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:
- Valium (diazepam): This old standby is relatively long lasting – 10 to 12 hours
- Ativan (lorazepam): Medium duration – lasting 6-8 hours
- Xanax (alprazolam): Shortest acting – lasting about 4-6 hours (but a long acting version is now available)
- Klonopin (clonazepam): Long acting – similar to Valium
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.
Potential Negative Side Effects
Because benzodiazepines are central nervous system depressants, they have the capacity to cause the following negative side effects:
- Severe sedation
- Potential lethal combination with alcohol
- Inability to drive or work
Anxiolytics in My Practice
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?