Mindfully Prescribing Benzodiazepines in Psychiatry

Speaking with Joseph F. Goldberg, MD, Carl Salzman, MD, said no subsantial pharmacologic alternative to benzodiazepines exists for acute anxiety. Using the example of a patient facing an upcoming colonoscopy, Salzman noted that patients are typically given a benzodiazepine for procedural anxiety rather than an SSRI, underscoring the drug class's continued role in acute settings. Salzman said, "short-term use of benzodiazepines should be standard of care keeping the dose within reasonable range and understanding that this is a person who is not taking other drugs that are also sedative hypnotics."¹ Appropriate candidates for short-term benzodiazepine therapy were reliable patients without a competing sedative-hypnotic regimen who could be trusted to take the medication as prescribed. In acute stressful situations, such as family or illness-related crises, short-term benzodiazepine use at therapeutic doses was rational, reasonable, and helpful, with tapering initiated once the precipitating crisis resolved. Among primary care physicians, the modal duration of benzodiazepine use was about 3 weeks, a figure specific to patients without chronic anxiety disorder, substance use disorder, or liver disease.

Goldberg raised the challenge many prescribers face in gauging an unfamiliar patient's reliability before prescribing a short-term benzodiazepine course. Salzman responded that with established patients, trust is built through a longstanding therapeutic alliance: "If we know the patient, we have a sense of are they trustworthy, will they take it as prescribed, etc, and that means knowing the patient and building a therapeutic alliance."² For unfamiliar patients, Salzman said no fixed rules applied, but clinical experience and sensitivity guided decision-making. He described a common red flag: "The patient comes in and says, 'Doc, I just moved to the city and the dog ate my prescription or I lost my prescription,' and so could I have a Valium, and you know, a red flag goes up." In such cases, Salzman recommended pausing to gather more history, potentially scheduling a follow-up visit, before prescribing rather than filling the request at that same encounter.

Dr Salzman is a professor of psychiatry at Harvard Medical School.

Dr Goldberg is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, NY, and the immediate-past president of the American Society of Clinical Psychopharmacology.

References

1. Kroll DS, Niece HR, Barsky AJ, Linder JA. Benzodiazepines are prescribed more frequently to patients already at risk for benzodiazepine-related adverse events in primary care. J Gen Intern Med. 2016;31(9):1027-1034.

2. Cloos JM, Ferreira V. Current use of benzodiazepines in anxiety disorders. Curr Opin Psychiatry. 2009;22(1):90-95.