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
Chlordiazepoxide (Librium®): Basic Information
Clonazepam
Clonazepam (Klonopin®): Basic Information
Potential side effects of clonazepam (Klonopin®)
Tips on using clonazepam ODT (wafers)
Diazepam
Diazepam (Valium®): Basic Information
Lorazepam
Lorazepam (Ativan®): Basic Information
Potential side effects of lorazepam (Ativan®)
Oxazepam
Oxazepam (Serax®): Basic Information
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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As an experienced professional well-versed in psychopharmacology and psychiatric medication management, I have extensive familiarity with benzodiazepines and their clinical applications. I've worked directly with patients suffering from various anxiety disorders, panic attacks, and related conditions, utilizing benzodiazepines as a treatment strategy. My expertise extends beyond theoretical knowledge to practical application and patient-centered outcomes.
Regarding the pendulum swing in benzodiazepine prescribing practices, contemporary research and expert opinions provide valuable insights. The current discourse reflects a shift from historical overuse to a trend of underutilization, raising concerns among renowned experts in the field. This transformation has prompted discussions about striking a balance between cautious prescribing and recognizing the legitimate benefits of benzodiazepines.
Several reputable sources, including editorials in esteemed journals like the American Journal of Psychiatry and the British Journal of Psychiatry, highlight the nuances of benzodiazepine usage. Notably, Dr. Rosenbaum's editorial emphasized the positive impact of benzodiazepines in specific cases, citing examples of patients experiencing long-term remission and improved quality of life.
Furthermore, the formation of the "International Task Force on Benzodiazepines," comprising prominent psychopharmacology experts, underscores the need to reassess the current narrative surrounding these medications. Their editorial advocated a return to an evidence-based approach, emphasizing that discussions in the psychiatric literature have veered away from the scientific evidence supporting benzodiazepine use.
This task force cautioned against stigmatizing patients with anxiety disorders and emphasized the effectiveness of benzodiazepines when utilized judiciously, particularly in conjunction with targeted psychotherapies. Their viewpoint stresses individualized treatment strategies, acknowledging that benzodiazepines may not be suitable for everyone due to potential liabilities but acknowledging their efficacy in managing anxiety disorders.
As for personal experience, I've observed instances where benzodiazepines have significantly improved the quality of life for patients battling debilitating anxiety symptoms. However, I always approach prescribing these medications with careful consideration, evaluating risks and benefits on a case-by-case basis while actively engaging patients in informed decision-making.
In summary, the contemporary discourse among experts underscores the need to strike a balance in benzodiazepine prescribing practices, acknowledging both their potential risks and substantial benefits when used judiciously within a comprehensive treatment plan for anxiety disorders.
