alprazolam

Alprazolam is FDA- and EMA-registered for panic disorder. Recommended as a second-line option after SSRIs and SNRIs. APA 2023, NICE CG113, and WFSBP list SSRIs (escitalopram, sertraline, paroxetine) as first-line due to a more favourable long-term profile: no dependence risk or withdrawal syndrome. Benzodiazepines are discussed as a 'bridge' during the first 4-6 weeks of treatment while SSRIs reach therapeutic effect, or when SSRIs are not tolerated.

Long-term use (> 4-6 weeks) is not recommended due to dependence risk. If continuation is required, alternatives are sought – another drug class or psychotherapy.

For GAD, international guidelines (APA 2023, NICE CG113) recommend SSRIs and SNRIs as first-line. Benzodiazepines are considered only briefly for severe symptoms that prevent waiting for SSRI onset. Long-term alprazolam use in GAD is associated with cognitive impairment in older adults, dependence, and a difficult withdrawal syndrome.

Alprazolam is not recommended for chronic insomnia. When pharmacotherapy is needed, AASM 2021 recommends melatonin agonists (ramelteon), orexin antagonists (suvorexant, lemborexant), and low-dose doxepin. Benzodiazepines are acceptable only short-term (< 2-4 weeks) and preferentially as longer-acting agents (temazepam), not alprazolam. 'For flights' or 'holiday' use is dangerous due to dependence risk.