Non-Addictive Alternatives to Benzodiazepines for Anxiety

Benzodiazepines offer rapid anxiety relief; however, they have a high risk of dependence, withdrawal and tolerance (requiring higher doses to achieve the same effects). This makes these medications unsuitable for long-term use.

Antidepressants such as Selective Serotonin Reuptake inhibitors and Serotonin Noradrenaline Reuptake inhibitors are first-line treatment for anxiety. They produce lasting improvement by gradually improving the brain’s chemistry without the risk of dependence or withdrawal. 

There are also other medications like Buspirone, Pregabalin or Propranolol, which work in slightly different ways to manage anxiety attacks through faster acting neurochemistry change or by controlling symptoms. 

Some of these medications are stronger than others, have their own side effect profiles and risk of discontinuation symptoms. This article provides an overview of some of the non-addictive medication options to deal with anxiety, as well as the use of alternative therapies like lifestyle changes or psychological changes.

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Why Many People Look for Alternatives to Benzodiazepines

Several key reasons drive the reasons for people to look for alternatives to benzodiazepines as a treatment for anxiety. 

While benzos (Benzodiazepines) have a calming and sedative effect, they can lead to dependence and withdrawal; regular use can cause tolerance and ineffectiveness, cognitive impairment and abuse potential. 

Dependence and withdrawal – Benzodiazepines cause physical dependence within a short period of time (2-4 weeks). Withdrawal from these seizures can be severe and lead to effects like seizures and anxiety; these acute episodes make it difficult to stop.

Tolerance – The anti-anxiety (anxiolytic) effect of benzodiazepine diminishes over time, leading to dose escalation, and this cycle reinforces the dependence cycle. 

Cognitive and psychomotor impairment – These lead to effects such as sedation, memory problems, impaired concentration and increased fall risk (especially in the elderly). 

Even national guidelines recommend using benzodiazepines only for short-term use to avoid these effects. 

Understanding the Risks of Long-Term Benzodiazepine Use

Benzodiazepines like diazepam, lorazepam, alprazolam are highly effective for short-term anxiety relief. They work to produce a rapid calming effect that very few other medications can accomplish. 

However because they are so effective, sometimes their strength can cause problems and this causes risks, especially in long term use. These concerns include the risk of dependence on these strong medications (due to withdrawal symptoms), tolerance and need for increasing dose to achieve the same effect and the potent symptoms that do occur during withdrawal (Figure 1):

Dependence, Tolerance, and Withdrawal Concerns

Physical dependence on Benzodiazepines is a risk that can develop with long-term use of benzodiazepines. It is not the same process as addiction but it can look the same. 

Because benzodiazepines calm the circuits in the brain, the neural networks get used to this low level of activity, these mans that when the someone tries to take the medicines away from the system, the body rebounds and produces even more anxiety and excitatory symptoms than before.

This physical dependence leads to people only taking the medication for long periods to prevent these rebound anxiety attacks.

Tolerance can occur in response to consistent and constant benzodiazepine exposure. The brain gets used to the constant low activity caused by benzodiazepines. The neural circuits get programmed to naturally act at this level, due to this effect, over time, higher and higher doses of benzodiazepines are required to achieve the same effects,

Due to a combination of dependence and tolerance , and the cycle that this creates, withdrawal concerns are especially important. Withdrawal concerns can range from mild to very serious:

• Mild symptoms include: rebound anxiety, difficulty sleeping, irritability and muscle tension/pain
• Moderate symptoms: Different in perceptions,  ringing in the ears and distress in the ears
• Severe symptoms: Being delirious, psychosis – this is more potent with abrupt stopping of the benzodiazepines.

The concerns regarding dependence, tolerance and withdrawal concerns depends on how long one has been using the medications, what the dose was and how strong their anxiety was before. 

Please seek advice from your healthcare professional regarding the prospect of dependence, tolerance and withdrawal symptoms from benzodiazepine sedatives. 

Figure 1: Benzodiazepines can be effective in the short-term but it is important to look for non-addictive anxiety medication. 

Prescription Medications Commonly Used as Non-Addictive Alternatives

Several non-addictive and sedative alternatives are there as anxiety medications. These include:

• Selective Serotonin reuptake inhibitors (SSRIs). Drugs like Citalopram, Sertaline or Escitalopram are generally used as the first-line drugs for anxiety and panic disorders. They increase the amount of happy hormones running through the nerves to reduce anxiety. They take around 4-6 weeks to achieve their full effect.
• Selective Serotonin Noradrenaline reuptake inhibitors (SNRIs) . Drugs like Venalaxafine and duloxetine are very useful in treating anxiety as well as chronic pain that sometimes goes with it. They can sometimes be used when the above SSRIs are not that effective
• Beta-blockers , drugs like Propranolol can be used to treat the symptoms of anxiety as opposed to the neurological processes contributing to it. They are especially useful in treating tremors, palpitations or sweating.
• Mirtazapine- This is a drug that can help anxiety along with symptoms of insomnia or weight loss. It works on hormones like noradrenaline and serotonin and has no abuse potential. 

Please speak to your healthcare provider about more suitable non-sedative anti-anxiety medications for you. 

How Antidepressants Can Help Manage Anxiety Disorders

Antidepressants are used in the UK as the first line treatment for anxiety. Drugs like Selective Serotonin Reuptake Inhibitors (SSRIs) and Selective Serotonin Noradrenaline Reuptake inhibitors (SNRIs) increase the amount of happy hormones, noradrenaline and serotonin that are being transmitted through the nerves. 

Unlike benzodiazepines which sedate the nervous system quickly , antidepressants produce slow changes in the nerve processes over time and this recalibrates the nerve’s processing slowly and gradually.

The slow , gradual and persistent change of antidepressants can help reduce anxiety without the need for sedation long term, even after antidepressants have been stopped. Most patients can taper off and reduce the medicines 6-12 months after patients are feeling better. 

When These Medications May Be Recommended

Antidepressants for anxiety management are generally reccomended in the following cases:

• There is persistent and impairing anxiety, symptoms are present most days, they interfere with work, relationships and daily functioning
• There is a recognised anxiety disorder such as general anxiety disorder, social anxiety disorder, obsessive compulsive disorder or Post-traumatic stress disorder (PTSD)
• Benzodiazepines need to be weaned and replaced: Patients already on benzodiazepines need to be switched to antidepressants to help reduce dependence and manage anxiety long-term. 
• Someone is suffering from both anxiety and depression: This often happens in a lot of people 
• The doctor anticipates that long-term anxiety treatment may be required: This is important as antidepressants are safer for long-term use. 

Non-Medication Approaches That Support Anxiety Management

The strongest approach to treating and managing anxiety is a combination of medical and non-medical management. Medical approaches affect the bio-chemistry of brain processes and alter them to reduce anxiety effects whereas non-medical and psychological approaches work on altering thought patterns, behaviour that are affected by and concurrently affecting anxiety. 

The non-medication approaches include:

• Cognitive Behavioural Therapy – This is a gold standard treatment to treat anxiety. It works by identifying and restructuring the brain’s thinking process, stopping catastrophic thinking patterns and negative perceptions . It also works by gradually exposing patients to anxiety inducing patients and helping them overcome their fear. The effects tend to be very strong and almost as effective as medicines by themselves. 
• Acceptance and Commitment Therapy – This form of therapy takes the angle of challenging anxious thoughts and it teaches patients to observe them without engaging with them and redirecting energy towards more productive and valuable ways of engaging themselves
• Physical exercise – Regular physical activity (150 minutes of exercise at moderate intensity) has been shown to produce a measurable reduction in anxiety by controlling stress hormones, releasing endorphins, improving sleep quality and reducing muscle stress and tension.
• Breathing and meditation – Meditation and slow breathing (6 slow breaths a minute) can activate the rest and digest processes in the body, this can help rewire neural processes over time and also help in acute attacks by slowing the body down.
• Reducing caffeine and alcohol – This is a simple but often overlooked strategy to reduce anxiety. Caffeine hyperactives the body’s processes including neural networks and can make anxiety worse.  Alcohol slows the body’s neural process in the moment and can numb anxiety temporarily but it produces rebound anxiety long term. 

A combination of non-medical and medical approaches can help effectively manage anxiety. Please speak to your healthcare professional about an appropriate treatment plan for you. 

Choosing the Right Long-Term Anxiety Treatment Strategy

Choosing the right long-term anxiety is a very individual and subjective strategy. The right strategy depends on diagnosis, severity, history, preferences and circumstances .

The most effective long-term strategy has often been found to be a combination of medical treatments (antidepressants) and non medical treatments (psychological therapy and lifestyle measures) and these are reviewed and adjusted over time as needed.

Factors to Discuss With Your Healthcare Provider

The following factors are important to discuss with your healthcare provider to help determine the right treatment strategy:

• Diagnosis and severity- What specific anxiety disorder someone has and how severe it is determines what treatment/combination of treatments are right for you.
• Previous treatment history – It would be important to discuss what has been tried before, what worked, what didn’t work and why it was stopped. This can help inform what treatments may be tried now.
• Any history of substance misuse or drug history – this is important as any past history of narcotic drug use, alcohol dependence or benzodiazepine use can alter which medications are given to you to make sure any medicines or treatments given to you are safe for you.
• Any medical conditions you have – Conditions like depression, anxiety or ADHD can frequently at the same time.  The right treatment will address the whole picture rather than just the anxiety as other conditions can sometimes precipitate the anxiety to come back. 
• Practical aspects of your life and logistics – Some psychological therapies like Cognitive behavioural therapy and psychodynamic therapy can take a lot of time and require a lot of self commitment to complete any “homework” or meditation/ thought changing exercises assigned to you. So it’s important to discuss your life pattern and whether you would be able to commit to this. 
• Medication you are on – Please let your healthcare provider know about any medications you are taking and any medical conditions you have as this helps them make an informed decision about which treatment would be right for you and avoid any unwanted interactions. 

Overall choosing the right treatment strategy is a very subjective process. It is important to consult with your healthcare provider and give them a full history so they can help you make an informed and effective decision regarding your treatment plan. 

Key Considerations When Exploring Anxiety Treatment Options

Effective and non-addictive management of anxiety is a long-term process that relies on a combination of medical and non-medical approaches. Benzodiazepines do have a role but their role is best limited to acting as a sedative during an anxiety attack or episode that refuses to calm down. Long-term use of benzodiazepines carries the risk of dependence, tolerance and withdrawal symptoms. 

Several prescription medications like Selective Serotonin Reuptake inhibitors and Serotonin Noradrenaline Reuptake inhibitors (antidepressants) are benzodiazpine alternatives  that can help alter the neurochemistry of the brain long-term and produce a durable and lasting change. To manage acute symptoms, medications like beta-blockers can be used to calm the body down. Sometimes medication like Mirtazapine can be used to manage anxiety and symptoms like insomnia and weight loss. 

In addition to helping alter the neurochemistry of the brain via medication, psychological approaches can be used to alter thought and behaviour patterns which can really help with anxiety. This includes psychological therapies like Cognitive Behavioural Therapy, Psychodynamic therapy, mindfulness and meditation. Lifestyle measures like reducing caffeine, and alcohol, as well as increasing physical exercise also play an important role.

Finally, when exploring which anxiety treatment would be right for you, please consult with your healthcare professional about your symptoms , their severity, any medical conditions you have, any other psychological conditions you may have or suspect you have and any medications you are currently on. This will help them make an informed approach to help you with your care and together you can make the right, safe and effective treatment plan.