The Use of Benzodiazepines in Patients With Anxiety Disorders

Manish Jha, MD, assistant professor of psychiatry, University of Texas Southwestern Medical Center, Dallas, discusses common clinical questions surrounding the use of benzodiazepines in patients with anxiety disorders.

Read the transcript:

Hi, everyone. My name is Manish Jha. I'm an assistant professor of psychiatry at UT Southwestern Medical Center in Dallas, Texas.

It is a pleasure today to talk to you about the use of benzodiazepines in patients with anxiety disorders, and address some of the questions that I often get asked about, from psychiatrists, mental health care providers, primary care providers, on the use of a benzodiazepine.

Here are some of the questions.

First question is, benzodiazepines are often used to treat anxiety. What are your thoughts on this?

My personal thoughts on the use of benzodiazepine in anxiety disorder is to avoid them if possible.

The first-line treatment before generalized anxiety disorder, pharmacotherapy-wise, I prefer a serotonin reuptake inhibitor. I'm also open to the use of an evidence-based psychotherapy approach. I typically use a shared decision-making approach, where we work together to come to an optimal treatment paradigm.

Use of benzodiazepines may often be relegated to people who are either coming to me while they are taking benzodiazepine or have, what we call, difficult-to-treat generalized anxiety disorder.

The next question is, if someone has a patient that has done well on benzodiazepines long term, would you recommend discontinuation of the benzodiazepine? If yes, why?

This is a great question. As I said, we often face it as clinicians, as psychiatrists. If someone is referred to us and they're already taking benzodiazepine, what is the approach? Should we continue the practice or should we try to discontinue it?

I, again, bring the idea of shared decision-making. That's a conversation to have with the patient, and educating them that the data on long-term benefit of use of benzodiazepine is restricted, and then what alternatives are there and how are we effectively treating the disorder that requires a certain form of treatment instead of benzodiazepine. That is the key approach.

I often would enlist the help of my colleagues who are practicing therapists and may help us out with the treatment of underlying disorders, so that we can safely discontinue benzodiazepine.

The reason why I would prefer to discontinue benzodiazepine is because of the risks associated with their prolonged use. It is very well established that use of benzodiazepines can increase the risk of fall. Fall ends up being one of the single biggest predictor of future mortality in elderly patients. We definitely want to avoid that.

We also know that often anxiety disorders are comorbid with substance use disorders. The use of benzodiazepine, along with other sedating substances such as alcohol or opiates, may lead to excessive sedation or respiratory depression.

Those are, again, things where continued use of benzodiazepine may incur high risk, and we want to avoid that. That's why I would want to just try to discontinue benzodiazepine with alternatives available.

Now, next question is, how do you safely wean a patient off chronic Xanax use for generalized anxiety disorders?

Xanax is alprazolam, and it's one of the shorter-acting benzodiazepine. The issue is, how do we go about discontinuing benzodiazepine, and builds up on the previous question.

The idea is, if someone has taken it for a long enough period of time, for weeks to months, the body has time to get used to it. There could be tolerance associated with the medication. We know that sudden discontinuation of benzodiazepines can increase the anxiety levels, and may even precipitate seizures if the dose of benzodiazepine is high enough. The approach is to go down slowly.

We also know that the initial decrements should be easier to tolerate. Going from, say 1 milligram to 0.5 milligram of alprazolam, may be relatively easier to tolerate as compared to going from 0.25 milligram to 0.

We may have to work with the patients as they are discontinuing to see how they are tolerating this, and provide alternative strategies or psychotherapy, other evidence-based treatment that allows them to have their illness to be well-controlled. That's my approach.

I do recommend use of measurement-based care here, because that allows us to systematically assess symptom severity, side effect, and adherence. That can then be used in titrating how we are lowering the dose of benzodiazepine.

Some patients may tolerate it very well and it may take a month to discontinue. For others, it may be a fairly protracted course. Using measurement-based care helps us to get through some of these limitations. Related to that, it comes up is, there are specific titration protocol for getting patients off benzodiazepine medications.

As I just talked about, it's not one-size-fits-all. We need to have a common decision that this is going to happen and then have a plan how to do it, with contingency strategies, that if we go down and there is a marked increase in anxiety symptoms, then maybe we need to go down in smaller steps.

That is how engaging the patients using a measurement-based care approach is what I recommend using for discontinuation of benzodiazepines, but also other medications such as serotonin reuptake inhibitors that may be associated with discontinuation symptoms.

Final question is, how do you handle the patient that only wants to stay on benzodiazepines and refuses other options, including psychotherapy?

This, again, is not atypical to encounter. The key elements are using event tools of motivational interviewing, but establishing a good relationship, a good rapport, and using education to educate patients about the advantages of long-term benzodiazepine use, the disadvantages of long-term benzodiazepine use, and what other effective treatments are available.

The key aspect with benzodiazepine is their immediate or almost very short time needed for their benefit to be obvious to the patients, whereas with a certain reuptake inhibitor or psychotherapy, it can take weeks to months to get the maximum improvement.

If we think, association-wise, this medication works, that doesn't work, it's often easier to link that to something that started working right away. Benzodiazepines that's why often become that. As soon as someone starts taking it, anxiety that had never gone away is suddenly lifted. Patients often feel that it's the only medication that works.

As providers, it's our responsibility to educate them about it so that we make a shared decision about it, and focusing on the harm that can occur from long-term benzodiazepine use, and the alternatives that are available would be helpful in getting patients off the long-term benzodiazepines, and use another evidence-based treatment that has much lower risks of side effects or adverse events.

I thank you again for taking a bit of time today to listen to me talk about the use of benzodiazepines, and some of the common questions that come up around it. We hope to have other similar topics for you in future. Thank you.

Manish K. Jha, MBBS, is an assistant professor of psychiatry at the University of Texas Southwestern Medical Center, Dallas, with substantial expertise in conducting clinical trials and extensive clinical experience in providing care to patients with treatment-refractory psychiatric illnesses. His work has focused on often-ignored features of depression such as irritability and he has evaluated clinical and biological markers that can prognosticate clinical outcomes for individuals with mood, anxiety, and related disorders. His program of research uses functional neuroimaging and affective neuroscience experiments to elucidate the neurocircuit mechanisms in order to develop the next generation of circuit-specific treatments for psychiatric disorders.