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Abstract
Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Benzodiazepines (BDZs) continue to be frequently prescribed for anxiety and related disorders, and for long-term use in these conditions, despite suggestions by the treatment guidelines to generally reserve these medications for short-term use and for patients who are resistant to newer antidepressants and/or psychological treatments.
The likely reasons for the ongoing popularity of BDZs include their consistent and reliable effectiveness for the most prominent symptoms of anxiety, relatively good tolerability, quick onset of action, possibility of using them on an ‘as-needed’ (prn) basis and the realization that newer antidepressants have not been as useful for anxiety and related disorders as they had initially seemed to be.
BDZs differ in terms of their potential to be associated with problematic use; for example, the longer-acting BDZs (such as clonazepam) are less likely to be implicated in the withdrawal symptoms than the shorter-acting BDZs (such as alprazolam).
It appears that some second-generation antipsychotics, especially quetiapine, are prescribed for anxiety and related disorders to avoid using BDZs; clinicians should be cautious about this practice, as there is no evidence that quetiapine is at least as safe and effective as long-term use of BDZs.
BDZs are generally a safe option for long-term treatment of many patients with anxiety and related disorders and may be chosen as the first-line pharmacotherapy for panic disorder, generalized anxiety disorder and social anxiety disorder.
In the absence of substance use disorders, BDZs are usually not associated with tolerance to their anti-anxiety effects in the course of long-term treatment of anxiety and related disorders, and they are rarely abused by patients with these conditions.
In the absence of substance use disorders, the risk of addiction to BDZs during long-term treatment of anxiety and related disorders has been exaggerated; the pharmacological dependence that develops when BDZs are used long-term does not denote an all-encompassing preoccupation with and craving for BDZs, compulsive or uncontrollable BDZ-seeking behavior and adverse health and/or social consequences.
The BDZ withdrawal syndrome is not an inevitable consequence of the long-term BDZ use; while an effort should be made to prevent withdrawal symptoms, it is not good clinical practice to portray the BDZ withdrawal syndrome in a catastrophic manner because it intimidates patients and veers them toward treatment options that are not necessarily safer or more suitable.
The choice between BDZs and antidepressants in the long-term treatment of anxiety and related disorders should be made on the basis of patient preference and careful consideration of the individual circumstances of each patient.
Evidence is emerging that combining BDZs with cognitive-behavioral therapy does not necessarily lead to poorer outcome of cognitive-behavioral therapy; more research is needed to ascertain how these treatment modalities can be optimally combined.