Six or seven years ago, a patient of mine was moving to a nearby state. Through the local university’s psychiatry department, I arranged for her care to be delivered by a recent graduate from their residency. We spoke by phone about the transfer. She sounded competent and nice.
My patient was taking an SSRI daily and a prn benzodiazepine—diazepam, I seem to recall. My younger colleague was appalled. She repeatedly questioned me with an anxious tone about the need and justification for this dangerous drug. I sought to clarify and reassure her.
Used appropriately and cautiously, benzodiazepines can do good. They can offer immediate relief of anxiety and insomnia, and they certainly feel different than an antidepressant. They work fast. They are good during the first few weeks of antidepressant treatment of depression or many anxiety syndromes. Benzodiazepines are also good for prn use during a “rough patch.”
Downsides? They have many. They should be prescribed with great caution, if at all, to patients with a history of dependency. Sudden withdrawal (even an abrupt reduction in dose) can be lethal. And they cause the full range of sedative-hypnotic side effects—like sedation, amnesia, confusion, and ataxia. Add alcohol or another sedative-hypnotic, and these effects can mushroom.
I caution patients strongly to be careful about driving or anything that can be hazardous—like climbing a ladder. If a patient takes a benzo at bedtime, I advise the patient to look for hazards between bed and bathroom. It’s so easy to trip in the dark if one is unsteady. With older patients, this problem is magnified.
Which benzo to choose? It depends. Know the pharmacokinetics. Duration of action is terminated by distribution with single use, so a lipophilic agent like diazepam is quick in/quick out. With repeated use, half-life determines how long the drug works. The one benzo I really dislike is alprazolam. Alprazolam’s kinetics and dynamics make it troublingly addictive and hard to stop.
Are benzodiazepines good? Or bad? They are drugs—double-edged swords. We can prescribe them wisely.