Alternatives to Benzodiazepines for Managing Anxiety
SSRIs and SNRIs should be considered first-line pharmacological treatments for anxiety disorders instead of benzodiazepines due to their efficacy, safety profile, and lower risk of dependence. 1
First-Line Pharmacological Options
SSRIs (Selective Serotonin Reuptake Inhibitors)
- Fluoxetine: Demonstrated efficacy in panic disorder with 42-62% of patients becoming panic-free compared to 28-44% on placebo 2
- Fluvoxamine, Paroxetine, Escitalopram: Covered by health insurance for social anxiety disorder 1
- Sertraline: Effective for anxiety disorders in children and adults 1
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
- Duloxetine: Approved for generalized anxiety disorder in patients 7 years and older 3
- Venlafaxine: Shows similar efficacy to SSRIs with NNT = 4.94 1
Non-Benzodiazepine Anxiolytics
Buspirone (BuSpar)
- Dosing: Initial 5mg twice daily; maximum 20mg three times daily 1
- Best for: Mild to moderate anxiety/agitation 1
- Note: May take 2-4 weeks to become effective 1, 4
- Advantages: Does not produce physical dependence, no interaction with alcohol, no psychomotor impairment 4
Pregabalin
- Evidence: Most robust evidence among anticonvulsants for GAD 5
- Benefits: Rapid anxiety reduction, safe side effect profile, low abuse potential 5
Antipsychotics for Anxiety
Atypical Antipsychotics
- Quetiapine: Effective for GAD in low dosages with efficacy similar to SSRIs 5
- Risperidone: Initial dosage 0.25mg/day at bedtime; maximum 2-3mg/day 1
- Olanzapine: Initial dosage 2.5mg/day at bedtime; maximum 10mg/day 1
Mood Stabilizers/Antiagitation Medications
- Trazodone: Initial 25mg/day; maximum 200-400mg/day in divided doses 1
- Use with caution in patients with premature ventricular contractions
- Divalproex sodium: Initial 125mg twice daily; titrate to therapeutic blood level 1
Non-Pharmacological Approaches
Cognitive Behavioral Therapy (CBT)
- First-line psychological intervention for anxiety disorders 1
- Available as insured psychotherapy treatment 1
Other Psychological Interventions
- Mindfulness-based cognitive therapy
- Acceptance and commitment therapy
- Psychodynamic therapy 1
Special Considerations
For Acute Anxiety Management
- In situations requiring immediate relief (like COVID-19 related anxiety), benzodiazepines may still be considered for short-term use 1
- Lorazepam 0.5-1mg orally four times a day as needed (maximum 4mg/24 hours)
- Reduced dose (0.25-0.5mg) in elderly patients
Cautions with Benzodiazepines
- Regular use can lead to tolerance, addiction, depression, and cognitive impairment 1
- Paradoxical agitation occurs in about 10% of patients 1
- Not generally recommended for chronic anxiety in children with intellectual disabilities due to potential for behavioral side effects like disinhibition 1
Algorithm for Anxiety Management Without Benzodiazepines
First attempt: SSRI or SNRI (8-12 weeks adequate trial)
- If effective: continue for maintenance
- If partial response: optimize dosage
- If ineffective or intolerable side effects: proceed to step 2
Second attempt: Switch to different SSRI/SNRI or add/switch to:
- Buspirone (for generalized anxiety)
- Pregabalin (for generalized anxiety)
- CBT (can be combined with medication)
Third attempt: Consider atypical antipsychotics (quetiapine, risperidone) at low doses
- Monitor closely for metabolic and extrapyramidal side effects
For treatment-resistant cases: Consider mood stabilizers or combination therapy under specialist supervision
Common Pitfalls to Avoid
- Expecting immediate relief with non-benzodiazepine options (most take weeks to work)
- Discontinuing SSRIs/SNRIs too early before therapeutic effect is achieved
- Using atypical antipsychotics as first-line without trying safer alternatives
- Failing to address psychological components of anxiety through therapy
By following this approach, clinicians can effectively manage anxiety disorders while avoiding the risks associated with benzodiazepines, including dependence, tolerance, and cognitive impairment.