Benzodiazepines and the Treatment of Bipolar Disorder

By Candida Fink, Joe Kraynak

The most commonly used purely antianxiety meds used int he treatment of bipolar disorder are benzodiazepines (also known as anxiolytics or tranquilizers, or benzos for short). These medications slow down the whole nervous system, thus reducing agitation and anxiety levels, both of which can be problems in bipolar disorder. Benzos appear to affect a brain chemical called GABA (gamma-aminobutyric acid), which has a calming effect on neurons.

For many people, just knowing they can take a medication to stop a panic episode helps reduce the secondary fear of having an episode. These medications can also be used as sleep aids when taken at night. The following table lists the pros and cons of benzos.

Potential Benefits and Side Effects of Benzodiazepines
Generic Name Brand Name Average Adult Dose Duration (hours) Potential Benefits Some Possible Side Effects*
Alprazolam Xanax
Xanax XR
0.75 to 4 mg/day divided into several doses; 0.5 to 10 mg/day
(XR)
4 to 6 Antianxiety; sedation Severe sedation; dependence/addiction; lethal combination with
alcohol; may reduce ability to drive or complete tasks
Clonazepam Klonopin 1.5 to 4 mg/day divided into several doses 10 to 12 Antianxiety; sedation
Diazepam Valium 4 to 40 mg/day divided into several doses 10 to 12 Antianxiety; sedation; anticonvulsant; reduces muscle
spasms.
Lorazepam Ativan 1 to 10 mg/day divided into several doses 6 to 8

mg/day = milligrams per day; other side effects may occur that are not listed.

Benzodiazepines are often useful at the beginning of treatment because they take effect much faster than other medications — within 20 to 30 minutes. They provide immediate relief during the two to six weeks or more you’re waiting for another medication such as an SSRI to take effect. But as soon as the SSRI takes effect, your doctor may wean you off the benzo.

SSRIs or SNRIs are powerful antianxiety medications and are the first line of treatment for anxiety for many people. But given the risks of agitation or mania that accompany these meds, they can be hazardous for people with comorbid bipolar disorder. Still, this class of medications is important and offers primary treatment for anxiety either alone or in combination with other meds, depending on your particular situation and symptoms.

In choosing a specific benzodiazepine, your doctor considers a wide range of issues related to your condition. With benzos in particular, some options are better tolerated with certain antidepressants or antipsychotics than others because the two types of medicines are metabolized by the same enzymes in your body.

Approach benzodiazepines cautiously. If the dose is too high, benzos can shut down various brain functions, causing severe sedation and stupor and eventually slowing a person’s breathing, which can be fatal. Also, benzos work on the same receptors that alcohol affects, so combining benzos and alcohol vastly increases the risk of a serious central nervous system shutdown. Another big problem with these meds is the potential for addiction and dependence: The body eventually becomes dependent on benzos and then requires ever-increasing doses. Careful monitoring of dose and use of these medications is important.

Several less commonly prescribed antianxiety medications include buspirone, pregabalin, and gabapentin, which aren’t considered tranquilizers:

  • Buspirone (Buspar): This medication affects serotonin, like an SSRI, but seems to work directly at the receptor rather than affecting re-uptake. Also like an SSRI, buspirone takes time to build up in the bloodstream to have its intended effect. Like benzos, this medication is used specifically for anxiety and has no known antidepressant effect, but unlike benzos, it doesn’t have any potential for addiction.

    Dosing for buspirone ranges from 20 to 60 mg per day, split into two doses. Many prescribers find minimal benefit with buspirone alone, so they often prescribe it as an add-on to other medicines. Buspirone can be a good option for people with a history of alcoholism or abuse of benzodiazepines, but its effectiveness is inconsistent.

  • Pregabalin (Lyrica): This medication is approved for the treatment of several types of pain syndromes and as an add-on agent for treating seizures. Although it’s not currently formally approved for treating anxiety, several studies have shown it to be helpful in treating some anxiety disorders. Side effects may include dizziness, sedation, tremors, and weight gain.

  • Gabapentin (Neurontin): This antiseizure medication is also used to treat some pain syndromes. Some studies have looked at its use in anxiety, but the results have been inconsistent. However, it’s used sometimes in people with anxiety who aren’t responding to more traditional medications, such as SSRIs, especially if using benzos because of addiction risk is a concern.