This leaflet may be helpful if you:
have been prescribed benzodiazepines
have used benzodiazepines
know someone who has been prescribed benzodiazepines
are worried about addiction and withdrawal effects with these medications.
What are benzodiazepines?
They are a group of medications which have been used since the 1960s to treat:
They replaced the barbiturates which had been commonly prescribed for 50 years around the 1950s, but which were addictive and very dangerous in overdose.
Some benzodiazepines commonly used in the UK:
Sleep, alcohol withdrawal
1. These are the trade names used in the UK – they may be different in other countries
They all work in a similar way (see below). Those which have a short effect have been marketed as sleeping tablets – the idea being that you don't get a muzzy head the next day. Others with a longer effect have been marketed for their use in controlling anxiety.
How do they work?
They boost the effect of a substance in the brain – GABA.
What is GABA?
GABA is a neuro transmitter – a chemical which is used in the brain to control the passage of impulses from one cell to another. GABA has a generally calming effect in the human brain.
What are the main side effects?
But most people find they don’t have significant problems of this sort.
Aren't benzodiazepines addictive?
Yes. Around 4 in every 10 people who take them continuously for more than 6 weeks with get withdrawal symptoms. These include difficulty in sleeping, feeling tense and agitated – rather like the return of the symptoms the medication was originally prescribed for. You can also get dizziness, metallic tastes, and disturbances of your vision.
They will usually start within 48 hours of stopping or reducing the dose of a benzodiazepine. They can be mild and pass off within a few days.
For some people they may be so severe that they produce confusion, hallucinations and epileptic fits.
Some people experience unpleasant symptoms for several months afterwards.
If you have been taking a benzodiazepine for more than a few weeks, talk it over with your doctor – you should probably reduce the dose by just 1-2 mg every 2 weeks. It may take a while, but nearly everyone can tolerate this very slow rate of withdrawal.
Are blood tests necessary?
Benzodiazepines are very safe and no routine tests are needed before taking them.
How effective are the benzodiazepines?
They are work well for the short term treatment of both anxiety and sleep. They work particularly well in generalised anxiety disorder and social anxiety disorder. They can also be helpful in panic and obsessive compulsive disorders, but in these conditions antidepressants - especially the SSRIs - seem to work better.
In all the conditions in which they are used, benzodiapines tend to produce dependence and withdrawal reactions. They should really only be used for periods of a few weeks or so.
How long does treatment last?
Just a few weeks, while other (often psychological) treatments have a chance to work. A very few people may benefit from taking them long-term, but this should only be carried out by a specialist unit after other treatments have been tried and have failed.
How do the treatments compare and how does one choose between treatments?
The main differences between the benzodiazepine type drugs are:
how quickly they start to act
how long they stay in the body.
When they are used to help sleep, then a short-acting drug is better so that you don't get a “hangover” effect the next day, which can make it dangerous to drive or use machinery. The “z-drugs” were designed to fulfil this need and do it well.
When anxiety is present all day long, then a longer acting benzodiazepine such as valium or ativan is used.
If someone is both anxious and sleeping badly, the longer-acting benzodiazepines can be taken at night - they will improve sleep but still be present the next day to help with the anxiety.
What can I do to help myself ?
Self-help treatments for anxiety and insomnia are available from psychologists, in books and over the internet. See the reading materials section at the end of this leaflet and of our other leaflets:
Cognitive behavioural therapy
What would happen without treatment?
Anxiety and insomnia can be short-lived, especially when they have started because of a stress such as bereavement or a job loss. However, many people have lasting anxiety and insomnia because of chronic stress or family tendencies. These need attention if the person is to get better.
Are there any major differences of opinion about benzodiazepines?
Most health care professionals now accept that the benzodiazepines and z-drugs can be helpful in anxiety and insomnia. However, it is universally acknowledged that they were overused in the 1960s and 1970s which led to many people becoming dependent on them – see above.
It now seems safe to use them in the short term (less than 4 weeks). Psychological therapies and/or antidepressants are needed in the longer term.
What are the main gaps in our knowledge about anxiety and sleeplessness?
We do not know why some people are more anxious or sleep less well than others. Brain scans suggest that they may not have enough GABA (see above). This also happens in some forms of epilepsy and alcohol withdrawal. The benzodiazepines increase the effects of GABA and so make up for this shortage.
Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson J, Den Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen H-U  Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2005; 19: 567-596.
Malizia AL, Cunningham VJ, Bell CJ, Liddle PF, Jones T, Nutt DJ (1998), Decreased brain GABA(A)-benzodiazepine receptor binding in panic disorder: preliminary results from a quantitative PET study, Arch.Gen.Psychiatry 55: 715-720.
Nutt DJ, Malizia AL (2001) New insights into the role of the GABA(A)-benzodiazepine receptor in psychiatric disorder. Br.J.Psychiatry 179: 390-396.
Nutt DJ  chapter on Medication, in The Mind – A Users Guide ed R Persaud. Royal College of Psychiatrists.
Wilson SJ Nutt DJ  Management of insomnia: treatments and mechanisms. Brit J Psychiatry 191: 195-197.
Nutt, DJ & Ballenger, JC. (2003) Anxiety disorders. Blackwell Science Limited, Oxford. I-xii, 1-542. ISBN 0-632-05938-9.
Doble A, Martin IL, Nutt DJ. (2004) Calming the brain: benzodiazepines and related drugs from laboratory to clinic. Martin Dunitz Limited, London. i-vi, 1-185. ISBN 1-84184-05201.
Wilson SJ and Nutt DJ (2008) Sleep Disorders; Oxford Psychiatry Library.