Clinical Summary
Clinical Summary: Posttrauma Benzodiazepine Use and Subsequent PTSD: A Population-Wide Analysis Following Extreme Traumatic Exposure
After mass trauma, patients often present with severe insomnia, anxiety, and hyperarousal, yet clinicians are warned that benzodiazepines given early may raise later PTSD risk. This study directly addresses that bedside dilemma by separating short-term posttrauma use from ongoing use in a large real-world cohort of newly prescribed patients.
Design
This retrospective, population-based cohort study used the de-identified electronic health record and pharmacy database of CHS, Israel’s largest integrated delivery network serving approximately 4 million adult members, covering approximately 54% of the population.
N
The final analytical cohort comprised 15,570 participants.
Population
In this population-based cohort of 15,570 benzodiazepine-naïve individuals prescribed benzodiazepines after the October 7 terrorist attacks
Duration
Follow-up ended at the earliest of first PTSD diagnosis, death, disenrollment, or 1-year follow-up.
Key Findings
- In the primary 3-group analysis, 12-month cumulative PTSD risk was 5.2% in nonpurchasers (217/4,210), 4.7% in early purchasers (172/3,647), and 5.0% in late purchasers (384/7,713), with overlapping Kaplan-Meier curves (log-rank χ2 =0.8; P =.7).
- In the fully adjusted Cox model, neither early nor late benzodiazepine purchase was associated with higher PTSD risk versus nonpurchasers: early purchase HR 0.98, 95% CI=0.80–1.20; P=.868 and late purchase HR 1.11, 95% CI=0.94–1.31; P=.218.
- Persistence of use separated risk clearly: 12-month cumulative PTSD risk was 9.1% in early-persistent users and 9.9% in late-persistent users versus 4.1% in early-discontinuation users, 4.4% in late-discontinuation users, and 5.2% in the no purchase group (log-rank χ2 =72.7; P <.001).
- Compared with nonpurchasers, persistent users had significantly higher PTSD risk after full adjustment, with HR 1.60, 95% CI=1.14–2.25; P=.006 for early-persistent users and HR 2.07, 95% CI =1.60–2.68; P<.001 for late-persistent users, while early-discontinuation users (HR 0.88, 95% CI=0.71–1.09; P=.235) and late-discontinuation users (HR 0.99, 95% CI =0.83–1.18; P =.903) did not differ significantly.
- Among residents near the Gaza border (n=238), overall 12-month cumulative PTSD risk was 39.1% (93/238); compared with nonpurchasers (37/70; 53.0% PTSD), early purchasers had 31.1% (23/74) and late purchasers had 35.1% (33/94), with unadjusted HRs of 0.52 (95% CI =0.31–0.88, P=.015) and 0.62 (95% CI =0.38–0.98, P=.043), respectively.
Clinical Bottom Line
Short-term posttrauma benzodiazepine use was not associated with increased PTSD risk in this large cohort, but persistent use was associated with substantially higher subsequent PTSD incidence. The practical signal is not the initial prescription fill but the refill pattern.
Practice Implications
- Do not assume that filling a new benzodiazepine prescription within 30 days of trauma increases PTSD risk; in this cohort, early purchase (≤7 days) and late purchase (8–30 days) had similar 12-month PTSD rates to nonpurchase.
- Treat refill requests as a high-priority reassessment point: persistent users had 9.1% and 9.9% 12-month PTSD risk and fully adjusted HRs of 1.60 and 2.07 versus nonpurchasers.
- If a benzodiazepine is used after trauma, keep use time-limited and monitor closely for unresolved distress rather than focusing only on categorical avoidance at initial presentation.
- Patients with the highest trauma exposure may still warrant symptom-targeted treatment and close follow-up; in the Gaza border subgroup, purchasers showed lower observed PTSD rates than nonpurchasers (31.1% and 35.1% vs 53.0%).
