Jul 17, 2019
By Jacqueline Posada, MD, 4th-year resident in the department of
psychiatry & behavioral sciences at George Washington
In this episode, Richard Balon,
MD, returns to the MDedge Psychcast to discuss benzodiazepines.
This time, Lorenzo
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, interviewed Dr. Balon about prescribing
benzodiazepines for patients with serious medical illnesses. They
also examine some of the controversies around benzodiazepines and
common mistakes that some clinicians make when prescribing these
Dr. Balon is professor of psychiatry at Wayne State University
And later, in the “Dr. RK” segment, Renee Kohanski, MD, explores the need
for psychiatrists to challenge the distorted thinking patterns of
patients, particularly in light of the growing influence of social
media. Dr. Kohanski, a member of the MDedge Psychiatry Editorial
Advisory Board, is a psychiatrist in private practice in Mystic,
Benzodiazepines can be used for patients with serious mental
illness across several areas of medical illness, including those
with cardiovascular, gastrointestinal, and sleep disorders, as well
as for those with generalized anxiety disorder (GAD) and panic
- Patients with cardiovascular illness might have just
encountered a near-death experience and present with somatic
symptoms of their cardiovascular illness and anxiety.
- This overlap of symptoms makes cardiovascular illness a
reasonable comorbidity in which to use benzodiazepines for
- A naturalistic study of patients with heart failure showed
patients on benzodiazepines had a small decrease in mortality. The
reason is unknown, but it could be from a decrease in anxiety and
stress, both of which affect the heart.
- Older studies show that some benzodiazepines can be used in
addition to antihypertensives.
- Benzodiazepines also are useful for such gastrointestinal
(GI) illnesses as peptic ulcer disease, inflammatory bowel disease,
irritable bowel syndrome, etc.
- The symptoms of GI illness, such as constipation, diarrhea, and
nausea, can complicate the use of SSRIs or tricyclic
antidepressants for anxiety.
- Older studies suggest that adding benzodiazepines to the
regimen of these patients, especially those without substance use
disorder, can improve outcomes.
- Five benzodiazepines have been approved for sleep disorders:
- These medications are used infrequently despite having a long
half-life, which is useful for sleep initiation and
- Quazepam is designed specifically for insomnia and has activity
at a different part of the alpha subunit on
the GABA receptor.
Clonazepam also is useful, especially for patients with
comorbid anxiety and sleep issues, because it contributes to
sedation, and as a result of its long half-life, it continues to
relieve anxiety throughout the day.
Generalized anxiety disorder (GAD) and panic
- Many clinicians are leery about using
alprazolam for several reasons.
- The medication’s short half-life contributes to patients using
the drug several times a day.
- Immediate relief of anxiety has a reinforcing effect, which in
turn, increases the risk of abuse.
- There are no well-designed trials comparing benzodiazepines
with SSRIs. Many of the recommendations about how to use
benzodiazepines come from clinical experience.
- Some patients with GAD without substance use benefit from
benzodiazepines such as clonazepam.
- It is possible for some patients to stay on long-term treatment
with benzodiazepines and not need higher doses because of
Clarity is needed about the true impact of
benzodiazepines on patients
- Benzodiazepines are an integral part of the psychopharmacology
armamentarium yet are underused.
- Their use is increasingly discouraged, and trainees are not
getting enough experience with prescribing benzodiazepines.
- Benzodiazepines are rarely abused on their own.
Common mistakes in using benzodiazepines
- Patients who might need or benefit from treatment with
benzodiazepines are not adequately assessed.
- Dose escalation with benzodiazepines often is avoided. When
patients ask for an increase in the dose, this is not necessarily
sign of abuse. A dose increase might be a sign that the patient is
- Trainees are not getting proper guidance in prescribing
benzodiazepines; they need to be familiar with prescribing all
classes of psychotropics.
Slee A et al. Pharmacological treatments for generalised anxiety
disorder: A systematic review and network meta-analysis. Lancet 2019 Feb
Guina J, Merrill B. Benzodiazepines I: Upping the care on
downers: The evidence of risks, benefits, and alternatives. J Clin
Med. 2018 Jan 30. doi:
Salzman C. The APA task force report on benzodiazepine
dependence, toxicity, and abuse. Am
J Psychiatry. 1991 Feb;148(2):151-2.
Fava GA et al. Benzodiazepines in anxiety disorders.
JAMA Psychiatry. 2015;72(7):733-4.
Tully PJ et al. The anxious heart in whose mind? A systematic
review and meta-regression of factors associated with anxiety
disorder diagnosis, treatment, and morbidity risk in coronary heart
J Psychosom Res. 2014 Dec;77(6):439-48.
Colussi GL et al. Benzodiazepines: An old class of new
antihypertensive drugs? Am J
Hypertension. 2018 Apr;31(4):402-4.
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