Mother needs something today to calm her down And though she’s not really ill There’s a little yellow pill She goes running for the shelter of a mother’s little helper
AS THESE LINES of the 1966 Rolling Stones song “Mother’s Little Helper” remind us, Valium and other members of the benzodiazepine class of tranquilizing drugs have long been a part of popular culture. But how well do these medications work, and what are their dangers?
At some point in their lives, 25 percent of Americans will develop an anxiety disorder: panic disorder, generalized anxiety disorder, phobias, obsessive-compulsive disorder, or post-traumatic stress disorder. Many other people will experience significant problems with anxiety and stress that are not severe enough to qualify for a formal diagnosis. It is therefore not surprising that psychiatrists and psychologists have sought effective treatments for anxiety. Psychologists have looked primarily to psychotherapy and psychiatrists primarily to drug therapy.
The main type of psychotherapy that has been shown to be helpful in the treatment of anxiety problems is cognitive-behavioral therapy (CBT). This therapy involves gradual exposure to feared situations and the implementation of cognitive methods to reduce the catastrophic thinking that is so common in anxiety. This therapy typically yields positive effects in approximately 16 sessions. When the anxiety problem is severe, however, or when other significant psychological problems are present, therapy may take considerably longer.
Two main types of drugs are used to treat anxiety: selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. SSRIs, which include Prozac, Zoloft and Lexapro, constitute the most common drug therapy for depression, and they also have proved helpful for anxiety. They typically require two to four weeks before they start to work and need to be taken daily. In contrast, benzodiazepines work soon after the patient swallows the pill—in most cases leading to relaxed feelings within 10 to 30 minutes. Benzodiazepines can be taken on either a regular or an as-needed basis. Given how they act, it is not surprising that they are among the most commonly prescribed medicines for anxiety [see table on opposite page].
Despite this understandable appeal, numerous concerns and controversies surround the use of benzodiazepines. Further, many people are unaware of many of the potential problems with these drugs.
Side Effects and Withdrawal
In general, benzodiazepines all have the same calming effects, but they differ in the strength of these effects (which also depends on dosage) and how long they stay in the system. Most people who take benzodiazepines experience few side effects if they take them for short periods or on an as-needed basis. Yet because anxiety disorders are usually chronic, benzodiazepine treatment is often prolonged, resulting in an increased risk of side effects.
Side effects that can occur primarily with regular and extended use include physical and psychological dependence, withdrawal symptoms (especially when the medication is discontinued abruptly), reduced alertness, drowsiness, physical fatigue, impaired physical coordination, and memory loss. When benzodiazepines are ingested along with alcohol, the likelihood and strength of these side effects increase greatly, because both are central nervous system depressants. In rare cases, the results can be fatal.
One of the most common withdrawal symptoms is rebound anxiety—return of the anxiety at the same or worse levels than before. Studies have shown that 50 to 75 percent of people with panic disorder relapse when they stop taking benzodiazepines. Other possible withdrawal symptoms include abdominal pains and cramps, depression, dizziness, lethargy (physical and mental inertness), flulike symptoms, palpitations, insomnia and irritability. People who experience withdrawal often return to the medication to avoid these symptoms, which can result in a vicious cycle of dependence.
New Options
Benzodiazepines and newer related medications that aid sleep—for example, Ambien and Lunesta—are also commonly prescribed for people with insomnia, which is often associated with anxiety disorders. Although both sets of medications can cause dependence, this problem is less serious for the newer sleeping medications. A recent study of a new nonbenzodiazepine sleeping medication called Rozerem raises the possibility that it may not have potential for substance abuse or for motor or cognitive impairment, although psychological dependence is still a possibility.
Research studies show that a viable alternative to anxiety or sleeping medications of any kind is CBT, which has proved quite helpful for patients. CBT and the benzodiazepines are about equally effective for anxiety when subjects are compared before and after treatment. After discontinuation of treatment, however, those who relied on a benzodiazepine experience much higher relapse rates. Generally, if patients keep taking the drug, they will relapse at a lower rate, but then they risk the side effects of regular and long-term use. In contrast, no such problems exist with CBT. Moreover, drug therapy is considerably more expensive than CBT because the medications must be taken continuously for their effects to persist. In contrast, the effects of CBT endure fairly well after treatment has ended.
Is combining CBT and antianxiety medication better than using either alone? Studies find that combined treatments (when the drug is either a benzodiazepine or SSRI) do not do any better than either treatment alone and find that subjects administered medication show significantly higher relapse rates when it is discontinued.
So, what’s the bad and good news? First, the bad news. Benzodiazepines work only as long as you continue to take them. They can cause psychological and physiological dependence, lead to serious withdrawal symptoms and engender a number of other undesirable consequences.
Now the good news. Used on an as-needed or short-term basis, benzodiazepines can alleviate anxiety problems while minimizing side effects. Used regularly, they are effective in reducing anxiety problems but cause side effects. Tapering off the drug, rather than stopping abruptly, can minimize problems with withdrawal.
Anyone seeking treatment for an anxiety problem would do well to first consider CBT. This treatment is more effective and cheaper than drug therapy and does not cause dependence, withdrawal or other side effects. A second option to explore before taking benzodiazepenes are SSRIs, which have fewer problems with dependence and withdrawal. As a third option, benzodiazepines may be helpful when their use is closely monitored by a knowledgeable psychiatrist or other medical professional.
AS THESE LINES of the 1966 Rolling Stones song “Mother’s Little Helper” remind us, Valium and other members of the benzodiazepine class of tranquilizing drugs have long been a part of popular culture. But how well do these medications work, and what are their dangers?
At some point in their lives, 25 percent of Americans will develop an anxiety disorder: panic disorder, generalized anxiety disorder, phobias, obsessive-compulsive disorder, or post-traumatic stress disorder. Many other people will experience significant problems with anxiety and stress that are not severe enough to qualify for a formal diagnosis. It is therefore not surprising that psychiatrists and psychologists have sought effective treatments for anxiety. Psychologists have looked primarily to psychotherapy and psychiatrists primarily to drug therapy.
The main type of psychotherapy that has been shown to be helpful in the treatment of anxiety problems is cognitive-behavioral therapy (CBT). This therapy involves gradual exposure to feared situations and the implementation of cognitive methods to reduce the catastrophic thinking that is so common in anxiety. This therapy typically yields positive effects in approximately 16 sessions. When the anxiety problem is severe, however, or when other significant psychological problems are present, therapy may take considerably longer.
Two main types of drugs are used to treat anxiety: selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. SSRIs, which include Prozac, Zoloft and Lexapro, constitute the most common drug therapy for depression, and they also have proved helpful for anxiety. They typically require two to four weeks before they start to work and need to be taken daily. In contrast, benzodiazepines work soon after the patient swallows the pill—in most cases leading to relaxed feelings within 10 to 30 minutes. Benzodiazepines can be taken on either a regular or an as-needed basis. Given how they act, it is not surprising that they are among the most commonly prescribed medicines for anxiety [see table on opposite page].
Despite this understandable appeal, numerous concerns and controversies surround the use of benzodiazepines. Further, many people are unaware of many of the potential problems with these drugs.
Side Effects and Withdrawal
In general, benzodiazepines all have the same calming effects, but they differ in the strength of these effects (which also depends on dosage) and how long they stay in the system. Most people who take benzodiazepines experience few side effects if they take them for short periods or on an as-needed basis. Yet because anxiety disorders are usually chronic, benzodiazepine treatment is often prolonged, resulting in an increased risk of side effects.
Side effects that can occur primarily with regular and extended use include physical and psychological dependence, withdrawal symptoms (especially when the medication is discontinued abruptly), reduced alertness, drowsiness, physical fatigue, impaired physical coordination, and memory loss. When benzodiazepines are ingested along with alcohol, the likelihood and strength of these side effects increase greatly, because both are central nervous system depressants. In rare cases, the results can be fatal.
One of the most common withdrawal symptoms is rebound anxiety—return of the anxiety at the same or worse levels than before. Studies have shown that 50 to 75 percent of people with panic disorder relapse when they stop taking benzodiazepines. Other possible withdrawal symptoms include abdominal pains and cramps, depression, dizziness, lethargy (physical and mental inertness), flulike symptoms, palpitations, insomnia and irritability. People who experience withdrawal often return to the medication to avoid these symptoms, which can result in a vicious cycle of dependence.
New Options
Benzodiazepines and newer related medications that aid sleep—for example, Ambien and Lunesta—are also commonly prescribed for people with insomnia, which is often associated with anxiety disorders. Although both sets of medications can cause dependence, this problem is less serious for the newer sleeping medications. A recent study of a new nonbenzodiazepine sleeping medication called Rozerem raises the possibility that it may not have potential for substance abuse or for motor or cognitive impairment, although psychological dependence is still a possibility.
Research studies show that a viable alternative to anxiety or sleeping medications of any kind is CBT, which has proved quite helpful for patients. CBT and the benzodiazepines are about equally effective for anxiety when subjects are compared before and after treatment. After discontinuation of treatment, however, those who relied on a benzodiazepine experience much higher relapse rates. Generally, if patients keep taking the drug, they will relapse at a lower rate, but then they risk the side effects of regular and long-term use. In contrast, no such problems exist with CBT. Moreover, drug therapy is considerably more expensive than CBT because the medications must be taken continuously for their effects to persist. In contrast, the effects of CBT endure fairly well after treatment has ended.
Is combining CBT and antianxiety medication better than using either alone? Studies find that combined treatments (when the drug is either a benzodiazepine or SSRI) do not do any better than either treatment alone and find that subjects administered medication show significantly higher relapse rates when it is discontinued.
So, what’s the bad and good news? First, the bad news. Benzodiazepines work only as long as you continue to take them. They can cause psychological and physiological dependence, lead to serious withdrawal symptoms and engender a number of other undesirable consequences.
Now the good news. Used on an as-needed or short-term basis, benzodiazepines can alleviate anxiety problems while minimizing side effects. Used regularly, they are effective in reducing anxiety problems but cause side effects. Tapering off the drug, rather than stopping abruptly, can minimize problems with withdrawal.
Anyone seeking treatment for an anxiety problem would do well to first consider CBT. This treatment is more effective and cheaper than drug therapy and does not cause dependence, withdrawal or other side effects. A second option to explore before taking benzodiazepenes are SSRIs, which have fewer problems with dependence and withdrawal. As a third option, benzodiazepines may be helpful when their use is closely monitored by a knowledgeable psychiatrist or other medical professional.
