Benzodiazepines: Fellow Psychiatrists, We Still Have Work to Do
While benzodiazepine prescribing certainly carries risks, those risks have been demonstrably exaggerated in the minds of government officials, critics, and the public at large.
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AFFIRMING PSYCHIATRY
Benzodiazepines are Bad
The Wall Street Journal has published an editorial entitled, “The Danger of Relying on Anti-Anxiety Drugs,” by Jenny Taitz, PsyD.1 The article is gracefully written and reasonably well informed. Taitz appears sympathetic to her patients and open to a variety of opinions from experts and critics alike. But there is nothing even slightly new or original in her content. It perfectly articulates the opinions of the vast majority of educated nonpsychiatrists on the subject of psychiatric medications in general, and benzodiazepines in particular. These talking points and assorted opinions have not changed significantly in the last 4 decades, which might give one impression that such an article is of no interest. Yet I think such a quick dismissal would be mistaken. Because what makes this article so important and interesting is precisely the fact that it represents ‘common knowledge’ about anxiolytics. This common knowledge, propagated by Taitz and consumed by millions, is unwittingly fostering stigma and harm.
I do not mean to imply that such thinking is entirely wrong. What Taitz writes is mostly true, as far as it goes. But it is fatally out of date and incomplete, and therefore misleading. What does she say? Taitz asserts 2 main points. First, that “when it comes to navigating anxiety, facing your fears rather than running away from them—or drugging them into submission—is essential to reclaiming your freedom.” Essentially, benzodiazepines numb individuals, fostering avoidance and inhibiting the constructive action that would lead to symptom resolution and growth. For Taitz, benzodiazepines throw a blanket over symptoms rather than rooting them out. Secondly, Taitz notes, those who start benzodiazepines go down a slippery slope leading to overuse and physical dependency and chronic symptoms.
In support of her theses, Taitz cites her own clinical experience, as well as well-known antipsychiatry journalist Robert Whitaker. Whitaker, in this case, claims that long term use of these medications can cause “iatrogenic brain injury.” Whitaker also detailed the way that lab mice became indifferent to their own safety on benzodiazepines, even “on the verge of being electrocuted.” She then quotes a couple of addiction psychiatrists who note the ways that individuals can become dependent on benzodiazepines (without ever implying that they are inherently destructive).
The Inflated Risks of Benzodiazepines
Taitz’s opinion piece just happens to coincide with a major editorial in the American Journal of Psychiatry, which details the way that dangers of benzodiazepine use have been overstated. To quote Soumerai et al directly: “[W]eak science, alarming FDA black box warnings, and media reporting have fueled an anti-benzodiazepine movement that at times even portrays appropriate benzodiazepine and related prescribing as a gateway to long-term dose escalation, tolerance, and drug misuse. This has created an atmosphere of fear and stigma among patients, many of whom can benefit from such medications.”2
The authors note that the largest long-term benzodiazepine study in history (tracking 950,000+ benzodiazepine users) showed that 85% discontinue use during the first year of treatment, and 97% at 7 years. Of all those who started benzodiazepines in this study, only 0.35% escalated doses above recommended levels. This is hardly the pattern we would expect to see for the highly addictive and destructive medications portrayed by critics. As it turns out, older studies probably exaggerated the risks themselves, due to failing to account for ways that patients prescribed these medications tended to already be at higher risk for medical outcomes such as dementia and hip fractures. So, while benzodiazepine prescribing certainly carries risks, those risks have been demonstrably exaggerated in the minds of government officials, critics, and the public at large. Most patients use benzodiazepines safely, and for limited amounts of time.
Medicines as Means of Avoidance
So much for the real but greatly exaggerated risks of addiction. But what about Taitz’s primary assertion, that these medications may allow patients to remain ‘comfortably numb’ rather than facing their problems and life challenges? I happen to agree that it is possible for benzodiazepines to numb patients emotionally, sapping motivation and allowing patients to so avoid anxiety that they never conquer it. And of course, overuse and dependence are real dangers. But knowledge of such dangers is commonplace amongst psychiatrists, who are ethically bound to educate their patients about such risks, and work to minimize them. Yes, Taitz cites the early mass marketing of Valium as “mother’s little helper,” but this literally occurred 60 years ago, and appreciation of the risks of benzodiazepines has been prominent since the early 1980s.3
Where Taitz truly errs is in speaking of risks of benzodiazepines as if they are typical effects. Yes, benzodiazepines can be numbing and demotivating when doses are too high. But the opposite is also true: When doses of medication are too low, severe anxiety can so paralyze patients that they are unable take the actions that would lead to diminished symptoms, such as initiating new outside activities with social phobia, or addressing intimidating subjects in psychotherapy. The answer to problems with benzodiazepines is not to ignorantly assume that these medicines are uniformly destructive of patients. Rather, it is to understand their risks and benefits, then use them skillfully and sensitively to best address symptoms. That, after all, is the essence of high-quality medical care.
Bad Thinking About Mental Illness: The Typical Trap
In my mind, Taitz’s worst error is entirely commonplace amongst the general public: The destructive habit of assuming that taking psychiatric medications and making life changes are mutually competitive alternatives. It is as if medication use signals a lack of effort, a moral laziness which consists of ‘taking the easy way out’ rather than ‘earning’ recovery based on the hard work of therapy and real achievement in life.
This attitude, at root, is woefully obsolete. It unwittingly depends upon outdated, dualistic beliefs about human nature. In this view, mental problems like anxiety ought to be faced and overcome with willpower or rational thinking, while physical problems like high blood pressure naturally and unproblematically benefit from medications. A straightforward corollary of this old way of thinking is the assumption that anxiety is not a medical illness, but a matter of mental attitude or practical problem-solving, of the kind that of course psychotherapy addresses.
This being the 21st century, it is not difficult to recall that anxiety disorders are, in fact, biological as well as psychological. Anxiety does not only represent distortions in cognitions and feelings among the worried well. In fact, anxiety disorders are a set of serious illnesses characterized both by mental symptoms and by biological pathology. Anxiety disorders represent a type of medical illness which is demonstrably common, chronic, and biologically destructive. The nature of mental illness is that it is no less biological than psychological. Because it is both, both biological and psychological treatments are indicated as medical treatments.
If we can hold on to the fact that anxiety disorders are biological, we are far less likely to lose sight of the fact that they are serious and destructive illnesses which require serious and appropriately aggressive treatment. With undertreatment or no treatment at all, anxiety disorders increase the risk of stroke,4 hypertension,5 and heart disease.6 Severe anxiety is life-threatening in other ways as well, due to the risk of suicidality7 and disability8 that it carries. Discouraging individuals with anxiety disorders from utilizing medications (when this is medically indicated) is irresponsible to say the least. To pretend that those disabled by anxiety are simply too weak face their fears without a pill is downright cruel, however well-intentioned.
Concluding Thoughts
Discouraging the use of medications in favor of psychotherapy is entirely unnecessary. Rather than being competitive with each other, medications and psychotherapy tend to be synergistic in their effects.9 Patients should never have to face an either/or dilemma between taking medications or using psychotherapy. Nor should they have inappropriate guilt heaped on them by ignorant critics of our field, even if those critics come from within our field. Patients suffer enough as it is, having to overcome stigma, as well as financial and bureaucratic hurdles just to access treatment in the first place. While benzodiazepines themselves do not represent first line treatment for anxiety disorders,10 medication plus psychotherapy frequently proves to be the optimal treatment for moderate to severe forms of anxiety disorders.11
As psychiatrists, we breathe the air of biopsychosocial holism, simply assuming that medications and psychotherapy are both legitimate medical treatments for illnesses such as the anxiety disorders. But we forget that most of the rest of the world has not yet arrived at this counter-intuitive understanding of mental illness or its treatment. In fact, as Taitz’s editorial shows, not even all psychotherapists have fully integrated this understanding of mental illness. And this understanding matters, because it can be the difference between receiving life-saving medical treatment, or facing disability and serious medical morbidity from an anxiety disorder.
Individuals with these illnesses are still turning away from treatment due to stigma and shame. They are still assuming that their anxiety is a sign of personal inadequacy and lack of willpower. They, and some of their therapists, still assume that medications simply numb them up and keep them from bravely facing life. They continue to feel that they are incompetent cowards who should not need the very medications which are medically indicated for their plight. It is up to us who prescribe those medicines to help them overcome such deceptive and destructive fables.
Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.
References
1. Taitz J. The danger of relying on anti-anxiety drugs. The Wall Street Journal. January 26, 2024. Accessed April 22, 2024. https://www.wsj.com/health/wellness/the-danger-of-relying-on-anti-anxiety-drugs-edbb2b5c
2. Soumerai SB, Mahnum S, Salzman C. Setting the record straight on long-term use, dose escalation, and potential misuse of prescription benzodiazepines. Am J Psychiatry. 2024;181(3):186-188.
3. Lader M. History of benzodiazepine dependence. J Subst Abuse Treat. 1991;8(1-2):53-59.
4. Pérez-Piñar M, Ayerbe L, Gonzáles E, et al. Anxiety disorders and risk of stroke: a systematic review and meta-analysis. Eur Psychiatry. 2017;41:102-108.
5. Lim LF, Solmi M, Cortese S. Association between anxiety and hypertension in adults: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;131:96-119.
6. Emdin CA, Odutayo A, Wong CX, et al. Meta-analysis of anxiety as a risk factor for cardiovascular disease. Am J Cardiol. 2016;118(4):511-519.
7. Kanwar A, Malik S, Prokop LJ, et al. The association between anxiety disorders and suicidal behaviors: a systematic review and meta‐analysis. Depress Anxiety. 2013;30(10):917-929.
8. Hendriks SM, Spijker J, Licht CMM, et al. Disability in anxiety disorders. J Affect Disord. 2014;166:227-233.
9. Bandelow B, Allgulander C, Baldwin DS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders–version 3. part I: anxiety disorders. World J Biol Psychiatry. 2023;24(2):79-117.
10. Szuhany KL, Simon NM. Anxiety disorders: a review. JAMA. 2022;328(24):2431-2445.
11. Leichsenring F, Steinert C, Rabung S, Ioannidis JPA. The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta‐analytic evaluation of recent meta‐analyses. World Psychiatry. 2022;21(1):133-145.
