Benzodiazepines and the Treatment of Depression

by Lory Bright-Long, MD

FROM THE AMERICAN JOURNAL OF PSYCHIATRY….

The American Journal of Psychiatry is published by the American Psychiatric Association, and is one of the most influential psychiatric journals in the world. The journal is published monthly and contains peer-reviewed articles on the latest research findings pertinent to mental illness. In this review, I highlight some relevant considerations related to patients using benzodiazepines (also known as ‘minor tranquilizers’).

In the course of prescribing antidepressant medications for patients with depression, I have often found that accompanying symptoms of anxiety or insomnia were best treated with medications such as lorazepam, alprazolam or clonazepam (benzodiazepines). While antidepressants have anti-anxiety effects and ultimately help to restore normal sleep, they take several weeks to take full effect, while the benzodiazepines bring about more rapid relief of the very distressing symptoms of anxiety and insomnia. Although these medications are generally advised to be prescribed for short-term use only, I have found that some of my patients have continued to take these medications for longer time intervals than anticipated, and have done very well.

The development of this class of medications (e.g., Valium, Xanax, Ativan, Klonopin) represented a major advance over older anti-anxiety drugs (e.g., barbiturates) in that they are relatively very safe and rapidly effective medications. Although most treatment guidelines recommend the short-term use of these medications, many patients benefit from longer periods of use than is generally recommended (more than 60 days).

Despite the safety of these medications, many physicians correctly worry about potential risks associated with long-term benzodiazepine use: psychological and physical dependency, uncomfortable and even life-threatening withdrawal symptoms, impaired concentration and coordination and slowed reaction time, and an association with a higher risk of falling or of being involved in automobile accidents. These risks are particularly worrisome among the elderly, who are especially prone to side effects, particularly if high doses of medication are prescribed.

Writing in the April, 2004 issue of the American Journal of Psychiatry, Dr. Marcia Valenstein and colleagues, from the University of Michigan and the Veterans’ Administration Hospital there, looked at benzodiazepine use among over 46,000 individuals who were treated for depression in VA mental health clinics.

Even though the study population was restricted to veterans, the findings of the study would not be surprising to most psychiatrists, in that at least one third of patients who were being treated with an antidepressant for depression were also being treated with a benzodiazepine. Patients who were more likely to be prescribed benzodiazepines were of Caucasian or Hispanic ethnicity, were more likely to have co-existing posttraumatic stress disorder or another anxiety disorder, and were older than those not being prescribed benzodiazepines. African-Americans and individuals with a history of substance abuse were less likely to have been prescribed these medications. Patients who were prescribed these medications usually received supplies of medication that would allow long-term use. Dispensing of less than a 30-day supply of benzodiazepines, a practice typically recommended by practice guidelines, occurred for only 6% of all patients whose records were reviewed.

Reassuringly, patients were not prescribed very high doses of these medications, and most patients seemed to take less of the medications than their doctors prescribed. However, the fact that more than 30% of these depressed patients were being prescribed benzodiazepines, and for more than a short time period, suggests that this is a very common prescribing practice that may, in some patients, raise the risk of adverse events. It is important for the patient taking benzodiazepines to work with his or her doctor to find alternative strategy to control anxiety or to work toward ingesting the lowest effective dose possible. While there may be some discomfort in lowering benzodiazepine frequency and dosage, the decreased risk of adverse side effects is, in my opinion, well worth it.

The views expressed in the above article are those of the author and do not reflect an endorsement by the Greater Long Island Psychiatric Society of any medications or treatment plans.

ABOUT THE AUTHOR:
Dr. Schwartz is the Director of Residency Training and an Associate Professor of Clinical Psychiatry at Stony Brook University School of Medicine.