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As more patients seek treatment for anxiety, more doctors are prescribing pills. But what happens when a short-term fix becomes a long-term problem?
Michael Tran always thought of himself as shy and a little anxious. But in 2012, he began having debilitating panic attacks. At the time, Tran was 19, a University of Maryland sophomore. He’d get tunnel vision. His heart rate would skyrocket. He’d lose the ability to walk, stand, or do much of anything. Tran stopped going to class and dropped out within a year. He eventually went to see a doctor. “I get really nervous,” he told his physician. “I can’t perform in front of people. I can’t . . . I get really bad anxiety driving.”
The visit lasted five minutes, and Tran walked out with a prescription for alprazolam, an antianxiety medication that is better known by its brand name: Xanax. On half a milligram twice daily, Tran felt comfortable going out. He made friends like never before and even went skydiving. “This is like a God drug,” Tran says.
Like Tran, nearly a third of all adults will be diagnosed with an anxiety disorder at some point in their life, according to the National Institute of Mental Health. A recent American Psychiatric Association poll revealed that 32 percent of Americans reported feeling more anxious than they did one year earlier. And that’s not necessarily a bad thing. Anxiety motivates us to solve problems and take care of business, and it can boost productivity. But when the frequency, intensity, or duration of symptoms interrupts your life, it can become pathological anxiety. Persistent. Nightmarish. Mental-health experts now recognize anxiety—the umbrella term that includes social anxiety and PTSD—as a legitimate brain disorder, sharing some of the same underpinnings as depression.
“People are more ready to have a medical diagnosis to describe their suffering,” says Anna Lembke, M.D., a psychiatrist and researcher at Stanford. “There’s a modern phenomenon of people being more anxious than they used to be.” The uptick in diagnoses may have to do with increased isolation and stress combined with the pressures of social media and hustle culture. Plus, the eroding stigma around mental illness means more people feel comfortable talking about their anxiety.
Many of us want quick fixes. Several online start-ups offer meds for social and performance anxiety, delivering beta-blockers right to your doorstep. Professionals favor the use of antidepressants, particularly serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs), as a first-line treatment. But the most broadly prescribed pills are the benzodiazepines, or benzos, which have been around since the 1960s and include Xanax, Ativan, and Valium. Benzos work. Short-term, their effect in reducing anxiety is undeniable. But as boomers and millennials seek out pharmacological fixes, doctors are now prescribing benzos in more than a quarter of all office visits (27 out of every 100)—nearly triple the number of benzos being dispensed in the mid-1990s. More than 48 million prescriptions were written in 2013 , and the use of benzos to treat chronic pain more than doubled between 2003 and 2015.
“Benzodiazepines are not a panacea for every twinge of anxiety,” says Timothy J. Wiegand, M.D., a medical toxicologist at the University of Rochester. They’re habit-forming. The medications come with a high risk of overdose, especially when combined with opioids or alcohol, or in patients with breathing problems or sleep apnea. Chronic use can lead to neurological changes, resulting in mental cloudiness or loss of coordination. Several studies have reported that long-term use and high doses can accelerate the onset of dementia. Because it’s extremely difficult to stop taking them, a short-term bid to relieve anxiety can, for some patients, unwittingly turn into a vicious cycle.
For Tran, things started to unravel as he built up a tolerance. The effects of his medication wore off, and he felt increasingly irritable between doses. By 2017, he was spending less time thinking about his ambitions and more time worrying about his next dose. His memory and cognition sputtered. Still, he thought, being medicated felt better than any debilitating anxiety. It would be another year before he finally said to himself, Being tranquilized 24/7 is no way to live. I’d rather suffer through the hard parts.
The decision presented him with a daunting, unforeseen challenge: How was he going to get off his meds? Cold turkey was not an option; the abrupt discontinuation of benzos can lead to seizures. Tran found an Internet forum called BenzoBuddies.org and learned about the Ashton Manual, a doctor–developed guide to the workings of benzos with methods for tapering—gradually reducing the total dose over a set period of time.
Web forums offered what physicians had not: validation and support. By 2018, Tran came to believe that most doctors didn’t want to hear from patients who wanted off, and so at his next visit, he asked for Valium, another benzo. At home, he used a volumetric doser to reduce his medicine by 10 percent every week. The withdrawal left him with constant severe nerve pain, as if his spinal cord had been plugged into an electrical outlet. The effects of withdrawal are lasting. He found it difficult to go outside, and the world seemed depersonalized, almost as if Tran were observing himself from outside his body.
At Dr. Lembke’s clinic at Stanford, about half the patients she sees are deprescribing, wanting to stop taking medication that was given for a legitimate medical condition. “I have a lot of high-functioning people who were prescribed small doses of benzodiazepines for decades,” she says. “But it’s very, very difficult to stop.” Some people take 18 to 24 months to taper down, she says. “And that’s with a lot of psychological support and other treatments.”
Alex Smith, a 33-year-old lawyer in Des Moines, learned firsthand that not all health-care providers recognize fatigue, full-body tremors, or even other, more obvious symptoms of benzo withdrawal. He’s had three seizures. Only after the third one, he says, in September 2019, was he informed that these resulted from not taking benzos. “I was told I’m lucky to be alive,” he says. Smith does not crave his meds. Since he doesn’t have a strong compulsion to use or extreme difficulty in abstaining, he doesn’t meet the formal criteria for addiction. This is a subtle but important distinction: Support groups won’t let him join because he’s considered an active drug user. Had he known it would take him more than a year to stop the medication, he says, “I would have never taken it to begin with.”
Another issue is that most physicians receive more training on prescribing drugs than on safely tapering patients off them. Christy Huff, M.D., a cardiologist and the director of the Benzodiazepine Information Coalition, says doctors—herself included—can be in the dark about potentially life-altering risks. Dr. Huff was prescribed benzos for insomnia and says withdrawal was the worst experience of her life. She suffered panic attacks, crushing fatigue, and akathisia (the inability to stay still). Having been off the medication for a year, she now has to contend with lasting neurological damage. The emergence of patient-led groups, she says, speaks to a greater unmet need: “People definitely need more answers than are being provided by doctors.” Her coalition was created to inform patients. Other experts make similar observations. “People are finding out that, you know, traditional Western medicine is not always the place to get the best treatment,” says Dr. Lembke.
Now health start-ups appear to be tapping into a subset of customers who want to stave off acute anxiety. Online providers Kick and Hims don’t sell controlled substances, such as benzos; they do sell a drug called propranolol. (Pricing varies, although both offer a virtual consultation and the first shipment of pills for less than $100.) Propranolol, a beta-blocker, slows down your heart and reduces blood pressure. Short-term use of the drug for performance anxiety and social phobias is legal and permissible. By some estimates, millions of prescriptions for beta–blockers are written for the treatment of anxiety, but it’s considered an off-label use since these medications are cleared primarily for cardiac purposes by the FDA.
When taken for less than two weeks, benzos remain an evidence-based option for treating panic disorder, social anxiety disorder, and generalized anxiety disorder, especially when psychotherapy or serotonergic agents fail. Clinicians recommend SSRIs, like Prozac and Zoloft, although these can require two to four weeks, or longer, to take effect.
Stefan Hofmann, Ph.D., a professor of psychology at Boston University, recommends keeping an open mind about nonpharmacological treatments. Try psychotherapy, such as cognitive behavioral therapy, he says. “It works for many people, and the potential adverse effects are considerably smaller compared to many of the pharmacotherapies.” Still, not all alternative therapies are created equal. Hypnosis and yoga are promising, but more research is needed. Despite the hype around CBD—the nonpsychoactive ingredient in marijuana—and mobile health apps, neither has much scientific support. For her part, Dr. Lembke recommends exposure therapy, a specific type of psychotherapy in which patients expose themselves to the source of their anxiety. It takes considerable time and effort to see benefits but “builds mental calluses that last a lifetime,” she says.
Since May 2019, Tran has been off benzos. Once a month, he sees a therapist to focus on cognitive behavioral techniques. He’s learned the 4-7-8 breathing method (breathe in for a 4-count, hold it for a 7-count, and exhale for an 8-count), which has helped ease tense situations that might have otherwise induced a panic attack. And he does mindfulness meditation daily. Like some patients who’ve successfully tapered, Tran still feels anxious and still experiences the residual effects of withdrawal. To alleviate them, he uses many methods he first learned about online, and there are times when he climbs into bed, pulls up a 17-pound weighted blanket, and puts on noise-canceling headphones.
Life feels better now—harder, he says, but also more rewarding. If he could start treatment all over again, Tran wouldn’t visit a general practitioner. “I would definitely go talk to either a psychologist, a psychiatrist, someone who is more specialized in this field,” he says. “If I could go back now, I would try to avoid medication. That’s my biggest regret.”
The Anxiety Spectrum
“Anytime medication is considered at any phase to treat anxiety, ask questions,” says psychiatrist Gregory Scott Brown, M.D. Ask: How long should I be on this medication? What’s the intended effect? Is it addictive? Use the chart below to plot a sustainable path forward.
Symptoms Pounding heart, shaky voice.
Rx Take a beta-blocker right before public speaking, a job interview, or another nonrecurring anxiety–producing situation.
Symptoms Racing thoughts, heart palpitations, excessive worrying, tension in your body.
Rx Have a doctor rule out underlying causes like hyperthyroidism; practice meditation using an app like Headspace, and consider yoga; try cognitive behavioral CBT).
Symptoms Inability to go to work or leave the house, substance abuse, suicidal thoughts.
Rx Explore benzodiazepines in addition to SSRIs/SNRIs; get help for drugs and alcohol; use CBT and meditation; consider a short-term stay at a mental–health treatment facility.