Managing Anxiety During COVID-19

Benzodiazepines are not the answer.

Posted Nov 08, 2020

This post is the first in a series on the management of anxiety during the COVID-19 pandemic.

Millions of people have been relying on benzodiazepines such as alprazolam (Xanax™), clonazepam (Klonopin™), lorazepam (Ativan™) and other prescription drugs to manage symptoms of stress and anxiety. While some medications are safe and effective treatments of anxiety, they have limited overall efficacy and potentially serious safety concerns. In this post, I briefly review the complex mental health impacts of the COVID-19 pandemic, talk about the limitations of conventional treatments of anxiety and growing public health concerns over increased uses of benzodiazepines during the pandemic, and comment on the medical and psychiatric risks of benzodiazepine use among individuals infected with SARS-CoV2.

In future posts, I will review the evidence supporting non-pharmacologic approaches for anxiety including dietary change, exercise, relaxation and mindfulness, select natural products, as well as biofeedback and virtual reality graded exposure therapy (VRGET).

A multiplicity of mental health impacts

The COVID-19 pandemic has had enormous impacts on the daily lives of tens of millions of individuals globally. Widely shared concerns about becoming infected with the virus affect our day-to-day choices, including how we work, how often we leave our homes, where we shop for essential needs, how we socialize and how we think about the future. The psychological and financial stresses associated with the pandemic have resulted in high rates of anxiety, depressed mood, substance abuse, and—for survivors of pandemic-related illness—high rates of post-traumatic stress disorder (PTSD) and severe depressed mood. Mental health researchers are developing diagnostic tools to help clinicians better understand and more accurately evaluate the range and severity of mental health problems associated with the pandemic. 

Limitations of conventional treatments of anxiety

Research findings support the idea that most currently available conventional treatments for anxiety are sometimes beneficial but have limited efficacy overall. The majority of individuals who use benzodiazepines to manage generalized anxiety initially respond well but continue to experience anxiety problems over the long-term. The severity and frequency of panic attacks lessen in response to benzodiazepines, however many individuals who use such drugs on an on-going basis are at significant risk of benzodiazepine tolerance, dependence and withdrawal. In this context over-prescribing and inappropriate prescribing of benzodiazepines (and other controlled substances) is a growing public health concern. A large cross-sectional study found that the rate for benzodiazepine prescribing doubled from 2003 to 2015 due largely to large numbers of prescriptions by family doctors and surgeons. This trend has accelerated since the start of the COVID-19 pandemic.  

The risks of benzodiazepine use—worse during the pandemic

There are growing public health concerns that widespread anxiety associated with the pandemic has resulted in rapid growth in the illicit market for so-called "novel psychoactive substances," non-prescription (i.e., unscheduled) benzodiazepines and other narcotics that are widely available on street corners in many cities and via the internet. This trend is resulting in increased rates of addiction and potentially serious medical and psychiatric consequences that are now worse in the context of the pandemic. 

There are even greater risks associated with benzodiazepine use in individuals afflicted with COVID-19. The National Health Service (NHS) of the U.K. published a short article outlining the risks of benzodiazepine use in individuals with COVID-19-related illness. For example, benzodiazepines worsen respiratory drive in individuals whose breathing has already been compromised by infection with the virus. Benzodiazepine use in individuals with pre-existing respiratory illnesses such as asthma and chronic obstructive pulmonary disease (COPD) may lead to severe respiratory compromise. Further, long-term benzodiazepine use is known to increase susceptibility to becoming infected with and succumbing to pneumonia.

Finally, a significant percentage of individuals who are hospitalized for management of acute illness related to COVID-19 experience delirium and other severe neurologic symptoms. Use of benzodiazepines in acutely ill or recovering individuals may exacerbate symptoms of delirium and increase fall risk and should be judiciously prescribed or (preferably) avoided. 

Bottom line

The direct and indirect consequences of the COVID-19 pandemic have resulted in high rates of anxiety, depressed mood, substance abuse and PTSD. Conventional treatments of pandemic-related stress and anxiety have limited efficacy and unresolved safety problems. Benzodiazepine prescribing and the illicit market for benzodiazepines have increased significantly since the start of the pandemic in spring 2020. Use of benzodiazepines in individuals with pre-existing medical conditions places them at risk of infection, and in individuals with COVID-19 related illnesses, exacerbates the risk of potentially serious medical and psychiatric consequences.