Evidence-Based Benzodiazepine Practice Guidelines Are Needed

See reply by Silberman et al and commentary by Silberman et al

To the Editor: Benzodiazepine exposure has resulted in considerable long-term harms to some patients¹ and benefits to others. The problem with benzodiazepine prescribing is that we have no way of knowing to which group a prospective patient belongs.

“Resolving the Paradox of Long Term Benzodiazepine Treatment: Toward Evidence-Based Practice Guidelines” by Silberman et al² published recently in JCP recommends greater guidance in benzodiazepine prescribing, which we wholeheartedly endorse. However, we must first resolve the paradox of harm/benefit among seemingly comparable benzodiazepine patient groups and the implications of long-term use.

This paradox manifests itself in conflicting literature about benzodiazepines. For example, the authors state that there is no confirmed relationship between benzodiazepine use and dementia, citing a single study. However, 2 independent 2018 systematic reviews have previously suggested the opposite.^3,4 The authors state that benzodiazepines are unproblematic and do not lose their therapeutic effect, but this was challenged by the US Food and Drug Administration (FDA) medication guide for each of the 4 most commonly prescribed benzodiazepines. The FDA reviewed the existing evidence for efficacy and duration of use, concluding that these medications have not been demonstrated to be effective for long-term use beyond 4 months (and only 9 weeks for clonazepam). In addition, these FDA guides state, “The continued use of benzodiazepines … may lead to clinically significant physical dependence.”⁵

We agree with the authors that patients should be thoroughly informed before consenting to initiate or discontinue benzodiazepines, so they can make an evidence-based decision for themselves.⁶ We would like to thank the authors for acknowledging the recent reviews that have shown that both benzodiazepines and antidepressants can have persistent and problematic withdrawal symptoms and life impacts when used long term.^7–9

The potential harms of benzodiazepine use are real and substantial, even if they impact only a subpopulation of benzodiazepine users. It is urgent that we study why these long-term symptoms occur and in whom, with the goal of identifying potential risk factors. The ability of clinicians to risk-stratify prospective patients would greatly reduce benzodiazepine injury while at the same time affording confidence to clinicians in making prescribing choices.

Article Information

Published Online: May 27, 2024. https://doi.org/10.4088/JCP.24lr15306
© 2024 Physicians Postgraduate Press, Inc.
J Clin Psychiatry 2024;85(2):24lr15306
To Cite: Sigler B, Silvernail B, Ritvo AD, et al. Evidence based benzodiazepine practice guidelines are needed.
J Clin Psychiatry. 2024;85(2):24lr15306.
Author Affiliations: Wegmans School of Pharmacy, St. John Fisher University, Rochester, New York (Sigler, Bressi); Alliance for Benzodiazepine Best Practices, Portland, Oregon (Silvernail, Bressi); Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado (Ritvo); Benzodiazepine Information Coalition, Midvale, Utah (Huff); Benzodiazepine Action Work Group, Colorado Consortium for Prescription Drug Abuse Prevention, Aurora, Colorado (Foster); Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee (Finlayson, Martin).
Corresponding Author: Alexis D. Ritvo, MD, MPH, Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, Ste 4020, Aurora, CO 80045 (alexis.ritvo@cuanschutz.edu).
Relevant Financial Relationships: None.
Funding/Support: None.