Benzodiazepines, or benzos, are a class of medications that act as central nervous system depressants. They’re used for a variety of different purposes, but in the context of psychiatric treatment, they sometimes end up being used in managing mental illnesses that they aren’t actually indicated for. In some cases, over-reliance on benzos can mean that people’s illnesses go under-treated. This post will look at how benzos are used and what they do and don’t help with.
What benzodiazepines are
Benzodiazepines bind to receptors for a neurotransmitter called GABA (gamma-aminobutyric acid), specifically GABA-A receptors. GABA is an inhibitory neurotransmitter that acts in opposition to the excitatory neurotransmitter glutamate.
Examples of benzos, which are often recognizable by names ending in -pam, include:
- alprazolam (Xanax)
- clonazepam (Klonopin)
- diazepam (Valium)
- lorazepam (Ativan)
- oxazepam (Serax)
- temazepam (Restoril)
- triazolam (Halcion)
The individual drugs within this class differ in a number of properties, including time to onset of action, duration of action, half-life, and whether or not they have active metabolites (i.e. whether they’re broken down by the liver into a compound that also acts as a benzo).
What benzos are used for
Benzodiazepines have sedative, hypnotic, anxiolytic, and anticonvulsant properties. They have a number of therapeutic uses, including:
- procedural sedation: IV midazolam is an example of this
- medical management of alcohol withdrawal: diazepam, which has a long half-life, is commonly used for this
- insomnia: oxazepam and temazepam are the most commonly used for this, based on their duration of action and lack of active metabolites
- seizures: clobazam is used in the management of a certain form of epilepsy, and lorazepam is used in status epilepticus, a neurological emergency
- anxiety and panic: they work well and they work quickly, but they’re more useful short-term than long-term
- acute agitation
They’re also sometimes used for muscle spasms and restless legs syndrome.
Potential adverse effects
The risk of adverse effects, especially with long-term use, is a major limitation of benzos. They can cause cognitive impairment (including confusion and memory problems), particularly in the elderly. They can also increase impaired coordination, with an increase in fall risk in the elderly.
They’re potentially addictive. Addiction encompasses psychological and physical dependence, and physical dependence involves tolerance (needing progressively higher doses to achieve the same effect) and withdrawal (symptoms that occur when the drug is discontinued). Ongoing benzo use is likely to cause conformation changes in GABA receptors, leading to the development of tolerance and susceptibility to withdrawal effects.
Discontinuing benzos after long-term use needs to be done slowly and carefully; there are various guidelines for tapering, including these in the journal Canadian Family Physician or these from the College of Psychiatric and Neurologic Pharmacists).
While benzos normally have a calming effect, in some cases, they cause the opposite effect, producing irritability, impulsivity, and aggression. This is called a paradoxical reaction, and it likely relates to the drugs’ disinhibiting effects.
The use of multiple CNS depressants (such as multiple benzos) at the same time increases the risk of side effects, and multi-benzo-ing should generally be avoided.
What they help with
In terms of the conditions that benzodiazepines are useful for, there’s research that they’re effective, when used short-term, in panic disorder, generalized anxiety disorder, social anxiety disorder, and insomnia.
While the research evidence is there for short-term use, it just isn’t there for long-term use. The development of tolerance is likely to limit their effectiveness, although, for some people, benzos are the only thing that works for their symptoms, and the benefits may outweigh the potential downsides.
In theory, benzos might be useful when starting an antidepressant for an anxiety disorder, as antidepressants take a while to work and can actually worsen anxiety initially. However, there’s a lack of research to support this approach, and even if the intention is to limit the duration of benzo use, that may not end up happening for various reasons.
Benzos can be very useful in acute settings for managing acute agitation. A common combination is a fast-acting drug like lorazepam and an antipsychotic like loxapine or haloperidol.
What they don’t help with
There are a number of conditions for which benzodiazepines are either unhelpful or can cause harm:
- Borderline personality disorder: the disinhibiting effects can increase impulsivity (which is a symptom of BPD)
- Depression: potential worsening of dysphoria and suicidality
- Dissociative disorder: benzos should be used with caution as they can exacerbate dissociation
- Phobias: not effective
- PTSD: not effective, and when taken in the aftermath of having experienced a traumatic event, they can actually increase the risk of developing PTSD
While benzos are effective for insomnia in the short term, their long-term usefulness is limited, as tolerance is likely to develop to the sedative effects, and there is the potential for rebound insomnia, meaning that discontinuation of the drug can lead to insomnia that’s worse than what the drug was initially prescribed for.
Benzos in bipolar and psychotic disorders
Mood stabilizers or antipsychotics for acute mania or psychosis take time to work, and benzos can manage agitation and get people sleeping until those drugs start working. They don’t actually treat bipolar or psychotic disorders, though, and they shouldn’t serve as a substitute for treatments that are indicated for those conditions.
However, that doesn’t stop them from getting prescribed that way. In her book Shame Ate My Soul, Sue Walz wrote about how she was treated inappropriately for years with clonazepam in relation to a diagnosis of bipolar disorder, and then it was stopped cold turkey rather than tapering her off.
Benzos often end up being used long-term in people with psychotic disorders like schizophrenia, but there’s a lack of evidence to support this practice. They can also negatively impact cognitive function, and they may even increase mortality risk.
For people who are experiencing akathisia (restlessness) as a side effect of antipsychotics, benzos can offer some relief. If that’s an ongoing issue, though, the prescriber should probably be re-evaluating the antipsychotic regimen to find a way to reduce the side effects.
Responsible prescribing is important
Benzodiazepines have their downsides, but that’s no reason to take them off the table entirely. It’s certainly not a justification for prescribers to pass judgment on patients who take them or to make it a massive pain in the ass for people to get their meds reordered. Drugs with the potential for abuse, whether that be benzos, stimulants, opioids, or anything else, should not be denied to patients who could really benefit from them. And don’t even get me started on GPs who are scared of psych meds and the people who take them.
To me, the key is responsible prescribing when docs are looking at starting people on benzos or bumping up their doses to deal with emerging or worsening symptoms of illness. Responsible prescribing should involve evidence-based practice, educating patients about the risks and benefits, and working collaboratively with patients to evaluate what’s working and what’s not. If a patient has a condition that a benzo isn’t indicated for, there should be a compelling reason for ordering one in the first place. If prescribers are using benzos as a bandaid, that’s one thing if it’s well thought out, but it shouldn’t be an excuse not to explore treatments that are likely to provide more lasting benefits.
There have been times in the past when I’ve used lorazepam or clonazepam as very intentional bandaids for specific things, but they’ve never played a big part in my treatment, which is appropriate, given that my diagnosis is major depressive disorder. Have you ever taken a benzo to help with managing your mental illness? What has that been like for you?
References
- CADTH (Canadian Agency for Drugs and Technologies in Health). (2019). Benzodiazepines for the treatment of adults with mental health conditions or sleep disorders: Guidelines.
- Gentile, J. P., Dillon, K. S., & Gillig, P. M. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innovations in Clinical Neuroscience, 10(2), 22.
- Guina, J., & Merrill, B. (2018). Benzodiazepines I: Upping the care on downers: The evidence of risks, benefits and alternatives. Journal of Clinical Medicine, 7(2), 17.
- Panesar, K. (2015). Controlling symptoms of borderline personality disorder. U.S. Pharmacist, 40(11), 44-47.
- Peritogiannis, V., Manthopoulou, T., & Mavreas, V. (2016). Long-term benzodiazepine treatment in patients with psychotic disorders attending a mental health Service in Rural Greece. Journal of Neurosciences in Rural Practice, 7(S 01), S026-S030.
- Sim, F., Sweetman, I., Kapur, S., & Patel, M. X. (2015). Re-examining the role of benzodiazepines in the treatment of schizophrenia: A systematic review. Journal of Psychopharmacology, 29(2), 212-223.
- The Royal Australian & New Zealand College of Psychiatrists. (2019). Professional practice guideline 5: Guidance for the use of benzodiazepines in psychiatric practice.
For more info and MH@H posts on psychiatric medications, visit the Psych Meds Made Simple page. There’s also a Psych Meds 101 series covering:
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
This is so good and so important. When I went to Cedars for my ED, I was addicted to benzos and didn’t know it, though I was popping 4-6 a day. The withdrawal from stopping precipitously was brutal – the restless legs still plague me. Doctors (MDs) gave me benzos to deal with anxiety, sleeplessness, ideation. I found they made me numb, so I took them regularly. Doctors don’t discuss aspects of medication enough, nor do they monitor enough those of us who might have proble s with the meds. My “choice” was very uninformed.
Doctors really need to be doing more.
This article is very well written. I have a prescription for clonazepam to use prn for panic attacks and a bottle of 15 often lasts me 6 months because I’m well managed on Prozac and Wellbutrin for my anxiety (working on a post about the Prozac induced weight gain…). I’m still baffled that my grandmother is prescribed Xanax as her sole prescription for her anxiety by her GP 😒
That’s pretty bizarre to be relying on a benzo for that in an elderly person.
Luckily my grandma is very cautious so she splits her already low dose pills into halves and sometimes fourths haha.
Informative article. It worries me that in my home country, Brazil, several pharmacists will dispense this medication without a prescription. I know a few elderly people who are dependent and take it without medical supervision. Those people, my parent’s generation, were formerly frequent users of Valium, which used to be freely sold without a prescription in that country in the 60s and 70s.
Oh that doesn’t sound very safe.
We were on xanax for years. Unsure how many, maybe 5? Usually, it was the only relief we experienced. We managed it pretty well, being careful not to take it too often. What ultimately led to our unknown addition were two factors: a mental health therapist that instructed us to take our Xanax on a regular schedule to give us some stability (we were taking it prn) and the pandemic, which resulted in people being in our home 24/7 with us, which jacked up our anxiety and increased our frequency and dosage.
We tapered too quickly and the withdrawal was very hard. We still feel worse physically and emotionally having gone through the withdrawal. We miss xanax soooooooooooooooo much. Thinking about getting back on it honestly.
It helps with panic and hyperarousal. We haven’t tried to fly on an airplane without it and probably won’t. Anti-depressants haven’t worked and we’ve tried at least half a dozen and in combination with each other and mood stabilizers. Xanax was the only med that gave any relief. Valium made us too tired.
Psychiatrist said we were dependent on xanax. Hell ya. It’d be nice to develop other coping skills. We are working on it, have been for years. It’s not effective yet.
That’s really tough.
Benzos have been overprescribed in my case as a rather long-term bandaid for my mental health conditions. Even though I do suffer with anxiety, mine is trauma-related and, as such, your comment about benzos exacerbating PTSD symptoms is rather enlightening. Besides, I do also have BPD symptoms and probable DID/OSDD, so that’s a triple reason I shouldn’t really have been put onto benzos. Of course, the first time I was prescribed oxazepam for agitation back in 2007, none of this was known about me and I was just seen as a manipulative, challenging pain in the neck of the psych ward nursing staff. Anyway, thanks for this interesting overview. I think I’m going to write a post of my own sharing my experiences.
That’s really crappy that the hospital staff just wrote you off that way.
Paradoxical reactions sound so mystifying – If Benzos had been discovered/developed in the last few years, would the onset of such effects during trials have seen Benzos get into the market I wonder, as the pathway to approval has become so stringent.
That’s a good question. I think they probably would, as for short-term or as needed use for the conditions they’re appropriate for, the benefits would generally outweigh the risks.
I kinda stopped reading at the first mention of ‘anticonvulsant’ because my husband takes primidone for his hand tremors, so I went down that rabbit hole – it was interesting reading.
I bet.
Never had any problems with Diazepam over here. They are the only meds I know will always definitely help me in an emergency or if I’m having a panic attack, a rage/anger attack or severe irritability… they help me relax and I use them to help me sleep at times… also anxiety… they pretty much help with everything.
Personally I love them.
I’ve never got addicted to them but I can see why they would be.
They are the go to drug of my choice though if I’m having a really super bad day, and it’s affecting me.
I’m glad you’ve got something that helps.
Oof, yes I’ve seen many patients with PTSD on benzos-usually xanax which honestly scares me in general. Your article essentially echoes my entire opinion on benzos! I think an unfortunate reason a lot of physicians and patients may over-rely on benzos has to do with the structure of our medical system, which often promotes the quick fix due to how expensive our care can get. There’s of course a lot more that goes into it than that. I could talk forever on why certain problems exist in our treatment of patients haha. Maybe you share similar thoughts?
I agree. Funding proper trauma therapy looks more expensive, but actually helping people heal works out a lot better for all involved in the long run.
Great post and excellent research done! I don’t take these types of drugs. I stick with the antipsychotic, mood stabilizer, and anti-depressant. Have a nice day!
I’m on a similar combo.
Thanks as always for the education. I use klonopin/clonazepam largely as a PRN to help with anxiety. I have often wondered if I have built up an immunity. So far, so good. Thanks again,
Limited prn use seems like a good way to avoid building up a lot of tolerance.
Yes, thanks.