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by Angelina F. Gomez, MA and Stefan G. Hofmann, PhD

Feeling anxious, worried, and tense? You are not alone! Anxiety disorders are the most common mental illness in the US, and General Anxiety Disorder (GAD) affects 6.8 million adults (or 3.1% of the population) every year (https://adaa.org/about-adaa/press-room/facts-statistics). When feeling overwhelmed with worries and tension, the first step many people take is to ask their doctors about medication. If you struggle with GAD, and are thinking about starting medication, here is some information about two of the most commonly prescribed types of medication: SSRIs and benzodiazepines.

Selective Serotonin Reuptake Inhibitors (SSRIs) include medications such as Zoloft (sertraline), Prozac (fluoxetine), Celexa (citalopram), and Lexapro (escitalopram). These medications work on serotonin, an important neurotransmitter that plays a role in feelings of well-being and happiness, as well as thinking, memory, sleep, digestion, and circulation. SSRIs are currently considered the first-line medication for many forms of anxiety. If you are considering starting an SSRI, here are some important things to consider:

  • Many people describe SSRIs as “turning the volume down” on their anxious thoughts. This can also help you engage more with psychotherapy and other wellness-related activities such as mindfulness.
  • SSRIs may also reduce the physiological symptoms of anxiety (sleep, muscle tension, headaches).
  • SSRIs are antidepressants; so if you struggle with depression as well as GAD, these medications can help with both.
  • SSRIs need to be built up in your system slowly. Your doctor will recommend a gradual increase in dosage over the course of 4-8 weeks. It may therefore take a while before you experience full, consistent effects on anxiety reduction.
  • When first starting SSRIs, you may experience some unpleasant side-effects, though these usually diminish or go away after 4-8 weeks. Some possible side-effects include nausea, diarrhea, insomnia, drowsiness, headache, dry mouth, dizziness, restlessness, and problems with sexual arousal.
  • SSRIs are relatively safe for long-term use, and are not addictive. It is hard to overdose on SSRIs, and they are thus considered safe for individuals with severe suicidal tendencies. While it is not recommended to mix SSRIs with alcohol, this is rarely a toxic combination.
  • Stopping abruptly (“cold turkey”) from SSRI treatment can throw your brain into a state of imbalance that leads to cognitive and physiological symptoms that are much worse than before. Some symptoms of rapid SSRI discontinuation include fever, nausea, panic attacks, hallucinations, vivid dreams, and impaired coordination. This can be quite dangerous, so check with your doctor before changing the dosage of your SSRI

Benzodiazepines (sometimes called “benzos” or “minor tranquilizers”) include medications such as Xanax (alprazolam), Ativan (lorazepam), and Valium (diazepam). These medications strengthen the effect of the neurotransmitter GABA, which is the primary inhibitory (“turn off”) signaler in the brain. GABA plays a role in sleep, feeling calm, muscle relaxation, and reduction in brain activity. If you are considering starting a benzodiazepine, here are some important things to consider:

  • Benzodiazepines reduce the intensity of physiological symptoms of GAD, such as muscle tension, headaches, panic attacks, sweating, insomnia, and restlessness.
  • Benzodiazepines may also reduce the cognitive symptoms of anxiety, such as worry and rumination.
  • Benzodiazepines are fast-acting, but do not stay in the system very long. Thus, people often experience immediate anxiety relief, which lasts for a few hours. This temporary relief of anxiety may help you complete important life tasks that you have been avoiding (e.g. giving a presentation, interviewing for a job, or travelling to see family).
  • Overall, people report relatively few bothersome side effects when taking benzodiazepines; some possible side-effects include drowsiness, confusion, dizziness, depression, impaired coordination, and vision problems.
  • Benzodiazepines are not considered safe for continuous use, as this can increase risk for physical dependence (addiction). Furthermore, mixing benzos with alcohol can be very dangerous. They are also not recommended for people with severe suicidal or addictive tendencies, or a family history of addiction.

 

Pros

Cons

SSRIs

Reduces cognitive symptoms (worry, rumination)

Safe for long-term use

Non-addictive

Also helps with depression

Less reduction in physiological symptoms

Takes a while to reduce anxiety

Unpleasant short-term side effects

Rapid withdrawal is dangerous

Benzos

Reduces physiological symptoms (tension, insomnia, panic)

Fast-acting

Few unpleasant short-term side effects

Temporary avoidance reduction

Less reduction in cognitive symptoms

Unsafe for continuous use

Potentially addictive when used inappropriately

Not recommended for people with addiction problems and suicidal tendencies

 

So what’s the take-home message? SSRIs are considered the first-line medication for GAD, and will typically be prescribed first. Benzodiazepines are considered a second-line or adjunctive medication for GAD, though are still prescribed frequently, especially when a person complains of panic attacks, sleep problems, severe muscle tension, or avoidance of specific situations due to anxiety. Depending on your symptoms, your doctor may recommend starting both an SSRI and a benzodiazepine, and then tapering off the benzodiazepine after 2-4 weeks. This may help you tolerate the initial unpleasant side-effects of SSRIs, while limiting the risks of longer-term benzodiazepine use.

Regardless of who you are or your thoughts on these medications, here are some essential things to know and do when taking medication:

  • Make sure you describe your specific symptoms with your provider. Rather than only saying “I’m anxious,” describe in more detail the most frequent and bothersome symptoms you are experiencing, and in what contexts these symptoms disrupt your life.
  • Tell your doctor if you struggle with suicidal thoughts, addiction, and/or cognitive impairment, or if these conditions run in your family.
  • Communicate with your doctor during the first few weeks/months of taking medications, so they are aware of any side-effects or other contraindications.
  • Always take your medication as prescribed, as deviations may lead to worse symptoms and will not help you know whether the medication is working for your anxiety.
  • Always consult with your doctor before stopping any medication. Do not withdraw cold-turkey or change your dosage on your own.
  • Consider psychological treatment as well as medication; if your provider does not suggest this, ask for recommendations. The most effective psychological treatment for GAD is cognitive behavioral therapy (CBT). Mindfulness-based therapies, such as yoga, can also be beneficial.

About the Authors


Angelina F. Gomez, M.A. is a doctoral student in clinical psychology at Boston University, working with Dr. Stefan Hofmann. Her research focuses on mindfulness-based treatments for anxiety, depression and trauma; understanding the neurobiological basis of adult psychopathology from trajectories of change throughout childhood and adolescence; and developing novel technology-based platforms to disseminate evidence-based treatments to underserved populations. She is passionate about helping individuals understand their mental illness and take empowered steps to live a life of fulfillment.

Stefan G. Hofmann, Ph.D. is Professor of Psychology at the Department of Psychological and Brain Sciences at Boston University. He has been president of numerous professional organizations and is currently editor-in-chief of Cognitive Therapy and Research. He has been included in the list of Highly Cited Researcher and received many other awards, including the Aaron T. Beck Award for Significant and Enduring Contributions to the Field of Cognitive Therapy and the Humboldt Research Award. His research focuses on the mechanism of treatment change, translating discoveries from neuroscience into clinical applications, emotion regulation, and cultural expressions of psychopathology. He has published more than 400 peer-reviewed journal articles and 20 books, including his recent self-help book, The Anxiety Skills Workbook.

I hate that benzos always get the reputation of being "bad." Sure, people become addicted to them. People become addicted to alcohol, food, and other things that are readily available. Some people just have more of a tendency toward addiction; it's partly genetic and partly environmental. HOWEVER, there are those of us who have safely taken benzos for many years with no problems. I hate to see people pill-shamed or looked at negatively because they are taking benzos. For some people, benzos are the ONLY medication that helps them function close to normal. I happen to take clonazepam once a day at bedtime....in addition to anxiety, I have psoriatic arthritis, which also causes sleep problems. If not for clonazepam, I wouldn't get much sleep and therefore could not function well mentally or physically for my job. I see clonazepam as somewhat of a savior for me. I realize the abuse potential is very high, and many people take benzos just to chill out, but there are those of us who use it for very legitimate purposes. Please take that into consideration.

I could not agree more. I take Clonazepam for my GAD on an as needed basis. A prescription of ten .5 milligram tablets has lasted me ten months. I take a .5 milligram tablet and cut it into fourths. The four pieces last me one month, as I take it once a week at bedtime.

Because it is a strong benzo with a medium half-life this works very well at calming my worst anxiety episodes. I have never had to updose. No alcohol since I started taking it, as per doctors advice, no other medications either. I researched clonazepam thoroughly before ever taking one dose.

It works for me, it is not evil or scary....it works.

i feel the same if you dont abuse the medicine it works really well, and its a shame you have to yake so many diffrent medicines to get to the one you told the doctor wored in the first place

Your comment just brought me so much comfort. I have a life limiting autoimmune disease, ptsd, and anxiety I am trying to convince my dr that benzos are the only thing that helps me and keeps me alive. I am 62...does it really matter if I take these drugs for the rest of my life as my quality of life has already been compromised with this chronic illness?
Would love to hear from others.

I agree I am 68 and been on Valium for 16 years, I often feel a shamed for being on them, as people put these medications down, but I feel I have a life, and at my age how much longer have I left, so I want to enjoy my life and not have acute anxiety where I cannot go or do anything.

hey, i read your comment about benzos and i completely agree with you.... i have sever social anxiety and panic disorder and ive tride probably 50 or 60 different types of medications and really bad combinations of pills for anxiety and i told the doctor that i would rather have one xanax than the 10 different pills im taking now to do the same thing for my anxiety and can posdsibly kill me or have some adverse reaction... i dont understand why they think thats better than taking the benzo... but ive been taking them for over 10 years now and they work just fine for me i dont abuse them or sell them i just take them like any other prescription i have and the difference it makes it night and day with me. i heard that there are online websites that you can buy them but i dont think i would want to try that because een though its hard to get the script from the doctor now for the right ammount i cant go online and buy them i dont even know how anyway.

I agree! I am so sick of this Benzo BS.
I have been taking them for 30 years for Chronic Anxiety and as of a few years ago, I am treated as a drug addict.
Ridiculous! I love your point that lots of things can be addictive. I have had enough of the shame that is inhumane and ridiculous.

(I am a retired MD--not psychiatry)
I doubt most psychiatrists trained in the past 20 years have much experience at all with benzos. It seems they simply parrot the consensus line: "Benzo's bad; S...RI's good!" They stand on the sidelines downplaying side effects for the 'first-line' (but second best) treatment with serotonergic meds, while a fairly high % of their patients undergo a sort of sertonergic 'hell' trying to adjust to starting the medication. They then downplay and use neutral-to-positive language (e.g., not calling it dependence) when a different 'hell' is experienced by a significant % when coming off those meds. A study showed 37 of the 42 listed/'expected' symptoms related to BZ 'withdrawal' are also experienced in SSRI/SNRI stoppage. However, all the language used to describe BZ sx is negative vs the neutral-to-positive when referring to sertonergic med withdrawal.
In 2018 in Expert Opin Pharmacother, a meta-analysis was published: "Comparing the Efficacy of Benzodiazepines and Serotonergic Anti-Depressants for Adults with Generalized Anxiety Disorder: A meta-analytic review". The conclusion: 'The results of this study suggest that the most common forms of pharmacotherapy for adult GAD are moderately effective, with BZs being the most effective drug.' The effect sizes were (Hedges) SSRI g=0.33; SNRI g=0.36 and BZs g=0.50.
The issue should not be 'dependence', but effectiveness minus observed abuse. This very organization site has stated that actual abuse of BZs when prescribed for anxiety disorders is rare.
The parrot needs to learn some new phrases--and hopefully ones better rooted in actual real-life experience and data. A re-assessment of the actual underlying hard support for the current consensus is long overdue, IMO.
All the best, and stay safe.

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