Anxiety

When It Comes to Treating Anxiety, Is There a Sensible Middle Ground Between ‘Hardcore Benzos’ and ‘Take a Relaxing Walk’?

And if so, how come doctors aren’t prescribing it more often?

I am never too far from a tiny white Ativan. Though I may go months between doses, I always know where the nearest one is. Its presence alone is a comfort: With an Ativan in my arsenal, I cannot have a panic attack. Without it, I could. Knowledge of that possibility is enough to inspire one. 

That’s the problem with anxiety and panic disorders: They serve only themselves, an ouroboros of fear. 

My mental health is now well-managed, but in some ways, I remain dependent upon an anti-anxiety medication I don’t even regularly take. I, like some 30.5 million other Americans, or 12.5 percent of the country, am prescribed benzodiazepines. It’s a decision I didn’t take lightly: After years of anxiety and a newly developed panic disorder in college, I finally agreed with my psychiatrist that it was an appropriate option. Some patients, however, report receiving benzos at the first mention of anxiety to their doctor. 

Dylan, a pseudonymous 24-year-old from Florida, was first prescribed Ativan (lorazepam) by a psychiatrist at their school’s health center. “The psych put me on it pretty much as soon as I came in telling him I was having anxiety symptoms,” they tell me. “The doctor was really willing to write me that script knowing full well I had a substance abuse problem (the same guy also later wrote me a script for Ambien), and it’s likely that when I had a manic episode and stopped taking all my meds, the withdrawals from the lorazepam accelerated/induced my psychotic break.” 

“I can’t speak to a value judgment of the drug as a whole because obviously it helps a lot of people, but I think I was a pretty cut-and-dry case of someone who shouldn’t have been put on it, and I just went along with it without doing any research because I trusted the lab coat,” says Dylan. “I honestly didn’t even know it was a benzo until months in.” 

Benzos work by slowing the nervous system, physically calming us and inhibiting our ability to panic. They’re typically prescribed as short-term, as-needed treatments — that is, they’re to be taken only over a brief period of time and only when one is experiencing severe panic or anxiety. They can be highly addictive, and withdrawing from benzodiazepines can be a grueling, even life-threatening process. It’s one of the only substances besides alcohol that can kill those who attempt to quit at high doses without weaning. 

For Charlie, 26, in Pennsylvania, Ativan has been a constant figure in maintaining their mental health. “The mental healthcare workers I’ve seen since have been really appalled, but no one is ever that appalled by the fact that I’ve been using lorazepam for many years, since the very early years, and have such easy and ready access to it,” says Charlie. “I’m lucky that I didn’t tilt into a heavy addiction, and it’s an amazing and effective medication, but everyone has always been so casual. The whole casualness seems like an alternate reality almost. Because I have friends who are in recovery from benzos, and I keep forgetting that I use them regularly.” 

It makes sense that the medical professionals who have expressed concern for Charlie’s lorazepam prescription were mental healthcare workers, specifically. According to clinical psychologist and president of the Anxiety and Depression Association of America Luana Marques, most anxiety and panic specialists prefer not to prescribe benzos as the first course of treatment. Rather, it’s commonly primary care doctors who are prescribing benzos to their patients

Instead, Marques sees Cognitive Behavioral Therapy and antidepressants as better options. The problem, however, is that both of these treatments take time. So for people in crisis, or those newly experiencing a panic disorder, benzodiazepines can indeed be the appropriate choice. 

“When it comes to anxiety, what we know is that the reason benzos got so over-prescribed is because they’re a very quick fix,” says Marques. “You take a Xanax, and within 20 minutes, you feel much better. The problem is, what maintains anxiety is fear of the anxiety. When you take benzos, what you learn is that the only way to manage it is to take benzos. The treatment, then, is the opposite. The treatment is to tolerate the anxiety. This is what Cognitive Behavioral Therapy is intended to teach. Naturally, for people suffering in the moment, this solution is less appealing.”

“It’s very difficult for people to get access to good CBT, so I imagine that’s one of the reasons why people don’t get CBT right away,” Marques continues. Only .01 percent of people are trained in CBT in Marques’ estimate, while 20 percent of people experience mental health issues. 

“I’ve seen patients that are very anxious and can’t do CBT, so their doctors will put them on a short-term course of benzos, maybe twice a day, so they can calm their physiology, engage better with therapy and then wean them off. What we don’t want to teach is to take it every time you’re anxious, because that’s how you build a tolerance,” says Marques. “Something like Zoloft [an SSRI antidepressant] could be as effective in optimal doses as benzos. There are prescriptions that can work just as well, they just won’t be as fast.” 

CBT may not work as quickly as benzos, either, but it can ultimately teach people how to manage their anxiety without medications. In fact, CBT is primarily used as a short-term treatment, with most patients undergoing less than 20 sessions, according to Marques. 

“The premise of CBT is that whatever we’re saying to ourselves affects what we’re feeling and doing,” says Marques. “In CBT, we teach patients to understand this link between their feelings, thoughts and behaviors and how when we have anxiety, we’re spinning in a cycle [of these feelings, thoughts and behaviors]. So CBT is designed to give hands-on skills to break that cycle by challenging their thoughts or tolerating their anxiety.” Marques and her colleagues are working to increase CBT training across the country, including training for those beyond the psychiatric field. “My job is to work myself out of a job,” admits Marques. 

The hope is that one day, people like myself, Dylan and Charlie will be able to coach our brains into preventing our fears from controlling our bodies. For some of us, it could work. For others, perhaps SSRIs will do the trick. And then, perhaps, for those who have exhausted other options, benzodiazepines will still be there. 

For myself, my anxiety will continue to be something I carry with me. Even if out of sight, tucked away for months, it will likely always be there. Just like my benzos.