Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? European Psych: Jan 2013

30.01.2013

The first benzodiazepine, chlordiazepoxide, was synthesised  in 1956 and was approved for clinical use in 1960. Diazepam was marketed in 1963 and soon became the most prescribed medication in many countries. BZDs increase the affinity of GABA for its own binding site ( allosteric modulation).

Dell’osso B and Lader M review the current role of BZD s in clinical practice.

1.Anxiety disorders: Emergence of SSRI as first line has considerably reduced the role of BZDs.Also, they are not recommended for long-term use. One important limitation is the lack of antidepressant activity (comorbid depression is common in anxiety disorders ). Dependence, sedation, cognitive/coordination problems and psychomotor impairment limit the use of BZDs. Long-term treatment studies with BZDs in GAD are lacking and these compounds should only be used when other drugs or CBT have failed. There is no evidence to support use in OCD or PTSD. BZDs are found to be effective  in Social Anxiety Disorder ( particularly Clonazepam, in short duration studies). BZDs are  effective in Panic disorder( acute efficacy), however there is no evidence for long-term efficacy.

2. Affective disorders: There is some evidence to support short-term  use of  BZDs  ( Benefits:  reduce side effects/ decrease anxiety) along with antidepressants.This benefit is seen only for 8 weeks. Most guidelines recommend to minimise the use.

3.Sleep disorders: Z drugs have taken over BZDs for this purpose because of their safety , efficacy and low abuse potential.

4.Alcohol withdrawal:  Continue to play an important role in treating alcohol withdrawal and evidence supports this use.

5.Delirium: No evidence to support use.

6.Psychotic disorders:  Available randomised trial-derived evidence is insufficient to recommend BZDs either as a sole or adjunctive agent   in psychotic disorders. Sedation and decrease in Extra Pyramidal Symptoms are benefits that is made use in short-term management of psychotic disorders.

7.Neuroleptic induced conditions: Routine clinical use is not indicated in tardive dyskinesia. BZD treatments remain  experimental only. Evidence supports use  in akathisia supported.

Authors review the current pattern of use in different countries and provide a  narrative review of side effects of BZD.

Conclusions: Evidence is robust for short-term use in Panic Disorder and Social Anxiety Disorder and alcohol withdrawal.Rapid one set of action and safety in OD makes BZDs still worthy  60 years after it was introduced. Overall prescription rates have fallen in UK but this is not the case in many other countries. High use of BZDs in primary care needs further scrutiny.

Summary of the article:

Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. Dell’osso B, Lader M. Eur Psychiatry. 2013 Jan;28(1):7-20

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