Question from a Member:
I work with several psychiatrists who have 30 and 40 years of experience. They are amazing physicians and prescribe benzodiazepines frequently. It has been said that “the pendulum has swung” from overuse of benzodiazepines to underuse of benzodiazepines. I would be interested to know what the current research shows regarding the risks and benefits of benzodiazepines, reducing benzodiazepine prescribing, and especially patient outcomes.
On other pages on this website, we have discussed in detail the use of benzodiazepines for various mental disorders, their pros and cons, and how to use them for maximum possible benefit with minimum possible risk (see Related Pages below). On this page, let’s discuss the big picture.
Of course, nobody with even a basic knowledge of psychopharmacology would disagree that benzodiazepines may be misused or abused and that they are associated with many risks including sedation, cognitive impairment, falls, traffic accidents, withdrawal symptoms, etc.
But, that’s not what we are talking about here. Our question here is: Has the pendulum swung from overuse of benzodiazepines to underuse of benzodiazepines?
With regard to our Member’s comment above, I agree that the pendulum has swung too far in the other direction—against even the legitimate, appropriate use of benzodiazepines. As we will see below, many leading psychopharmacology experts agree.
In an editorial in the American Journal of Psychiatry, titled “Benzodiazepines: A perspective“, a leading expert on psychopharmacology in general and on benzodiazepines in particular (and the former Chair of the Department of Psychiatry at Harvard Medical School), discussed the pros and cons of prescribing benzodiazepines (Rosenbaum, 2020).
He noted that “…some of the most gratifying memories in my career had to do with benzodiazepines”. He cited some examples of patients whom he treated with a benzodiazepine with excellent results, including a “physician with a history of panic attacks, ongoing social anxiety, and irritable bowel syndrome who achieved remission for decades on clonazepam and as-needed alprazolam for emergencies…”.
But, he joked, “…based on the current practice of many more recently trained physicians, these medications reduce anxiety for the physicians themselves by their refusing to prescribe them”. 🙂
While there are definitely some risks associated with the use of benzodiazepines, many of which he discussed, he argued that we should realize that “There may be times when the best or only way to comfort will be to use or add a benzodiazepine.”
A group of very well-known and senior psychopharmacology experts has formed an informal “International Task Force on Benzodiazepines” (Balon et al., 2018).
In an editorial, they noted that the group feels that the risks and side effects of benzodiazepines have been overemphasized. An editorial from this team, titled “Benzodiazepines: it’s time to return to the evidence” and published in the British Journal of Psychiatry, argued for their thesis that “…discussions of benzodiazepines in the current psychiatric literature have become negatively biased and have strayed from the scientific evidence base” (Silberman et al., 2020). They expressed concern that “Clinicians who advocate use of benzodiazepines may risk opprobrium from peers and institutions.”
The authors argued that patients with and without a history of substance use are two very different populations and confusing the risk in one with the other stigmatizes patients with anxiety disorders and deprives them of a medication that might be very helpful (Silberman et al., 2020).
The group summed up their view very nicely as follows:
“Benzodiazepines are highly effective for treatment of anxiety disorders, but are not for everyone, have potential liabilities and are best used in conjunction with targeted psychotherapies.”
What do you think? Do you prescribe benzodiazepines to persons with anxiety disorders? What has your experience been? Please do share your views below, under “Leave a Reply”.
On other pages on this website, we’ll discuss in detail the specific risks associated with the use of benzodiazepines and some prevalent myths in this regard. See Related Pages below.
Related Pages
Benzodiazepines: General
Benzodiazepines in the elderly and in liver disease
Cytochrome P450 drug interactions with benzodiazepines
Three important pieces of information about benzodiazepines
Viewpoint: Has the pendulum swung too far against the use of benzodiazepines?
Should we consider a benzodiazepine for persons with major depressive disorder?
Alprazolam
Alprazolam (Xanax® or Xanax-XR®): Basic Information
Potential side effects of alprazolam (Xanax®)
How to convert from alprazolam immediate-release to extended-release
Potential advantages and disadvantages of alprazolam extended-release (Xanax XR®)
Chlordiazepoxide
Clonazepam
Clonazepam (Klonopin®): Basic Information
Potential side effects of clonazepam (Klonopin®)
Tips on using clonazepam ODT (wafers)
Diazepam
Lorazepam
Oxazepam
References
Balon R, Chouinard G, Cosci F, Dubovsky SL, Fava GA, Freire RC, Greenblatt DJ, Krystal JH, Nardi AE, Rickels K, Roth T, Salzman C, Shader R, Silberman EK, Sonino N, Starcevic V, Weintraub SJ. International Task Force on Benzodiazepines. Psychother Psychosom. 2018;87(4):193-194. doi: 10.1159/000489538. Epub 2018 May 22. PMID: 29788029.
Balon R, Starcevic V, Silberman E, Cosci F, Dubovsky S, Fava GA, Nardi AE, Rickels K, Salzman C, Shader RI, Sonino N. The rise and fall and rise of benzodiazepines: a return of the stigmatized and repressed. Braz J Psychiatry. 2020;42(3):243-244. doi: 10.1590/1516-4446-2019-0773. Epub 2020 Mar 9. PMID: 32159714; PMCID: PMC7236156.
Jørgensen MB, Osler M. Should benzodiazepines be avoided? Acta Psychiatr Scand. 2018 Aug;138(2):89-90. doi: 10.1111/acps.12943. PMID: 30398297.
Neves IT, Oliveira JSS, Fernandes MCC, Santos OR, Maria VAJ. Physicians’ beliefs and attitudes about Benzodiazepines: a cross-sectional study. BMC Fam Pract. 2019 May 25;20(1):71. doi: 10.1186/s12875-019-0965-0. PMID: 31128589; PMCID: PMC6535184.
Rosenbaum JF. Benzodiazepines: A Perspective. Am J Psychiatry. 2020 Jun 1;177(6):488-490. doi: 10.1176/appi.ajp.2020.20040376. PMID: 32475138.
Silberman E, Balon R, Starcevic V, Shader R, Cosci F, Fava GA, Nardi AE, Salzman C, Sonino N. Benzodiazepines: it’s time to return to the evidence. Br J Psychiatry. 2020 Oct 12:1-3. doi: 10.1192/bjp.2020.164. Epub ahead of print. PMID: 33040746.
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Let us differentiate between acute and chronic situations. Benzodiazepines are effective in many acute psychotic and manic states and in the emergency department. I use them also to ameliorate acute withdrawal states from both SRIs and illicit substances.
In chronic situations, there are two populations, broadly speaking.
The first are severe personality disorders with high vulnerability to misuse as well as rapid tolerance. Any dose eventually proves insufficient and they suffer terribly no matter what medication is used.
The second are people with anxiety or panic with no personality disorder, no substance dependence and function well, that is, hold jobs and relationships together, once symptoms are controlled. They have a lot to lose, if not treated.
They are also people who have intolerable adverse effects to SRIs or do not respond to them. Within this population is a smaller sub-group who have tried every option, psychological and chemical, except benzodiazepines.
For these patients, I consult with a colleague, documenting that every other option has been tried. I also talk to the GP and to the patient laying out the reasoning, the benefit and the risks. Once all this has been done, I use a long-acting benzodiazepine only; never Alprazolam. In the last 20 years, working in a community clinic, I have done this with less than 20 patients.
I work in 3 community health clinics as the mental health provider. I prescribe benzos rarely and for PRN use. I don’t know how many times I have evaluated patients wanting to continue a multiple day benzo with no other psychotropic medication on board. This is concerning to me, as they have no interest in trying anything else actually treat their anxiety or other undiagnosed mood concerns. Other patients come to the visit in a panic because their last provider cut them off and are experiencing withdrawal symptoms. I do think benzos are appropriate for short term use, but TID dosing for 10+ years is not treating their anxiety. Even the example given of clonazepam + alprazalam PRN is concerning. The patient may have been functional but not in remission. If he missed a dose for 1-2 days his anxiety would come back full force, along with uncomfortable withdrawal symptoms. I use the bandaid analogy when explaining what benzos do for anxiety, as well as use them for “break the glass emergencies” for PRN use.
Thank you for sharing your thoughts and experience!
In my experience, younger psychiatrists are even avoiding the use of benzodiazepines in treating sleep abnormalities and agitation in bipolar patients with acute mania, preferring quetiapine 50 mg to treat these states. I find this concerning, as in my experience the rapidity and effectiveness with which a short – course of a benzodiazepine like clonazepam, for example, can address sleep disturbance and calm the acutely decompensated bipolar 1 or 2 patient is often superior to that of low-dose quetiapine for the same indication. Moreover, clonazepam [can be useful for] the treatment of acute agitation in bipolar mania, which younger doctors are often not aware of. Getting acutely manic patients sleeping and controlling agitation are critical to effectively and expeditiously treating acute mania, and I find the reluctance to use it in acutely manic patients because of the pendulum swing alarming. The agitated, manic patient who is not sleeping is at particular risk for suicide – and other complications. Benzodiazepines use in that context is therefore potentially life-saving, and should not be withheld because of the proliferating prejudice against the use of benzodiazepines in general now occurring in psychiatry. Although Clonazepam is not FDA-approved for the treatment of acute mania, several prominent treatment guidelines, including the APA, CANMAT, BAP, and WFSBP, recommend it’s short-term adjunctive use for control of agitation, anxiety, and sleep induction in the treatment of acute mania, a fact that psychiatrist’s influenced by the pendulum swing against the use of benzodiazepines may be unaware.
Thank you, Dr. State, for your comment. I totally agree with you that benzodiazepines like clonazepam can sometimes be very helpful for stabilizing some patients with bipolar disorder when they are manic or hypomanic.
Gabapentin and pregabalin cause weight gain leading to diabetes, obstructive sleep apnea, high cholesterol, and many other complications. I always start first with an SSRI and therapy but some patients would be unable to work without benzodiazepines for the panic disorder. I’d rather my patient be dependent on a benzodiazepine than a diabetic because of a medication I prescribed
Thank you, Dr. Deeves, for sharing your viewpoint! Yes, we do have to weight the pros and cons of the treatment options that are available to us.
The primary issue in my view is that benzodiazepines in panic disorder are a form of avoidance but avoidance is what causes panic attacks to become panic disorder. An adequate course of CBT can cure panic disorder in a matter of months. CBT is superior treatment in this respect to even SSRIs. SSRIs are superior to benzodiazepines in that they are preventative and so it is impossible to use them PRN or as a form of avoidance. Avoidance of any form complicates the course of panic disorder. This is the primary issue. The other issues, some of which can result in lethal outcomes, are really just secondary issues. Overdose risk when combined with alcohol and opiates, the risk of causing addiction due to benzodiazepine exposure and the medical issues such increase in all cause mortality, falls, dementia in patients over 60 are really just ancillary. The so called, much vaunted, evidence supporting the use of benzodiazepines is mostly short term evidence and there is no doubt, in the short term, that benzodiazepines stop panic. It’s also true, in the short term, the alcohol stops panic and meth makes people happy. ‘Evidence’ is not partisan but it does not think for itself either. It is not that I never prescribe benzodiazepines for panic and anxiety but benzodiazepines are third line both because they are more dangerous and less effective than other options.
Benzodiazepines are an easy out without treating the cause. Even pregabalin and gabapentin work better. Yes I work mainly in addiction but I see benzodiazepines lose efficacy and addiction follows. It is actually the much older and much younger psychiatrist using it. I dont know why. Maybe because the older psychiatrists got into the habit before CBT was proven to be more effective? And the younger ones never saw the danger of benzos?
I do believe that addiction is a mental disorder no matter the the substance was bought from the streets or prescribed. It’s hard to detect, but we should evaluate and continuously re-evaluate and educate our patients, and choose the appropriate medication or withdraw it accordingly.
How do you determine which patient will become addicted and who not? If the efficacy of benzodiazepines decreases, what is the use of long-term use? I feel that short term use is very useful. Even giving a patient a limited number of tablets ie 20 a year make sense. But long term? Addiction devastates families. To be the cause of that?? Thea v d Merwe (South Africa)