The role of benzodiazepines in anxiety disorders in adults and young people
The role of benzodiazepines in anxiety disorders is controversial. Benzodiazepines are rapid acting, well tolerated and effective anxiolytics for the most prominent symptoms of anxiety with a strong evidence base. However, benzodiazepines should not be used as first-line therapy for anxiety disorders because of potential harms (including increased risk of falls, memory problems, accidents, daytime sedation and dependence). Because of these harms, caution is needed in older patients and patients who have a history of problem substance use (particularly problem alcohol use). Also consider that there are few data on psychotropic use in young people because young people are poorly represented in clinical trials.
Benzodiazepine use is usually restricted to acute crises and the immediate short term. Maintenance therapy may be appropriate in patients who have not responded to other treatments and in those who are stable on a long-term regimen with good clinical response.
Benzodiazepines with short half-lives (ie less than 6 hours) are not recommended for anxiety disorders in these guidelines because they are the most addictive.
Considerations for benzodiazepine use for an anxiety disorder in an adult or young person outlines considerations for benzodiazepine use for an anxiety disorder in an adult or young person.
Consider the patient’s age, frailty and comorbidities [NB1] and the harm–benefit profile.
Assess the risk of misuse of benzodiazepines (either by the patient or other members of the household):
- check for a history of problem substance use (eg check a prescribing register or prescription monitoring service); if suspected refer the patient to a specialist service if possible
- be wary of prescribing to unfamiliar patients, particularly if the patient asks for a specific drug—this may indicate drug-seeking behaviour or risk of diversion.
Discuss the potential for addiction with the patient.
When selecting a suitable dose, consider factors such as body size, age, comorbidities, drug history, previous response to sedative drugs and response to treatment. Older patients, particularly if frail, may require doses of drugs lower than the recommended range.
Prescribe small quantities at a time.
Provide advice about possible adverse effects, including the effects on a person’s ability to drive, operate heavy machinery or perform other tasks that require motor coordination and concentration.
Specify the expected duration of therapy and review the patient’s response regularly.