Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice

Figures & data

Table 1 Guidelines for use of BDZs in obsessive–compulsive disorder, post-traumatic stress disorder, anxiety, and psychosomatic and sleep disorders

Disorder	BAP (2014)	WFSBP (2008, 2010, 2012)	APA (2007)	NICE (2005, 2011)	Clinical practice
Obsessive–compulsive disorder			Modest doses of BDZs may be used for anxiety and distress without reducing obsessions or compulsions	BDZs may be used cautiously for short periods to counterbalance the early activation of SSRIs	BDZs are widely used in clinical practice despite lack of evidence on their efficacy. Clinicians may perceive BDZs as useful add-on treatments for OCD patients, at least at the beginning of SSRI treatment
Post-traumatic stress disorder	No efficacy (alprazolam in acute treatment) No efficacy for PTSD	Lack of evidence. BDZs are contraindicated in the first few hours after trauma exposure	BDZs are not a first-line treatment, but may be considered helpful on the basis of individual circumstances, in order to reduce anxiety or improve sleep		BDZs are among the most commonly prescribed psychotropic medications in PTSD, despite guidelines discouraging their use
Panic disorder	Alprazolam, clonazepam, diazepam, and lorazepam are considered among the evidence-based acute therapies. The combination for a few weeks of a BDZ with a SSRI is recommended for minimizing the side effects of the AD	BDZs combined with ADs in the first weeks of treatment before the onset of AD effect. BDZs may be used in treatment resistant cases when the patient does not have a history of dependency	BDZs as adjunctive treatment to ADs to improve residual anxiety symptoms		Current clinical practice: BDZs as adjunctive treatment to ADs. Desirable (on the basis of the literature) clinical practice: BDZs
Generalized anxiety disorder	Alprazolam, diazepam, and lorazepam are considered among the evidence-based acute treatments, although they are not recommended as a first-line choice	Alprazolam and diazepam are recommended. BDZs should only be used for long-term treatment when other drugs or CBT have failed		Do not use BDZs, except as a short-term measure during crises	Current clinical practice: BDZs as adjunctive treatment to ADs Desirable (on the basis of the literature) clinical practice: BDZs
Social anxiety disorder	Clonazepam and bromazepam are listed as evidence-based treatments, but not as a first-line choice	Clonazepam is the only BDZ listed among the evidence-based therapies, with limited evidence. BDZs can be combined with ADs in the first weeks of treatment
Psychosomatic disorders	Lack of evidence		BDZs are not recommended (APA 2013)		BDZs are not usually recommended. The most common treatments are “relaxing” techniques, CBT, SNRIs, and SSRIs
Sleep disorders (insomnia)	Z drugs and short-acting BDZs are efficacious for short-term insomnia (<4 weeks)		BDZs are not recommended as first-line treatment. Interventions should focus on psychological treatments, including CBT, sleep restriction and sleep hygiene

Abbreviations: BZDs, benzodiazepines; BAP, British Association for Psychopharmacology; WFSBP, World Federation of Societies of Biological Psychiatry; APA, American Psychiatric Association; NICE, National Institute of Clinical Excellence; ADs, antidepressants; PTSD, post-traumatic stress disorder; BDZs, benzodiazepines; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; CBT, cognitive-behavioral therapy.

Table 2 Guidelines for use of BDZs in primary psychoses and depressive disorders

Disorder	BAP (2009)	CANMAT (2013)	PORT (2009)	APA (2004)	NICE (2014)	WFSBP (2012)	Clinical practice
Schizophrenia and treatment-resistant schizophrenia			BDZs, alone or in combination with antipsychotics, for treatment of acute agitation	BDZs helpful for managing anxiety during the stable phase of treatment and for acute agitation			BDZs are frequently used in association with APs. BDZ use should be discouraged when directed at augmenting AP efficacy. BDZs could be considered for anxiety or sleep comorbid disturbances
Depression and treatment-resistant depression		BDZs used in patients with pronounced anxiety/insomnia not responding to SSRI or SNRI		BDZs used in patients with pronounced anxiety/insomnia not responding to SSRI or SNRI
Bipolar disorders	Adjunctive clonazepam or lorazepam for agitated patients or sleep disturbances in the short term	BDZs not in monotherapy. Use of BDZs in patients refusing oral medications as adjuncts to sedate acutely agitated patients		Short-term adjunctive in manic or mixed episodes, in severely ill or agitated patients, and catatonic symptoms (clonazepam and lorazepam alone and in combination with lithium)*	Short-term BDZs for behavioral disturbances or agitation. Long-term use for patients with comorbid anxiety disorders	Clonazepam and lorazepam as add-on treatment to primary mood stabilizers	BDZs are widely prescribed, usually for a short time, as adjunctive treatment to mood-stabilizing drugs

Note:

* Refers to APA Guidelines 2002 Edition for management of bipolar disorders.

Abbreviations: BAP, British Association for Psychopharmacology; WFSBP, World Federation of Societies of Biological Psychiatry; APA, American Psychiatric Association; NICE, National Institute of Clinical Excellence; CANMAT, Canadian Network for Mood and Anxiety Treatments; PORT, Schizophrenia Patient Outcomes Research Team; AP, antipsychotic; BDZs, benzodiazepines; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors.

Table 3 Guidelines for use of BDZs in impulse control, personality, and eating and addictive disorders

Disorder	BAP (2012)	APA (2001)	WFSBP (2011)	NICE (2009)	Clinical practice
Impulse control disorders	–	–	–	–	BDZs are often used in aggressive patients via the intramuscular route to achieve a rapid onset of action
Borderline personality disorder	–	BDZs, particularly clonazepam, in the treatment of “affect dysregulation” in the presence of anxiety symptoms that fail to respond to ADs. Particular caution when using BDZs with a short half-life	–	Use of BDZs as a short-term second-line therapy in conditions of “crisis” and for the treatment of severe insomnia requiring rapid-acting drugs	BDZs are still widely used to treat several anxiety symptoms in BPD patients
Eating disorders	No specific guidelines on this topic	No indications	BDZs are not reported for pharmacological management of eating disorders	No indications	No clear indication about whether, when, or how to use BDZs in patients with EDs
Dual diagnosis	Assessment by a specialist addiction service is recommended prior to using a benzodiazepine to treat their anxiety	–	–	–	Caution should be applied in prescribing BDZs to people with severe mental illness and co-occurring substance use disorders
Novel psychoactive substances	–	–	–	–	Oxazepam, chlordiazepoxide, alprazolam, and lorazepam have been used in subjects with multiple substance abuse, including novel psychoactive substances

Abbreviations: BAP, British Association for Psychopharmacology; APA, American Psychiatric Association; WFSBP, World Federation of Societies of Biological Psychiatry; NICE, National Institute of Clinical Excellence; ADs, antidepressants; BDZs, benzodiazepines; EDs, eating disorders; BPD, borderline personality disorder.

Table 4 Clinical use of most frequently prescribed BDZs

	Alprazolam	Bromazepam	Chlordiazepoxide	Clonazepam	Diazepam	Lorazepam	Lormetazepam	Midazolam	Oxazepam	Temazepam	Triazolam
AA						x		x
AP-IMD
BD
BPD
Cancer	x					x		x	x	x
DD
DD/TRD	x		x	x	x		x
EDs
Elderly	x										x
GAD	x				x	x
ICD
Liaison
Migrants
NPS
OCD
PC								x
PD	x			x	x	x
PTSD						x
PSD	x	x
SAD				x
SKZ/TRS				x		x			x
SR

Abbreviations: AA, acute agitation; AP-IMD, antipsychotic-induced movement disorders; BD, bipolar disorders; BPD, borderline personality disorder; BZDs, benzodiazepines; DD, dual diagnosis; DD/TRD, depressive disorders/treatment-resistant depression; EDs, eating disorders; GAD, generalized anxiety disorder; ICD, impulse control disorders; NPS, novel psychoactive substances; OCD, obsessive–compulsive disorder; PC, palliative care; PD, panic disorder; PTSD, post-traumatic stress disorder; PSD, psychosomatic disorders; SAD, social anxiety disorder; SKZ/TRS, schizophrenia/treatment-resistant schizophrenia; SR, suicide risk.