The Effects of Benzodiazepines like Ativan and Xanax on Mental Health
What are Benzodiazepines?Benzodiazepines or sedatives, such as Xanax and Klonopin, are prescription medications that act as central nervous system depressants and are commonly used to treat anxiety and sleep disorders.
Benzodiazepines are often combined with alcohol and/or opioids; this results in an exacerbation of CNS depression, frequently resulting in overdose and death.
Benzodiazepines are often used with methadone in order to increase the desirable effects of, or to “come down” from, stimulant intoxication.
Benzodiazepine addiction often co-occurs with other mental health disorders such as:
- Bipolar disorder
- Antisocial personality disorder.
Benzodiazepines and the Brain
In the brain, benzodiazepines act on the neurotransmitter gamma-aminobutyric acid (GABA), which exerts an inhibitory effect on action potentials.
In other words, it helps prevent the firing of neurons, which can be helpful in cases like modulating fear responses.
In anxiety disorders, there is believed to be a deficit in GABA production, leading to the inability to suppress or “inhibit” fears and worries.
Benzodiazepines increase the effectiveness of GABA which means your brain will produce less of it. Long term benzodiazepine use causes tolerance, and abstinence after prolonged use can result in withdrawal.
Symptoms of withdrawal tend to present as the opposite of the therapeutic effects benzodiazepines elicit. These withdrawal symptoms include:
- Increased heart rate.
- Increased blood pressure.
- High body temperature.
- In about 20-30% of cases, grand mal seizures.
Long-term use of multiple drugs that act on GABA systems (as both benzodiazepines and alcohol do) can result in depressive symptoms or induce depression in people with a vulnerability to it. Contextual factors, like poor social support, can further exacerbate this association.
SAMHSA reports that research into the pathophysiological effects of alcohol and other drugs–such as enduring and permanent neurological changes–provides evidence of common etiology or developmental pathways for substance abuse and mental health disorders.
In 2009, 22.4 percent of adults and 18.9 percent of youth had co-occurring major depression and substance use disorders. High doses of benzodiazepines can lead to mood swings and hostile or erratic behavior.
In the case of dually diagnosed depression, research on pharmacological interventions favors antidepressants over benzodiazepines.
Antidepressants might be considered for anxiety disorders, too, due to their similar effects and less addictive nature.
There is some indication that a combination of benzodiazepines and SSRIs has been effective in treating comorbid anxiety and depression.
Since benzodiazepines would not be a good first line of therapy in the case of comorbid substance use and depression, they might be added to an established regimen of antidepressant medications to assist in managing anxiety symptoms.
Scarcely using anxiety relieving agents in combination with SSRIs for depression may also prevent relapses to heavier active benzodiazepine use, given the presence of a “safety net” for managing anxiety and mood symptoms.
According to the Center for Substance Abuse Research, benzodiazepines are among the most commonly prescribed CNS depressant medications to treat anxiety disorders, such as generalized anxiety disorder and panic disorder.
According to SAMHSA:
- In 2008, 9.3 million adults were prescribed benzodiazepines for anxiety.
- Between 2001 and 2004, 31 percent of adolescents ages 13 to 18 had a lifetime anxiety disorder, with the first onset of symptoms usually around age 6.
- Between 2001 and 2003, 11 percent of adolescents ages 13 to 18 met criteria for lifetime alcohol or drug use disorder.
- Early onset of substance use and mental health disorders result in more severe symptoms and chronicity.
When addiction co-occurs with an anxiety disorder, there is a greater risk of abusing other substances as well, such as alcohol or opiates, to relieve anxiety.
The co-occurring addiction and anxiety disorder must both be treated in order to achieve successful recovery.
Anxiety disorders lead to functional impairment and can decrease a person’s quality of life, often predisposing them to develop a co-occurring addiction.
Cognitive Behavioral Therapy (CBT) may also improve outcomes in comorbid benzodiazepine abuse and anxiety issues.
- Maladaptive thoughts about coping without medication and self-efficacy are important predictors of anxiety management.
Stopping the use of benzodiazepines without the supervision of a doctor is not recommended as withdrawal symptoms can range in severity from anxiety to seizures.
Aside from normal anxiety experienced during withdrawal, you may also experience what is known as rebound anxiety.
- Rebound anxiety is characterized by a worsening intensity of anxiety compared to the level of anxiety felt prior to treatment with benzodiazepines.
- Rebound anxiety has been observed in patients receiving as little as four weeks of benzodiazepine treatment.
Physical dependence is found to be most likely established after three to four months of benzodiazepine use, increasing prevalence and severity of rebound anxiety.
- In heavy and chronic benzodiazepine use, anxiety can, unfortunately, persist for several months and up to two years in severe cases.
Benzodiazepines are commonly prescribed to treat insomnia. Insomnia is a common disorder characterized by:
- Difficulty falling asleep.
- Staying asleep.
- Returning to sleep if woken up.
In addition to rebound anxiety, rebound insomnia can persist for months during post-acute withdrawal from benzodiazepines. Chronic insomnia can lead to:
- Low energy.
- Difficulties in cognitive performance.
- Deteriorated quality of life.
Some studies indicate that the co-occurrence of benzodiazepine dependence and insomnia may be indicative of underlying psychiatric issues. It is also a risk factor in the development of depression and anxiety disorders.
It is especially difficult to treat insomnia while treating addiction because of how long into sobriety rebound insomnia can last and because of how readily available benzodiazepines are.
The use of non-benzodiazepine agents in the treatment of comorbid insomnia is recommended with caution, as psychiatric issues can increase the risk of abuse.
- Bobo, W.V., Reilly-Harrington, N.A., Ketter, T.A., Brody, B.D., Kinrys, G., Kemp, D.E., Shelton, R.C., McElroy, S.L., Sylvia, L.G., Kocsis, J.H., McInnis, M.G., Friedman, E.S., Singh, V., Tohen, M., Bowden, C.L., Deckersbach, T., Calabrese, J.R., Thase, M.E., Nierenberg, A.A., Rabideau, D.J., Schoenfeld, D.A., Faraone, S.V. & Kamali, M. (2014). Effect of adjunctive benzodiazepines on clinical outcomes in lithium- or quetiapine-treated outpatients with bipolar I or II disorder: Results from the bipolar CHOICE trial. Journal of Affective Disorders, 161, 30-35.
- Center for Substance Abuse Research. (2013). Benzodiazepines. Retrieved from http://www.cesar.umd.edu/cesar/drugs/benzos.asp
- Chung, K.H., Li, C.Y., Sithole, T., Liu, W.W. & Chung, M.H. (2015). Risk of psychiatric disorders in patients with chronic insomnia and sedative-hypnotic prescription: A nationwide population-based follow-up study. Journal of Clinical Sleep Medicine, 11(5), 543-551.
- Cvjetkovic-Bosnjak, M., Soldatovic-Stajic, B., Babovic, S.S., Boskovic, K. & Jovicevic, M. (2015). Pregabalin versus sertraline in generalized anxiety disorder: An open label study. European Review for Medical and Pharmacological Sciences, 19(11), 2120-2124.
- Ford, E.S., Wheaton, A.G., Cunningham, T.J., Giles, W.H., Chapman, D.P. & Croft, J.B. (2014). Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among U.S. adults: findings from the national ambulatory medical care survey 1999-2010. Sleep, 37(8), 1283-1293.
- Liebrenz, M., Gehring, M.T., Buadze, A. & Caflisch, C. (2015). High-dose benzodiazepine dependence: A qualitative study of patients’ perception on cessation and withdrawal. BMC Psychiatry, doi: 10.1186/s12888-015-0493-y.
- Roy-Byrne, P. (2015). Treatment-refractory anxiety; Definition, risk factors, and treatment challenges. Dialogues in Clinical Neuroscience, 17(2), 191-206.
- Schweizer, E., Rickels, K. & Uhlenhuth, E.H. (2002). Neuropharmacology – Fifth Generation of Progress. Philadelphia, PA: Lippincott, Williams, & Wilkins.
- Substance Abuse and Mental Health Services Administration. (2013). Behavioral Health, UnitedStates, 2012. HHS Publication No. SMA-13-4797, Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Substance Abuse and Mental Health Services Administration, General Principles for the use ofPharmacological Agents to Treat Individuals with Co-Occurring Mental and SubstanceUse Disorders. HHS Publication No. SMA-12-4689, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
- Substance Abuse and Mental Health Services Administration. (2012). Mental Health, UnitedStates, 2010. HHS Publication No. SMA-12-4681, Rockville, MD: Substance Abuse and Mental Health Services Administration.
- Takaesu, Y., Komada, Y., Kagimura, T. & Inoue, Y. (2014). Factors associated with long-term use of hypnotics among patients with chronic insomnia. PLoS, 9(11), doi: 10.1371/journal.pone.0113753
- Verster, J.C. & Volkerts, E.R. (2004). Clinical pharmacology, clinical efficacy, and behavioral toxicity of alprazolam: A review of the literature. CNS Drug Reviews,10(1), 45-76.
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th Edition (DSM-V).. Arlington, VA: American Psychiatric Association.
- Licata, S., & Rowlett, J. (2008). Abuse and dependence liability of benzodiazepine-type drugs: GABAA receptor modulation and beyond. Pharmacology Biochemistry and Behavior, 90(1), 74-89. doi:10.1016/j.pbb.2008.01.001