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Depression and Anxiety Special Report

Treating Anxiety -- Avoiding Dependence on Xanax, Klonopin, Valium, and Other Antianxiety Drugs

Johns Hopkins Health Alerts Depression and Anxiety Treating Anxiety with Benzodiazepines

Benzodiazepines—such as Xanax (alprazolam), Klonopin (clonazepam), and Valium (diazepam)—are effective for alleviating anxiety, but they are also powerful drugs with serious side effects. Among the most dangerous is the development of both physical and psychological dependency. In fact, more than one third of people taking benzodiazepines for anxiety for more than one month become dependent on them.

Because of this high risk, the prescribing physician should monitor patients closely, and patients considering these antianxiety drugs should understand both the possible side effects and the precautions to take to avoid developing dependence.

Two classes of antidepressant drugs—selective serotonin reuptake inhibitors (SSRIs) and tricyclics—have become the first line of treatment for anxiety disorders in many people. Serotonin and norepinephrine reuptake inhibitors and tetracyclics are also used to treat anxiety disorders. These drugs are not habit forming and are indicated when a person with anxiety is also depressed.

In addition, a newer drug called BuSpar (buspirone) has fewer adverse effects than benzodiazepines, but it may be less effective, in particular for panic disorder. As a result, benzodiazepines are still prescribed for many people with anxiety.

Dependence vs. Addiction on Medication for Anxiety Disorders
The words “addiction” and “dependence” are often used interchangeably, but they are not synonymous. Dependence and tolerance refer to physiologic responses to a drug, while addiction is a behavioral and psychological phenomenon.

Tolerance is defined as a reduction in response to a drug over time, and physical dependence means that withdrawal symptoms would occur if a substance is abruptly stopped or dramatically decreased. Tolerance and physical dependence do not necessarily lead to addiction, which involves the compulsive, uncontrolled use of a drug with no regard for any harm it may cause. Tolerance, physical dependence, and addiction are all possible with benzodiazepines.

Who Is at Risk?
The risk of becoming dependent on a benzodiazepine for anxiety is influenced by personal characteristics and increases with long-term use and high doses. Patients most at risk include those whose anxiety is combined with depression or obsessive-compulsive disorder and those with a history of drug abuse. Older patients and women are also more likely to develop a dependency, which may be because they are also prescribed benzodiazepines more often.

Preventing Dependency Problems
The short-acting benzodiazepines, such as Ativan (lorazepam) and Xanax (alprazolam), are the most potent and therefore should be taken with the most care. Moreover, doses should be as low as possible because excessive doses increase the risk of adverse effects, dependence, and problems in withdrawal.

In addition, duration of treatment should be as short as possible—ideally, no longer than four weeks. If patients need treatment for a longer period, it is preferable to use intermittent therapy—for example, two to four weeks of taking the drug regularly interspersed with tapering off it for one to two weeks—rather than continuous long-term therapy.

Coping Effectively With Withdrawal
Patients who become addicted to these drugs usually experience both physical and psychological withdrawal symptoms when the medication is discontinued. Physical symptoms include increased anxiety, irritability, agitation, restlessness, loss of appetite, and muscle aches. Psychological dependency is characterized by a persistent desire for the drug after it has been discontinued.

Patients should not stop taking any medication without consulting their physician: Abrupt discontinuation of benzodiazepines can cause dangerous complications such as insomnia, loss of appetite, tremor, muscle aches, and—in some people—confusion or seizures. But if you feel you are developing a dependency or need increasingly higher doses to feel the same effects, inform your physician immediately. The drug will need to be discontinued very carefully.

To avoid withdrawal symptoms, your doctor will prescribe a discontinuation program in which the dose of the benzodiazepine is gradually decreased over a period of three months to a year. You may also require extra psychological support, such as psychotherapy, to help you learn alternate methods of managing anxiety and confronting the sources of your anxiety.

Alternatives to Medication
Other treatment methods used in conjunction with psychotherapy may help and may be even more effective than medications for certain patients with anxiety disorder. For example, relaxation techniques—exercises involving slow, deep breathing and positive visualization—may relieve the physical effects of anxiety.

Such techniques can help to achieve and maintain a feeling of calm and confidence in anxiety-provoking situations or during a panic attack. Some experts have found that people with panic disorder, for example, tend to have slightly higher-than-average breathing rates; learning to breathe slowly can help them both deal with an attack and prevent future ones.

Psychological relaxation techniques, such as meditation and self-hypnosis, may also be useful tools. These methods involve learning to remove yourself mentally from a distressing situation by concentrating on a word or phrase or by imagining a calming place or event. Joining a support group for people with anxiety may also prove helpful.

  • For more Depression & Anxiety articles, please visit the Depression & Anxiety Topic Page

    Posted in Depression and Anxiety on November 26, 2005

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