The truth about benzo's...


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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.





small yellow clockFollowing is a concise but comprehensive account of benzodiazepines. Reading time: approximately forty minutes.



THE TRUTH ABOUT BENZODIAZEPINES AND THE MALIGNING OF A SAFE AND EFFECTIVE MEDICATION



Anxiety
What are they?
Seeking treatment
Maligning
Medical profession
The elderly



INTRODUCTION

The information on this page is intended to inform 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. It is not intended to be advisory in nature. 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 appropriate, the most likely scenario is that they will not be treated effectively. 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 many doctors won't prescribe them as a matter of course. Currently, there is a worldwide situation of safe, effective and inexpensive anxiety medication (benzodiazepines) being intentionally withheld by many within the medical profession. This has serious consequences for those suffering from anxiety and those who care about them.




Unfortunately, the medical and psychiatric professions have reached a point of being almost 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 permitted for the majority of medical or psychiatric conditions. For people with problematic anxiety however, this situation is a common and unfortunate reality.





ANXIETY

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, the loss of a job or bullying. Once the anxiety-provoking trigger ceases, the anxiety generally dissipates and finishes.

Constitutional anxiety - A person can have anxiety when there is no immediate threat in their lives. These people tend to be born with this inclination to be fearful and a tendency to worry excessively. The anxiety will generally 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 the loss of a job or bereavement.


BENZODIAZEPINES- WHAT ARE THEY?

Benzodiazepines are regarded as the prototypical medication class for anxiety, meaning they are essentially the original and the standard by which others are measured. 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 recognised of the class is perhaps Diazepam (Valium).

oxazepam tablets

Oxazepam tablets

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.

Anxiety could be described as the body's alarm system, whose job is to assist in surviving a threatening situation. 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. A major component of the process is the reduction of worry. 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.





The attributes of benzodiazepines when used for treating anxiety

At the correct dose, the benzodiazepines used to treat anxiety, alleviate worry and anxiety -

bullet pointwithout inducing euphoria (feeling high) or disinhibition (acting without concern for social restraints)

bullet pointwithout inducing problematic levels of sedation

bullet pointwithout having to be taken on a regular basis (they can be taken only as needed)

bullet pointwithout having to be taken at a mandated dosage level (the dose can be customised by the user to the minimum required)

bullet pointwith 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 worry and the resultant anxiety to levels that allow a much more enjoyable and productive life.


Tried and true benzodiazepines

Many variants evolved over time 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.

bullet pointDiazepam - Possibly the most widely recognised benzodiazepine, with three active metabolites: nordiazepam, temazepam and oxazepam

bullet pointOxazepam - A product of the metabolism of diazepam, with no active metabolites and which is often prescribed for Generalised Anxiety Disorder

bullet pointTemazepam - A product of the metabolism of diazepam and often prescribed for insomnia

bullet pointAlprazolam - A rapidly-acting variant commonly prescribed for Panic Disorder

bullet pointMidazolam - An essential medication for use in medicine, commonly utilised in anaesthesia before a surgical procedure

The great majority of circumstances where an anti-anxiety medication is required, will be successfully and safely treated by the medications listed here.


What benzodiazepines are not

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 the treatment of anxiety, their use is a balance between relief of symptoms and sedation. In regards to anxiety, benzodiazepines appear to inhibit activity in areas of the brain that initiate worry and thereby act to reduce the release of stress hormones. 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 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. If you are an inherently anxious person 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 can become 'anxious about anxiety'. People know that a certain situation such as a meeting or public speaking engagement will provoke anxiety. 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 and can assist in reducing avoidance of anxiety provoking situations.


Benzodiazepines as a long term treatment

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 -

bullet pointThey 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.

bullet pointThey have extremely low toxicity. The medication class is well known to be very safe and well tolerated.

bullet pointThey have no arbitrary dose and can be taken on an as-needed basis in a dosage tailored to the effective treatment of symptoms. This makes them valuable as a medication that does not arbitrarily cause neuroadaptation (physical dependency, 'addiction'), as do anti-depressants.

bullet pointThey are inexpensive, as they are generally 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 perceived risk of physical dependency. The sources claiming this commonly promote anti-depressants, primarily SSRIs, as the 'first-line' treatment for anxiety: a medication class for which physical dependency is completely normal.

So obviously, the 'risk' of physical dependency is not a genuine nor valid reason for sufferers of anxiety to be denied benzodiazepines on a long-term basis. Furthermore, there is no evidence that benzodiazepines commonly cause physical dependence at genuine therapeutic doses.


WHEN A PERSON WITH PROBLEMATIC ANXIETY SEEKS TREATMENT

If a person in Australia and by all accounts elsewhere in the world consults a doctor about anxiety, there is an extremely high probability that initially, they will not be offered the option of treatment with benzodiazepines. If it is apparent that they would benefit from pharmacotherapy (being treated with a medication), it is likely the following will happen -

1. If a medication is prescribed, it will most likely be an anti-depressant rather than a benzodiazepine and therefore will not be truly effective for anxiety

2. They will be referred for psychological intervention

3. They will be prescribed a medication whose effectiveness for anxiety has not been proven and also referred for psychological intervention

Currently, many doctors believe it is acceptable on their part to withhold safe and effective treatment for anxiety (benzodiazepines). Drug Truth Australia wishes to make the point that no doctor has the right to refuse treatment or to treat knowing that the treatment they have dispensed is not optimum in nature.


Medications prescribed for anxiety

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. The use of such a medication for anxiety might be questioned, as it has long been demonstrated that an inhibitory drug, the benzodiazepines, already have excellent efficacy.

SSRIs 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)

pink tablets

Image: Pexels

SSRIs have to be taken regularly to maintain the 'brain adjustment' that they induce and 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 have 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 concerning consequences of the maligning of the benzodiazepines is the prescription of anti-psychotics rather than the administering of benzodiazepines, which are known to have a relatively benign side effect profile. Doctors that submit to pressure to avoid benzodiazepines sometimes resort to prescribing anti-psychotics in the hope that they treat anxiety or 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.


Psychological interventions for anxiety

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 reducing anxiety to manageable levels, then medication is entirely appropriate.

Cognitive behaviour therapy will be of limited assistance if a person has a constitutional anxiety in which the worry is compulsive in nature. 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.

One distinct advantage that benzodiazepines have over the sole implementation of psychological interventions, is that medication can control worry and allow the person to concentrate on living. Psychological therapy inherently requires the devotion of thought to the process, which invariably distracts the person from everyday tasks at hand. The therapy therefore exacts a secondary burden, which is the time required to be devoted to implementing it.



red question markBenzodiazepines are the only genuinely effective pharmacological treatment for anxiety. Why then, are they prescribed reluctantly or not at all by many doctors?




THE MALIGNING OF THE BENZODIAZEPINES

There are obviously some reasons why a safe and effective 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 -

bullet pointThe original benzodiazepines are long out of patent and can no longer deliver the substantial profits that products under patent protection can. The patent protecting Diazepam expired in 1985, after commencing in 1963.

The primary mechanism that allows companies to recoup the immense development costs and maximise income from a new product, is the patent system. It allows a retail price that is unaffected by market-place competition. A product for which there is no direct competition can deliver returns that are unachievable by those affected by normal market forces.

As the 'benchmark' treatment for anxiety, the benzodiazepines are the inherent commercial competition to any other medication promoted for the treatment of anxiety. It would make good commercial sense to portray the benzodiazepines as problematic, whilst providing an alternative that provides a greater financial return.

bullet pointNo better medication for the treatment of anxiety has been developed. This situation denies industry the opportunity to market a genuinely superior medication for anxiety that is under patent protection. Benzodiazepines are safe and effective, with a minimal side-effect profile. It is conceivable that a better pharmacological treatment for anxiety will never eventuate.


Research and literature

It is almost inevitable that authors of research and literature that promotes the use of anti-depressants as treatment for anxiety and/or criticises benzodiazepines, have at some stage and in some way, received some kind of reward from the pharmaceutical industry. 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.


The treatment guidelines for anxiety disorders published by the Royal Australian and New Zealand College of Psychiatrists states that "[a]ntidepressants, especially the SSRIs and, to a lesser extent the SNRIs, are the first-line medications for panic disorder, SAD [Social Anxiety Disorder] and GAD [Generalised Anxiety Disorder], ...", despite also stating that "[b]enzodiazepines have well-established anxiolytic effects, ...". (3)

Two of the co-authors are on record in "Appendix 2" as having received "speaker fees" from pharmaceutical companies. These particular companies have amongst their products, anti-depressants and anti-psychotics. The 'speaker fees' are described in both cases as being "... outside of the submitted work ...".


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 in return for speaking when that activity is nominally performed 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.

The payment of medical personnel and researchers for the promotion of products and for the purposes of maligning the commercial competition, is an issue that fundamentally compromises the integrity of the medical profession as a whole.


Common themes used in maligning the benzodiazepines


Physical dependence

The maligning of the 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 -

bullet pointBenzodiazepines 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.

bullet pointThere has been a long-standing and concerted campaign to malign the 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.

bullet pointThere 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.




In terms of avoiding physical dependence, benzodiazepines are actually the ideal medication. 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, must be 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 physical dependency.

Simply put, physical dependency 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 (homeostasis). When the substance is removed suddenly or reduced in dose, a withdrawal syndrome can result.

representation of brain nerve-cell junction

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.


Protracted 'withdrawal'

'Withdrawal' that allegedly persists for extended periods of time is widely publicised as a reason for avoidance of benzodiazepines and the suffering of people with an underlying condition that was originally treated with the medication class.


Florid accounts about the medication allegedly being responsible for physical dependence that persists for extended periods abound in online 'support' and 'information' groups. Self-reported accounts of people 'withdrawing' for months or years are common. Elaborate 'tapering' regimes are often undertaken. No evidence exists indicating that benzodiazepines commonly cause physical dependence at genuine therapeutic doses or a withdrawal syndrome more persistent than any other medication or substance.


It is a basic trait of human behaviour that people can sometimes insist on apportioning blame for an undesired circumstance in their lives to something which has no relationship to the problem. Scapegoating is a common mechanism that can be employed by people in order to cope with an undesirable circumstance.

Consider a person with a constitutional (inherent or genetic) anxiety condition, 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 the underlying anxiety disorder to a withdrawal syndrome caused by benzodiazepines. They focus their frustration, resentment and hostility on benzodiazepines, a safe and effective medication that was not responsible for their malaise.




Some universal themes are present: a pre-existing condition which was initially treated with benzodiazepines, a decision to discontinue the medication, an insistence on suffering from a perceived benzodiazepine withdrawal syndrome and comprehensive denial of the underlying condition. Pre-existing conditions are commonly panic disorder and generalised anxiety. Conditions unrelated to anxiety, such as brain injury, are also encountered.




Many such people claim to be suffering from protracted withdrawal syndromes attributable to benzodiazepines, often quoting a plethora of bizarre symptoms. A claim of benzodiazepine-related withdrawal lasting for years is indicative of one thing: that the person is suffering from the symptoms of the underlying disorder and not from a withdrawal-related syndrome.

Some people who insist on scapegoating benzodiazepines take this to an extreme level, such as forming support groups, some of which have substantial resources. These groups aggressively lobby politicians and encourage measures such as restrictions on benzodiazepine prescribing for example.

They often utilise social media and post videos proclaiming their 'injured' status. People with the same tendency to scapegoat see these accounts and proceed to unfairly blame benzodiazepines themselves, apparently assuming credibility purely due to the apparent weight of numbers claiming to be afflicted. The phenomenon intensifies, and has taken on the form of a significant world-wide subculture.


Potential for 'abuse'

'Potential for abuse' is commonly cited as a factor by those seeking to portray benzodiazepines as problematic. 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 who 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'.


Falls amongst the elderly

Possibly the most cynical method of maligning the medication class is to infer a 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 rather than there being any evidence that the medication actually contributed to an adverse event. Studies are typically based on the 'meta-data' style of research rather than clinical, controlled methodology.





THE MEDICAL PROFESSION AND BENZODIAZEPINES

Following are some points regarding the reluctance of many in the medical profession to prescribe benzodiazepines -

bullet pointDoctors 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 industry is very aggressive regarding the promotion of their products and the provision of free samples of medications and gifts such as stationary to doctors, is a common example of this.

bullet pointDoctors can be heavily influenced by their own professional organisations. If their professional bodies advise them to discourage benzodiazepine use, this is what many doctors will feel bound to do, regardless of the ramifications for their patients or the rationale for the advice.

bullet pointSome doctors and other medical personnel such as psychiatric nurses, mistakenly believe that benzodiazepines commonly induce physical dependence at therapeutic doses. They, along with some patients, can incorrectly attribute the return of anxiety symptoms on discontinuation of benzodiazepines to withdrawal from the medication.

These doctors 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 problematic and are to be avoided.

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 concern or reluctance when prescribing substitute medications such as anti-depressants that induce physical dependency as a matter of course.




The prescribing of benzodiazepines has almost reached the stage of having the characteristics of a clandestine practice, such is the pressure on practitioners to avoid the medication class.




The maligning of the benzodiazepines has resulted in a situation where many doctors have submitted to the burden of peer pressure to avoid the medication class. There is a subset of doctors however, that acknowledge the value of benzodiazepines and will treat their patients with them. These doctors presently appear to comprise a minority amongst the medical profession.





ANXIETY, THE ELDERLY AND OTHER VULNERABLE GROUPS

The elderly, like everyone else, have the right to be treated correctly. Currently in Australia however, it is highly unlikely that an elderly person with anxiety will be treated effectively. The medical profession in general, have an extreme aversion to treating an elderly person with benzodiazepines.

If an elderly person has problematic anxiety, it is likely they will be treated with medications that are not truly effective for anxiety and have many more side-effects than benzodiazepines. These medications can include SSRIs, tri-cyclic anti-depressants, anti-psychotics and anti-histamines. The most concerning treatment modality is Electro Convulsive Therapy (ECT).

The rationale for withholding appropriate treatment with a safe and effective medication is not based on evidence, but simply on the anti-benzodiazepine hysteria that has led to a large proportion of the medical profession being highly reluctant to utilise the medication class. Following is an actual account of the situation that can arise when appropriate treatment is withheld.


A real-life example

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 effectively 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 imaginable 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, 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 to intentionally initiate a grand-mal seizure.

The procedure is often carried out multiple times. The idea that passing a large electric current through the brain results in a beneficial therapeutic effect, has not been proven. Common sense would suggest it is nothing short of an archaic and brutalising procedure.

ECT machine

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 of being 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 pharmacological 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 -

bullet pointBeing refused correct pharmacological treatment for anxiety (benzodiazepines)

bullet pointBeing treated with medications that are not effective for anxiety

bullet pointBeing subjected to a 'treatment' (ECT) that is known to not be effective for anxiety and which cannot be described as being safe

bullet pointFinally, 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.




REFERENCES

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

3. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Gavin Andrews, Caroline Bell, Philip Boyce, Christopher Gale, Lisa Lampe, Omar Marwat, Ronald Rapee and Gregory Wilkins. First published in the Australian and New Zealand Journal of Psychiatry 2018, Vol. 52 (12) 1109 - 1172.




five drug types