Panel: Carefully evaluate candidates for benzodiazepine treatment

NEW ORLEANS — A panel of experts at the American Psychiatric Association annual meeting agreed that benzodiazepines are effective for a number of conditions, but patients must be selected and followed carefully.

In response to moderator Josepha A. Cheong, MD, asking if they or any colleagues they know have a policy of never prescribing benzodiazepines, about half of the audience said, “yes,” and half said, “no,” highlighting the controversy surrounding this topic.

“I got a lot of referrals for panic disorder patients who were doing well in a study on benzodiazepine and needed follow-up care,” panelist Edward Silberman, MD, said. “They were salt-of-the-earth people; I followed them for years. They led very productive and stable lives. They never asked for an increased dose, and I never saw signs of substance abuse. They all said they had been crippled for years with panic attacks.”

O. Joseph Bienvenu, MD, PhD, another panelist, recognized the usefulness of these drugs, “but they are not my first choice for a lot of things. I came through at a time when benzodiazepines were demonized. Many of my colleagues say there’s no place for benzodiazepines in psychiatry.”

Panelist Donovan Todd Maust, MD, MS, noted that most benzodiazepine prescribing, “is not done by experts in this area. The vast majority is done by non-psychiatrists. “

Ilse R. Wiechers, MD, MPP, MHS, noted substantial evidence of misuse, particularly in younger patient groups.

“Donovan [Maust] and I come down on the side of caution,” Wiechers said. “The way we carry ourselves in the field of psychiatry about prescribing is important, because we carry the message.”

Some of the panelists touted the benefits of this drug class.

“They are better tolerated than antidepressants for anxiety,” Silberman said. “In the individual case, they may have unique benefits. Some people just don’t respond to other things as well as they respond to a benzodiazepine.”

“They are uniquely beneficial for lysing catatonia ... without being debilitating,” Bienvenue said.

“They absolutely have a role for anxiety disorders like catatonia,” Maust agreed. “Again, the point is how they’re actually prescribed. A lot are prescribed as add-ons in schizophrenia, depression and dementia, and there’s little evidence that they have any benefit in those conditions — and can make things worse.”

“We need to make sure we’re doing a good job evaluating patients,” Wiechers said. “I’m most cautious of using a benzodiazepine in someone who’s been in sustained [alcohol] remission and has severe panic disorder. But if a small dose would help, I would consider that. But with someone in rehab in remission, I’d think twice.”

Silberman agreed: “It’s very important to make a distinction in people who are established substance abusers. Taking a benzodiazepine is not a risk factor for addiction. Addiction is a risk factor for benzodiazepine.”

Bienvenue acknowledged prescribing a low dose to stable people experiencing alcohol withdrawal: “I watch them and meet with them frequently.”