Last Updated on February 16, 2021
As a psychiatrist, I think of anxiety and depression as existing on two sides of the same coin.
These twin conditions often occur intertwined: Each phenomenon disabling in its own right, and one of them often triggering the other. Severe depression can lead to anxiety. Severe anxiety can lead to depression.
This negatively reinforcing pattern can cause a person to feel overwhelmed, sometimes leading to a downward spiral both at work and at home, making it more difficult than ever to cut down or stop drinking alcohol.
Those people who drink too much alcohol carry a heavier burden of anxiety and depression compared to those who don’t drink at all, or who drink smaller amounts of alcohol.
That’s the bad news.
The good news is that anxiety and depression are both treatable.
For many, the best results come from treating excessive alcohol use, anxiety, and depression simultaneously. Targeted psychotherapy, such as cognitive-behavioral therapy (CBT), often in conjunction with prescribed medications, can treat all three of these conditions at the same time.
This article is the first in a two part-series, outlining an approach to diagnosing and treating anxiety and depression in heavy alcohol users. We’ll begin here with part 1: How anxiety is connected to alcohol use disorder (AUD), and how this problem can be treated.
Part 1: Treating Anxiety and Alcohol Addiction
About half of all people with drinking problems suffer from anxiety.
Excessive worry, nervousness, thinking too much (also known as obsessing or ruminating), anticipating the worst, experiencing panic attacks, and avoiding or isolating due to a fear of feeling overly self-conscious in public settings are all symptoms of anxiety.
To break it down, two types of anxiety exist in those who are heavy alcohol users:
The first group includes those who drink alcohol to self-medicate anxiety. And why not? Alcohol seems well suited to the task (at least on the surface).
This is a big reason why people start drinking in the first place. Alcohol is a relaxant, making one feel less self-conscious and more at ease within a few minutes of imbibing—especially in social situations.
This seems all well and good until one feels a need to drink to relax or have fun. That’s when alcohol dependence can sneak up on you—causing you to drink greater amounts than planned and/or more frequently to get the same effect.
Anxiety Caused By Alcohol
This second type of anxiety may be less obvious in its origin. This is the anxiety that occurs once the alcohol leaves your system. This can mean acute alcohol withdrawal, long-term readjustment to not consuming alcohol, or even day-to-day impacts while you are still drinking. Disrupted sleep and hangovers, for example, are symptoms of a mild form of withdrawal.
As you drink more often and in greater amounts, your withdrawal episodes1 are more likely to include increased anxiety, and a sense of dread and foreboding. This is often accompanied by shaky hands, sweating, a racing heart, and even outright panic attacks. These symptoms often go along with the low energy, headaches, and nausea experienced with a typical hangover.
Those who don’t experience hangovers often find it harder to stay motivated to quit or cut down. The adverse experience of a bad hangover is a natural consequence that can increase your motivation to address your drinking.
Challenges in Managing Anxiety
Anxiety is tricky2 because it’s a normal part of living. Feeling anxious gives us motivation, helps us figure out what matters to us, and gives us the energy to carry out those tasks. Anxiety can become a disorder, however, when it causes an inordinate amount of distress and impairs your ability to function in some or all aspects of your life.
It’s important for a health care provider to find out if you have a specific anxiety disorder such as obsessive-compulsive disorder (OCD), social anxiety disorder, panic disorder with or without agoraphobia, or even post-traumatic stress disorder (PTSD), which is technically not classified as an anxiety disorder.
PTSD, however, manifests with a great deal of anxiety: A tendency toward vigilance and fearfulness, startling easily, having panic attacks, sleep problems including nightmares, and avoiding situations that remind you of the traumatic event.
Each of the above conditions require specific psychotherapy techniques, and a focused medication approach. Additionally, most people with an anxiety disorder suffer from generalized anxiety disorder (GAD), which takes a little bit from each of the more specific conditions noted above.
Medication Options for Anxiety and Alcohol Addiction
Anxiety can be treated with benzodiazepines, aka “benzos”, such as chlordiazepoxide (Librium), diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax).
The upside is that these medications work quickly and effectively to reduce anxiety. The downside is that they mix terribly with alcohol, increasing the risk for alcoholic blackouts (technically called alcohol-induced amnestic disorders). They also carry the risk of inducing confusion, memory loss, drowsiness, fatigue, and problems with balance and coordination at higher doses. On top of this, they are habit-forming in their own right.
The most legitimate use of benzodiazepines in AUD is in treating severe alcohol withdrawal, which can cause full-blown delirium tremens (associated with a 5 to 25 percent3 mortality rate), or alcohol withdrawal seizures.
An alternative to benzodiazepines for treating alcohol withdrawal, gabapentin may be the treatment of choice for those suffering from a combination of anxiety and AUD.
Gabapentin provides the first line of medication treatment for anxiety in people who drink too much. It works as quickly as a benzodiazepine, targeting some of the same brain receptors as benzodiazepines without the addiction risk. It also treats insomnia, and nerve-based pain such as alcoholic neuropathy.
Another mainstay of anxiety treatment is the group of medications called selective serotonin reuptake inhibitors (SSRIs). Originally authorized by the FDA for treating major depression—beginning with Prozac (fluoxetine) in the late 1980s—it became clear pretty quickly that SSRIs work just as well, if not better, for anxiety disorders than depression.
Although they can take up to 12 weeks to kick in, SSRIs can definitely reduce obsessive thinking, suppress panic attacks, and dampen an unnecessarily heightened “fight-or-flight” response to what is, in actuality, a non-emergency situation. Other SSRIs include Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Lexapro (escitalopram), and Luvox (fluvoxamine).
These SSRIs do come with their own side effects. They can sometimes cause either increased anxiety or drowsiness/fatigue, gastrointestinal side effects, weight gain over time, headaches, motor restlessness, and sexual side effects.
The most frequent sexual side effect, in both men and women, is the slowing or stopping of the ability to have an orgasm. Other side effects can include reduced libido, less genital sensitivity, impaired arousal, and, in men, erectile dysfunction.
Other Medication Options
Another antidepressant, Remeron (mirtazapine), which is unique in its mechanism of action, can be extremely useful for treating anxiety, depression, and insomnia. Mirtazapine, prescribed at bedtime, is well tolerated overall, with minimal gastrointestinal or sexual side effects. Unfortunately, increased appetite with weight gain can occur. This can generally be caught early in the treatment process. Once the medication is stopped, this side effect subsides.
Finally, research performed with an older medication called BuSpar (buspirone) shows that it can effectively treat the symptoms of generalized anxiety disorder in those patients also diagnosed with AUD. Buspirone is non habit-forming, generally well tolerated, and can kick in within a few weeks. SSRIs, by comparison, usually take longer to work.
Getting Help For Anxiety and Alcohol Misuse
We know that anxiety and excessive alcohol use are frequent diabolical companions in a person’s life. We also know that these conditions are treatable.
If you struggle with both anxiety and alcohol, don’t hesitate to be open with your primary care provider, therapist, or psychiatrist about the role of anxiety in your drinking habits. The more they know, the better they can craft a treatment plan to improve your quality of life, and help you succeed in your quest to cut down or stop your alcohol use.
Continue Reading: Part 2—Treating Depression and Alcohol
Professional support for alcohol use disorder, including prescription medications that treat both anxiety and alcohol addiction, is now available online. Get expert medical advice, weekly coaching support, and tools to measure your progress—all from an app on your smartphone. Get in touch today, or learn more about how it works.