Benzodiazepines are among the most commonly used medications in primary care. As physicians we often are conflicted about prescription of these agents; however, just as often, our patients are not—from their perspective, benzodiazepines are the only medications that provide them relief from intolerable symptoms. Even after 40 years of experience, we in primary care frequently face one basic question: all things considered, are the benefits of benzodiazepines worth their risks? This quandary frequently stems from our lack of clarity about the risks and benefits of benzodiazepines, not only with short-term use, but particularly for patients who require long-term treatment. This Supplement provides an excellent review of the relevant scientific evidence accompanied by expert guidance in its interpretation and clinical application.
In managing our concerns and attitudes about the use of benzodiazepines and those of our colleagues and patients, an understanding of the history of benzodiazepine use that has resulted in such attitudes is very helpful. Jerrold F. Rosenbaum, M.D., provides such an overview based on his career experience and professional notes over recent decades. As he outlines, an unfortunate effect of our concerns about the use of benzodiazepines has been trivialization of the anxiety disorders—a result that has led to frequent underdiagnosis, undertreatment, and suffering.
Samantha A. Stewart, M.D., next provides a case that reflects the patient history and therapeutic dilemmas that many of us encounter daily in primary care and uses this as a basis to review a key concern for many of our patients—the potential effects of benzodiazepines on cognition, especially with long-term use, and the degree of recovery from such effects following withdrawal of therapy. Dr. Stewart translates the evidence we have about these potential detrimental cognitive effects into practical guidance regarding the counseling we should provide patients considering long-term treatment.
Peter P. Roy-Byrne, M.D., then provides a clinically useful overview of the “basic science” behind benzodiazepine therapy. He succinctly describes the nature of the γ-aminobutyric acid (GABA) receptor complex and current theories regarding the role of GABA in anxiety disorders, along with the neurochemical and neuroimaging evidence that informs these theories. Critical to our patients with severe chronic anxiety disorders, we now have insight into the potential alterations in such basic processes that occur with long-term treatment, and Dr. Roy-Byrne translates these into clinical guidance.
Chronic use of benzodiazepines is a source of major concern, not only for us as prescribers, but also for our patients and their families. Do patients develop tolerance? Do they escalate dose? Do the benzodiazepines lose their anxiolytic efficacy following long-term use? What are the effects on psychomotor activity and on cognition? Julie C. Stevens, B.A., and Mark H. Pollack, M.D., provide the data that address these questions and then consider potential alternative pharmacotherapies currently available and in development for the anxiety disorders.
Charles P. O’Brien, M.D., Ph.D., explores the common uses and abuse of benzodiazepines and provides the studies that clarify that these agents are infrequently abused by those to whom they are prescribed. Indeed, they are not preferred agents of abuse and are mainly used for secondary control of unwanted symptoms due to abuse of other agents. However, they do induce dependence, depending on the duration of use and half-life of the agent and possibly the psychiatric diagnoses affecting the patient. Understanding these issues provides a rational basis for prescribing and tapering benzodiazepines and for counseling our patients.
For those of us who optimize treatment of anxiety disorders through combining therapies, including cognitive-behavioral therapy (CBT) with benzodiazepine pharmacotherapy, several questions regarding the interactions of the 2 therapeutic modalities are pertinent. Does the use of benzodiazepines interfere with the effectiveness of CBT? Can CBT help with withdrawal of benzodiazepines? How does the neuropsychological dysfunction inherent in anxiety disorders and that which accrues from the use of benzodiazepines affect patients? Michael W. Otto, Ph.D., and colleagues discuss these issues and how they should influence treatment decisions.
With the clinical insights derived from this Supplement, primary care physicians can understand the emotional basis of our and our patients’ reactions to the benzodiazepines and the hidden impact of these responses on our care of those with anxiety disorders that might benefit from benzodiazepine use. We can inform and counsel our patients using the best available evidence on the short- and long-term impact of these agents, both beneficial and detrimental. Finally, we can also consider alternatives to the benzodiazepines, both those currently available and those in development. While the ultimate decision of what is best for a patient who might benefit from benzodiazepine treatment is not easy, this Supplement provides us with the evidence and guidance to determine what is best given our current understanding of anxiety disorders and benzodiazepine treatment.
Larry Culpepper, MD, MPH
Editor in Chief
The Primary Care Companion to the Journal of Clinical Psychiatry