when a safe and effective drug treatment (benzodiazepines) exists is an obscenity.
Be aware of medical and nursing staff stating or suggesting that ECT is the logical progression in anxiety treatment when anti-depressants and anti-psychotics have not provided relief. Obviously, it is not part of a logical treatment progression. The logical and safe intervention for problematic anxiety is treatment with benzodiazepines.
The elderly are subject to an inherently anxiety-provoking situation: their own mortality. There is no way of removing this stressor and therefore, drug treatment for anxiety can be fundamentally necessary for their health, both mental and physical.
If an elderly person gets to the stage that they are in an anxious stupor and not eating and drinking, then death is a distinct possibility. The only course of action open to those who care about the person is to advocate on behalf of them and plead for treatment with benzodiazepines. This must be in writing to have any real chance of success.
Some doctors will act if they know the guardians of the patient are aware that benzodiazepines are the only true drug treatment for anxiety and are prepared to advocate strongly for the person. In these extreme circumstances, a sub-cutaneous injection of Midazolam for instance, can be life saving. This can be followed with ongoing treatment with medications such as Diazepam and/or Oxazepam for instance, to ensure that the person is not left to the ravages of extreme anxiety.
It is entirely possible for a vulnerable person with extreme anxiety to experience the following scenario -
Being refused correct pharmacological treatment for anxiety (benzodiazepines)
Being treated with medications that are not effective for anxiety
Being subjected to a 'treatment' (ECT) that is known to not be effective for anxiety and which cannot be described as being safe
Finally, essentially being left to die if they are unable to eat or drink due to anxiety
In summary, please be forewarned regarding the cold and dispassionate preparedness of many in the medical profession to not treat effectively, someone with life-threatening anxiety.
1. SSRIs - selective serotonin reuptake inhibitors. NPS Medicinewise. (2015) Web page.
Address: http://www.nps.org.au/ conditions/ mental- health- conditions/ mood- disorders/ depression/ for- individuals/ medicines- for- depression- antidepressants/ types- of- antidepressants/ ssris- selective- serotonin- reuptake- inhibitors
2. Stopping antidepressants. Schweitzer, isaac and Maguire, kay. Article on NPS Medicinewise. Aust Prescr 2001;24:51-51 Jan 2001DOI: 10.18773/ austprescr. 2001. 008. (2001) Web page.
Address: https://www.nps.org.au/ australian- prescriber/ articles/ stopping- antidepressants