Over the past year or so, this sort-of-biweekly series has shined the spotlight on a host of medications used to treat the two poles of bipolar disorder. The medications and medication classes we have covered so far include lithium, anti-seizure medications (including Depakote and Lamictal), antipsychotics and atypical antipsychotics (including Zyprexa and Seroquel), SSRI antidepressants (including Prozac and Paxil), SSNRI antidepressants (including Cymbalta and Effexor), and the older Tricyclics and MAOI’s for treating depression.
This week, we shift gears to start our coverage of medications not exactly designed for treating mania or depression but that nevertheless may come in very handy for treating symptoms that often accompany bipolar disorder and may contribute to its severity – symptoms such as anxiety and sleeplessness. Today, we examine anxiolytics (pronounced ang-zee-oh-li-tiks), sometimes referred to as tranquilizers – medications used to alleviate anxiety and calm the nerves. The main family of anxiolytics is made up of the benzodiazepines – commonly referred to as ” benzos.”
Benzodiazepines are central nervous system depressants – they slow down the whole nervous system. They are extremely effective at quickly reducing anxiety and agitation, both of which can be problems in bipolar disorder. These medications act within 20-30 minutes in most cases, unlike antidepressants or the atypicals that have to build up in the system. Panic attacks commonly co-exist with bipolar disorder, and these medications are often used to shut down a panic disorder immediately. They appear to work at the level of a brain chemical called GABA (gamma-aminobutyric acid), which has a calming effect on neurons.
A major concern with benzodiazepines is that if the dose is too high it will start to shut down various brain functions, causing severe sedation and stupor and eventually slowing a person’s breathing, which can be fatal. Benzos work on the same receptors that alcohol affects, so combining Benzos and alcohol vastly increases the risk of a serious central nervous system shut down. Another big problem with these medications is the potential for addiction and dependence – the body will become dependent on benzodiazepines if they are used regularly and will typically require ever increasing doses. These medications are at high risk for being abused.
The most commonly prescribed are the following:
In choosing between these medications, the primary criteria are duration of action and patient reaction. Some people find one or the other more or less effective or tolerable, and reactions are very individualized.
The primary benefit of the medications in this class is that they rapidly alleviate anxiety and agitation. They are also used as anti-seizure medications and are core medications in treating people with alcohol dependence who are detoxing and at risk of seizures due to the detox. These medications can also be used as sleep aids when given at night.
Because benzodiazepines are central nervous system depressants, they have the capacity to cause the following negative side effects:
I prefer to avoid this class of medications, if possible, because of the risks they present, but when they are necessary, they are powerful and effective. The most common way I use them is at the beginning of treatment for anxiety – if we are waiting for an SSRI to begin to reduce anxiety or panic attacks, for example. These medications are powerful for panic – they can shut down an attack very quickly. For many people, just knowing they can turn off a panic episode helps reduce the secondary fear of having an episode – a fear that can trigger or exacerbate panic. Just knowing they have a pill with them is sometimes enough to significantly reduce frequency of panic.
When a benzodiazepine is necessary, I always look for ways to reduce the dose and use, if possible, but some people require these medications on a daily basis to help manage their anxiety. Careful monitoring of dose requirements is important here.
We tend to avoid using these medications in children and teens when possible. They can sometimes have a paradoxical response in young people, disinhibiting them and causing more agitation.
If you’ve taken any of the anxiolytics covered in this article or are a doctor who has prescribed them, please post a comment to share your experiences and insights. If you’ve taken the medication, include specifics on why you were prescribed it and how you felt when taking it – did it help or do more harm than good?
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Hello.
I have been taking Xanax for a few years for generalized anxiety. I could not dream up a better drug for myself. Despite good counseling, exercise, etc., I still have a strong tendency towards anxiety. Xanax works well for my anxiety with no side effects. It gives me flexibility in dosing – I use as much or as little as needed, including zero on some days. When I do not need it, I experience no withdrawal effects, nor have I experienced a general need for increased dose.
The only drawback is that it can make me sleepy, but I have gotten fairly good at taking small enough amounts to minimize that. It’s very good long-term option for me, especially given that SSRIs cause problems for me.
Martina
I have anxiety problems along with being bi-polar (whatever that is exactly) and am having to use a regular dose of Klonepin for the anxiety which seems to work well. I have high blood pressure (seriously high blood pressure which requires some help with the stress and anxiety). It is a never ending merry go round of meds and I haven’t found perfect one yet. I am now going through pretty bad depression episode and don’t know what to try next…
Lynda
I take Abilify and Sertraline (Zoloft)daily but have Klonopin available if my anxiety breaks out. I find the biggest advantage is one you mentioned – that it calms me to know that I have a med available if I panic. I find the Klonopin sedates me a little too much so I avoid taking it unless I really have to…the prescription is to take 0.5 mg up to twice a day but if took it twice in one day, I’d never get out of bed. As it is, I take one once a week or so, and am glad to have it as an option.
The few times I’ve been on benzos (Valium and Serepax), within a week I was addicted and needing more. Even with 2.5mg of Valium a night prescribed, I was soon taking 40mg at a time.
While very effective for anxiety, I personally cannot use them as I’m extremely prone to downing a bottle in time of stress.
Should possibly add I was on Zoloft at the time, now also take Zyprexa, and started at 16, now 18.
My experience with “benzos” was not a happy one. I was prescribed Ativan for sleep but found quickly that it was not strong enough. I was then given Klonopin, which worked better. Soon I was having terrible daytime agitation and irritability. My doctor was on vacation and his on call suggested I increase my intake of Klonopin. Soon I was taking 1mg three times each day plus another mg to sleep at night. This proved to be too high a dose for me, and when I found I was going to run out of pills before my doctor was back to prescribe them, I called every doctor I had spoken to before to try to get a new prescription. No one could prescribe it for me, and I found myself in the ER in a panic, and feeling suicidal. I was admitted and when I saw the doctor in the hospital, he took one look as me and saw that I wa heavily sedated, but still agitated and panicky. I had thoughts of taking entire bottles of medicine to try to feel better. He weaned me off of Klonopin and I am no longer using “benzos.” It seems to me that many doctors treat this class of drugs very casually and allow patients to regulate their own intake of the drugs. In my case, it was not a good idea because even in larger doses, I was having the opposite of the expected reaction which was leading me to take more and more of the drug. I was in the hospital for 11 days largely because of Klonopin.
I was prescribed Klonopin about 15 years ago for severe panic attacks and general anxiety. I had just started therapy for DID/clinical depression and was also prescribed Zoloft. The initial dose was 1 mg. 3 times a day. That helped very much but certainly did not make me sleepy at all. I have to add that at that time I was an active alcoholic consuming close to a quart of whiskey a day. Before I started Klonopin I could barely speak to anyone without blushing profusely. This stopped immediately when I started Klonopin, what a relief. Over the following years there have been short periods where I have taken 4 mg. per day but as my psychotherapy progresses I find taking 2 mg. per day works very well. I have since stopped drinking without having the feeling that I needed to replace the drinking with a higher dose of Klonopin. I have also taken Ativan for brief periods.
Have been on Prozac so long I needed something for panic. Was given Klonopin. Hated it because it made me feel like I was underwater. But it did work for the panic. Then went on Topomax. Hated that too. Kept getting those “shocks” in the back of my head. Finally found the mix that seems to work. Fluoxtine (40 mg morning, 20 mg afternoon); Aplenzin 348 mg (instead of Wellbutrin XL 150 because of cost); 70 mg. Not sure why this works, but almost no panic, am awake most of the time (haha)and depression I can handle most of the time.
I’m diagnosed with anxiety, bipolar type I, and adhd. I was put on clonazepam (klonopin) for my anxiety and adderrol for my adhd which was the completely wrong thing to do bc I suffer from addiction as well (goes hand in hand w/ bipolar). I would not suggest these medications bc they are benzos and they can become addictive. i was on such a high dosage of clonazepam, that I had some pretty serious withdrawls when a new psychiatrist took me off of them.
How come who were given the benzos 30 years ago are looked like dirt and treaded like crap by doctors. Doctors should know that in the 60 and 70s they were given mlike candy. I started to take them for a slipped disc. I am tired of the way you friends, family ,and doctors treat you. No one for at least 30 years wARNED ME OF ANYTHING.
bOTTOM LINE DOCTORS NEED A BETTER UNDERSTANDING RATHER THAN TREAT PEOPLE LIKE AS CRAP. tHIS IS WRONG AND SOME DAY WILL CHANGE IT EVEN IF IT KILLS ME. ANY DOCTORS WHO READ THIS WAKE UP AND LEARN HOW TO TREAT PATIENTS WHO HAVE BEEN ON IT FOR MANY YEARS.
My son has been on many ADHD and SSRI’s but never helped him feel “good”. When he took Abilify and Prozac – he felt great and acted very appropriate. It seemed to be enough for his severe anxiety also.
Just read about Adult ADHD on Web MD and he is that to a tee. Not sure how his bipolar was diagnosed. The meds above worked beautifully but he needed something for sleep – trazadone was given.
http://benzoisland.org/index.html
Iatrogenic addiction is real, sad and rampant. As a former victim who’s totally recovered from a doctor manufactured Klonopin habit of 12 years, I owe my new healthy life (the result of a 3 year withdrawl detox plan) partially to the folks from these web sites.
Good luck to others who desire to be free of benzodiazpines.
Terramuggus
I take zoloft and trileptal for bipolar disorder and flexeril and klonipin for fibromyalgia. I am on a standard dose of Klonipin 0.5 mg in the morning and 0.5 mg at night. I don’t have daytime sleepiness anymore although I did at first. I don’t tremor anymore from fibromyalgia. I am dependent on Klonipin but not addicted. If I were to stop using it I would have withdrawal but I have no need to increase my dose. By managing my bipolar symptoms my previous abuse of drugs and alcohol is also controlled. After 20 years of abuse I can now have ONE drink and not need more and I take all my meds as perscribed. Everyone is different and each case needs to be individualized. Now and again I have severe anxiety but instead of reaching for an extra Klonipin I change my focus to take my mind off my anxiety and I also remind myself that I take Klonipin so the anxiety will not get worse but better.
I have been taking Klonopin for 6 years now, and I find that it is integral in helping me with my day to day life.
I take some for sleep and then .5 mg as needed for stress. I become highly agitated in stressful situations, and just 1 pill is enough to help me function–at most once a week.
I’ve never had to increase the dosage to deal with stress, but I have had to increase the dosage for sleep over time to 2 mg at night. Other sleep medications are either too expensive or have very bad side effects.
It has been a battle with my doctor, because she doesn’t want to increase the dose as needed. I go to a clinic, and she has only seen me a few times. Yet, she acts like I’m an addict when I ask for an increased dose for sleep.
When I first started taking the medication, my doctor at the time told me flat out that I would have to increase as I went along, but that if it worked, then that was all that mattered.
It is frustrating that I have been successfully managing my bipolar for so many years, yet doctors don’t see Klonopin the way I do. Another tool to help manage the disease.
I’ve been diagnosed with Bipolar I, ultradian cycle. I take 200 mg of lamotrigine, which seems to stabilized me somewhat. I have debilitating levels of anxiety for which I was prescribed clonazepam, 1mg bid. Because it made me too sedated, it was first dropped to .5mg bid and then .5 daily.
It was only when I dropped down to .5 daily that I realized I still had been experiencing a level of sedation which interfered with my energy levels and my affect. It’s a balancing act for me-how much anxiety am I willing to experience-in order to feel “more like myself.”
Linda,
I have struggled for years with depression/anxiety disorder and too have been on so many medications/wholistic help/ acupuncture etc. When I was on Klonapin it eventually turned on me and gave me sucidal depression which I had never ever encountered … this went on for a year and finally put it together. The doctors could not put the puzzle together … and I have had multiple friends the same has happened. I just wanted to share that with you. I have since had the VNS implant put in as of two years ago … used for refractory depression and it is starting to work miracles in my life … it too is used for bi-polar. I will pray that all gets worked out for you because my experience with that benzodizapene was absolutely horrible … after I was on it for a while. Blessings, Shellie
Took Ativan 20 years ago for panic disorder and Diazepam (Valium) lately for PTSD. Am currently taking Diazepam again as recent PTSD flareup has occurred. Maximum script is 5mg 3x daily but rarely reach that as makes me dopey. Sometimes take 1/2 tab. As I tend to be a very compliant patient, understanding the dangers and symptoms of addiction, I don’t have too many problems with developing dependence upon habit-forming drugs. If I find a prescribed dosage isn’t working, I look to alternative methods to supplement the meds, such as relaxation techniques or exercise. Benzos are a definite help to me, especially now when my startle response is acute. Keeps me from slugging someone! 
Also helped when panic disorder was present. They deninitely have their place but I know how powerful they are and how addicting they can be.
should i take my meds at a regular time each day?
Vickie and all, yes I know how dependent one can become on Ativan. I was on .05 2x’s per day and am still on 1.0 at bedtime. My psych cut the .05’s right away (when I first saw her.) I hated her for awhile and then I loved her. I am having trouble sleeping right now (manic maybe) I don’t work and have soc.sec. disability. Lately, the days are so long and I can’t sit in front of the t.v. anymore like I used to ( which is good and bad.) What’s aggravating is that I’m smoking more taking 3 puffs at a time and putting it out. I want to quit but I don’t know if my anxiety is too great. Sometimes I just want to take more ativan and sometimes do. Right now I’m tryin 3 trazadone, 2 ambien ( which is a problem for my ins. co. but not my doctor.) Thank God, I go to the doctor now every month and sometimes more instead of worrying about the cost. God help us all. By the way,my ins. company is very strict about filling ativan too early.
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