Q: Could Benzodiazepines Worsen Hypomania or Depression?
Hello Dr. Phelps, I have been diagnosed and am being treated for bipolar II
depression. I was wondering a few things. For one, do you have any
experience/have you ever seen the effects of benzodiazepines on bipolar II
patients? I was wondering if they could have the effect of worsening either
hypomania or depression. Also, I find that anxiety is often a key
player in setting off my depression and I wanted to know if you could recommend
a mood stabilizer targeted toward that.
Dear Mr. C' --
1. As you know, benzodiazepines (Valium, lorazepam/Ativan, clonazapam/Klonopin,
alprazolam/Xanax, others) are "anti-anxiety" medications, formally referred to
as "minor tranquilizers". They are often used in bipolar disorder as anti-manic
agents, primarily to help people sleep and decrease agitation. Concerns have
been raised about worsening depression by using such medications, although in
practice this seems to be a very minor problem if it indeed is an issue at all.
If so, it might be through lowering energy levels so that people don't get up
and do the things they need to do -- but in my experience, this has not been a
major problem. Indeed, I have stopped these medications on a few occasions to
see if mood might improve, and offhand I can think of only one or two cases that
might have improved thereby, and even then it was equivocal.
As for worsening hypomania, I'm not sure I have ever seen that concern raised.
We often use them to damp down energy levels when only a minor adjustment is
required (they do not have the clout to act as a "mood stabilizer" by
themselves, although some mood experts think that clonazapam comes pretty close
in this role).
Occasionally one sees a "disinhibition" in people who are already not inhibiting
their impulses very well, e.g. in hypomania or mania, when a benzodiazepine is
added. 10 years ago this was such a concern that we avoided using Valium in
favor of lorazepam, which was taught not to be as "disinhibiting". Since we
hardly ever use Valium anymore this issue has largely disappeared.
In your circumstances, I would keep clonazapam on the list as a possible "mood
stabilizer" in the hopes that by addressing anxiety one might be able to prevent
depression, as you describe.
2. Which mood stabilizers have anti-anxiety affects? Well, that depends on where
the anxiety is coming from. As you have probably learned, there are several
different kinds of anxiety which have been characterized: social anxiety,
restricted largely to interactions with others or anticipation thereof;
generalized anxiety, characterized by excessive worry; obsessive-compulsive
disorder, in which the anxiety is focused on particular excessive concerns; and
most common of all, most problematic in terms of its overlap with bipolar
disorder, "posttraumatic stress disorder" (PTSD).
PTSD causes a general overactivation of the "sympathetic nervous system", an
automatic portion of our nervous system which is designed to monitor for threats
and prepare to react to them. There is a complex interaction between PTSD and
bipolar disorder: they can be mistaken for one another diagnostically, that
commonly occur together, and each seems to be capable of making the other worse
when they do co-occur. In this context, clonazapam/Klonopin is very commonly
used. What about other official "mood stabilizers"?
As you probably know, there is really no official list of "mood stabilizers".
Lately everybody wants to be one. Here's my working list of
stabilizer options. From this list, which ones have the most anti-anxiety
affect? Certainly I think most psychiatrists would put Zyprexa and Seroquel very
high on that list. Zyprexa is very fast and can reduce anxiety from completely
out-of-control to manageable within 45-60 minutes; but it can be quite sedating,
and it is one of our worst medications for causing weight gain. Seroquel is much
slower, has to be ramped up to full dose, and causes a significant morning
slowness even after you get used to it. It helps a great deal with sleep at
night but is also associated with a potential for substantial weight gain.
Because of the concern about weight gain, it would be nice to find a candidate
or two which is not associated with that problem. Lamotrigine, one of the few
such candidates, is one of my favorite medications for Bipolar II, but it is not
famous for anti-manic effects. To my knowledge, it has never been studied in
terms of potential anti-anxiety affects. It does not generally have a reputation
for this, although occasionally it seems to do very well (I think perhaps most
particularly so when the anxiety is "cyclic", where the lamotrigine can prevent
anxiety by preventing cycling).
By contrast, carbamazepine is much more complex to use than lamotrigine and
carries a similar risk of a serious rash. It interacts with other medications,
changing their levels. It can bother one's liver and, more rarely, blood cell
production. But it does not cause weight gain (with some rare exceptions) and
often has quite substantial anti-anxiety affects, in my experience.
Good luck finding your way along.
Published March, 2008