Suicidal Thoughts: The Dark Side of Benzodiazepine Withdrawal

If you are having thoughts of suicide right now, get help before you read on.

If you are thinking about killing yourself, or you are afraid you might act on a thought, call or text 988 to reach the 988 Suicide and Crisis Lifeline, any hour, any day. It is free, and the person who answers has heard this before.

Call 911 or go to the nearest emergency department if any of these is true:

• You have a plan, the means to carry it out, or you have already taken something to harm yourself.
• You cannot keep yourself safe for the next few hours.
• You stopped a benzodiazepine suddenly and now have a seizure, severe confusion, or hallucinations. Call emergency services for a seizure or any medical emergency.

Nothing below replaces that call.

Can benzodiazepines cause suicidal thoughts?

Yes. Benzodiazepines can cause depression and suicidal thoughts during long-term use, and again during withdrawal, and the person taking them is often the last to suspect the pill. Professor C. Heather Ashton, in Chapter I of the Ashton Manual, states that benzodiazepines may both cause and aggravate depression, possibly by reducing the brain’s output of neurotransmitters such as serotonin and norepinephrine, and that the drugs sometimes seem to precipitate suicidal tendencies.

The same chapter calls “emotional anaesthesia,” an inability to feel pleasure or pain, a common complaint of people who take these drugs for years, and describes patients who took overdoses while on prescribed treatment, most of them with no history of depression before the prescription. Their prescriptions had not run out. Their mood had.

Withdrawal adds a second layer. In September 2020 the United States Food and Drug Administration (FDA) required the boxed warning on every benzodiazepine to address, among other risks, physical dependence and withdrawal reactions, and its list of severe withdrawal symptoms includes thoughts about killing yourself. So, why would a calming drug do this, and why does coming off of it make things worse?

Why does coming off of the drug make the thoughts worse?

Benzodiazepines work on gamma-aminobutyric acid (GABA), the brain’s main calming chemical. They make the GABA system more effective, and with regular use the brain adjusts by making that system less responsive. The Manual calls this tolerance, and it develops during continued use, as the same dose does progressively less.

Withdrawal is what happens when the drug is reduced faster than the brain can undo those adjustments. The calming system runs below normal, the alarm systems run above it, and mood sits on top of both.

An analogy might help, though it is not a perfect one. Imagine wearing earplugs every day for years. Your ears turn up their own volume to compensate. Pull the earplugs out in one motion and a dripping tap sounds like a hammer, and the ears need time to turn themselves back down.

Withdrawal depression is that dripping tap, felt in the mood instead of the ears. The thought that you cannot live like this is a symptom the drug created, and the earplugs come out one thin layer at a time.

These thoughts are drug-driven, and they lift.

Is the despair real? It feels completely real, it deserves to be taken seriously, and it is still a symptom. In Chapter III of the Manual, Professor Ashton writes that depressive symptoms are common both during long-term use and in withdrawal, that severe depression may result from biochemical changes in the brain induced by benzodiazepines, and that suicides have occurred in reported trials of benzodiazepine withdrawal. She does not soften it, and neither should anyone else.

Yet, the same chapter says that the steady decline in symptoms almost invariably continues after withdrawal, though it can take a long time. Anxiety gradually diminishes over a year, and sensory and motor symptoms may last at least a year and occasionally several. Symptoms wax and wane, the windows of feeling normal grow longer, and the mood lifts as the nervous system recovers. What you need to hear is the direction, not a date.

None of this is a character flaw, a weakness, or proof that the “real you” is depressed. It is what a nervous system does when its chemistry has been altered for years and then changed too quickly. The person who took the pills as directed did nothing wrong.

What should you do when the thoughts appear during a taper?

Tell your prescriber the same day, and do not wait for the next visit. Suicidal thoughts during a taper are a signal about the pace. In fact, the usual first response is to hold the dose where it is and let the nervous system catch up, with slower or smaller next steps as the other half of the answer.

Never stop the drug abruptly, and never let despair push you into stopping. The FDA’s 2020 label update states that stopping abruptly or reducing the dose too quickly can result in withdrawal reactions, including seizures, which can be life-threatening. Call emergency services for a seizure or any medical emergency.

Tell one person in your home what is happening, and let them hold anything you could use to hurt yourself. Keep the days simple: food, daylight, and a short walk. Write down how you feel each evening so the doctor sees the pattern. Professor Ashton advises in Chapter III that depression which does not lift within a few weeks, and does not respond to simple reassurance and encouragement, deserves a medical opinion.

The same section of the Manual notes that withdrawal depression can occasionally be severe enough to pose a risk of suicide, and that this is unusual with slow tapering. That is the whole argument for the pace. Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, tapers on that principle: the first response to a darkening mood is a slower taper, and depression that is severe or does not lift is a matter for a medical visit, the same day, not for a web page.

Physical dependence is a medical condition, not a moral one.

A family member who finds a person crying at the kitchen table, unable to stop a pill the doctor prescribed, often reaches for the wrong word. Dependence is not addiction. The FDA’s 2020 update is explicit that physical dependence can occur when benzodiazepines are taken steadily for several days to weeks, even as prescribed.

Addiction is a pattern of behavior, compulsive use despite harm. Dependence is chemistry, the brain’s adjustment to a drug it was told to expect. In fact, most people who come to a doctor for benzodiazepine tapering have never taken an extra pill in their lives.

Unfortunately, “benzo detox” is what most people type into a search box at 2 a.m. What that searcher needs is not a facility stay measured in days but a gradual, medically supervised benzodiazepine taper measured in months, sometimes longer, at home, with the prescription still in hand.

What does a safe taper look like when depression is part of the picture?

Slow, and at the patient’s pace. Professor Ashton writes in Chapter II that the person withdrawing must be in control and must proceed at the pace that is comfortable, and that whether the taper takes six months, twelve months or eighteen months is of little significance after years on the drug. Each reduction can be up to one tenth of the current dose, and the interval between reductions belongs to the person taking them.

The Manual’s crossover taper moves people on potent, short-acting drugs to diazepam, a long-acting benzodiazepine whose slow elimination allows a smooth, gradual fall in blood level. The Maudsley Deprescribing Guidelines add the hyperbolic shape: reductions get smaller as the dose gets lower, because the last milligrams do the most work at the receptor.

Dr. Leeds tapers this way, and he does not recommend stopping any benzodiazepine abruptly. The Manual makes one exception, for triazolam (Halcion), a very short-acting sleeping pill that Chapter II says is eliminated so quickly a person is practically withdrawn from it each day, and which can therefore be stopped abruptly without first switching to a long-acting drug. Dr. Leeds prefers a gradual taper even there, consistent with the 2020 FDA label update, and a person with suicidal thoughts is the last person who should be stopping anything suddenly.

What can family members do?

Stay close, and do not argue with the thought. A person in withdrawal depression cannot be reasoned out of a symptom, but they can be accompanied through it. Watch for the warning signs: talk of being a burden, giving things away, a sudden flat calm after weeks of agitation, or a plan spoken out loud.

Go to the doctor’s visit with them if they will allow it, and carry the evening notes. Keep firearms and stockpiled medication out of the house. And, resist the urge to make them stop the drug to “get it over with.” That instinct is the one that lands people in the emergency department.

Before you close this page.

If the thoughts are here tonight, call or text 988 to reach the 988 Suicide and Crisis Lifeline. Call 911 or go to the nearest emergency department if any of these is true:

• You have a plan or the means, or you have already acted on a thought.
• You cannot keep yourself safe until morning.
• You stopped a benzodiazepine suddenly and now have a seizure, severe confusion, or hallucinations.

Dr. Leeds’ practice offers one thing: gradual, medically supervised benzodiazepine and z-drug tapering for patients in Florida, planned with the patient and adjusted to the person, so that the depression of withdrawal is met with a slower pace rather than a faster stop. If you are being told to hurry, or nobody has asked how your mood is, Contact Dr. Leeds.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.