ARLINGTON, VA. - Widespread long-term use of benzodiazepines for anxiety remains a reality, despite guidelines that recommend against the practice, according to speakers participating in a roundtable discussion at the annual conference of the Anxiety Disorders Association of America..
Benzodiazepines alleviate anxiety symptoms, but they do not help to resolve anxiety disorders in the long term, with posttreatment relapse rates reported as high as 63%. Learning impairment associated with benzodiazepines is the side effect that "significantly diminishes the effects" of cognitive-behavioral therapy (CBT), said Dominic A. Candido, Ph.D., a psychologist in the department of psychiatry at the Dartmouth Geisel School of Medicine, Hanover, N.H.
He cited a 2010 study that found benzodiazepine usage rates in the general population ranged from about 2% to almost 18%. In the study, about one-third of people who received an initial prescription stayed on the drug long term – despite the recommendation in treatment guidelines that suggests limited short-term use. Recently, the departments of Veterans Affairs and Defense guidelines recommended against the use of benzodiazepines for posttraumatic stress disorder – partly because benzodiazepines increase the likelihood of stress symptoms.
"When practitioners do not have alternatives, they tend to go to these agents that will give them short-term relief but often at long-term detriment to the patient," he said.
Shanna Treworgy, Psy.D., also of Geisel medical school, said the impact on procedural memory "perhaps is the worst side effect" of benzodiazepines in the treatment of anxiety. "Research that has successfully pulled apart explicit and implicit memory has demonstrated significant effects on procedural learning and memory" during treatment with benzodiazepines, she said. "This happens through impairing acquisition of new memories through reduced arousal or sedative effects."
The studies include a 1997 investigation of exposure therapy in women with flying phobia, which evaluated the acute and long-term effects of alprazolam. Women on alprazolam had significantly reduced levels of anxiety compared with those on placebo during the first flight. But during a second flight a week later, when the former group of women was not medicated, they had significantly increased feelings of anxiety, an increased heart rate, a desire to leave the plane, and panic, while those who had been on the placebo during both flights showed decreases in multiple measures of anxiety. "We’re wondering if this perhaps was preventing new learning," Dr. Treworgy said, adding that the authors suggested that exposure therapy to flying phobia was incompatible with benzodiazepine treatment.
Summing up the evidence, she said, "What seems to be happening is that the result is reduced anxiety in the moment but worse long-term anxiety reactions documented in both animal and human studies."
A psychiatrist at Geisel School of Medicine, Dr. Matthew S. Duncan said that in clinical practice, benzodiazepine prescribing can be tailored to CBT to help patients stop taking the medications and become more functional. He added that he has experienced a paradigm shift in the prescribing of benzodiazepines, which also entails explaining this approach to patients. "I have to be able to convince them and articulate that prescribing benzodiazepines for your anxiety may have short-term gains but keep you sicker longer," said Dr. Duncan.
Dr. Candido said he and his colleagues have developed a CBT protocol to treat patients with anxiety that involves starting patients with 3 days of a benzodiazepine administered at three doses a day (preferably one with a short half-life, such as lorazepam) and no beta-blockers, followed by 3 days with no benzodiazepine treatment, gradually increasing the drug-free period. Single as-needed doses are never taken, and the drug is never used before a coping skill session, he said.
An audience member pointed out that as CBT becomes less available, the use of benzodiazepines for anxiety increases, and another member of the audience commented that he would use this approach all the time if more CBT therapists were available.
Dr. Candido and Dr. Treworgy said they had no relevant financial disclosures. Dr. Duncan reported having no relationship with any entity or institution other than the Geisel School of Medicine.