Benzodiazepine Use in Anxiety Management

Evidence Against Long-Term Use

The American College of Physicians and other consensus guidelines advise the use of benzodiazepines solely on a short-term basis, due to significant risks of dependence, cognitive impairment, falls, and lack of evidence supporting efficacy beyond 4 months 1, 2
For anxiety disorders, benzodiazepines should be time-limited in accordance with established psychiatric guidelines, with caution warranted specifically over longer-term use 3

Benzodiazepines are associated with multiple serious adverse outcomes that worsen with prolonged use, including cognitive impairment, reduced mobility, unsafe driving skills, decline of functional independence, falls, fractures, and addiction 1, 2
There is an increased risk of abuse and dependence, though this is more common in patients with other substance use disorders 3

High-potency, long-acting, or prolonged use of benzodiazepines is considered high risk by Beers criteria, with particular concerns including sedation, cognitive impairment, fall risk with injuries, and impaired clearance in older patients 1, 2, 4

Consider short-term benzodiazepines (2-4 weeks maximum) only if there is severe symptomatic distress with significant functional impairment, acute crisis requiring rapid symptom control, or bridge therapy while waiting for antidepressants/therapy to take effect 3
Prescribe at lowest effective dose with clear endpoint, using short-to-medium acting agents and avoiding long-acting agents especially in elderly 1, 3, 4

Never prescribe benzodiazepines as monotherapy for chronic anxiety without concurrent psychological or antidepressant treatment 3

Current clinical guidelines do not recommend benzodiazepines for treating anxiety disorders for a duration exceeding one year, as stated by The Lancet Psychiatry 5
Long-term benzodiazepine use is associated with significant risks including physical dependence and withdrawal symptoms upon discontinuation, according to The Lancet Psychiatry 5

For patients already on long-term benzodiazepine treatment, sudden cessation should be avoided due to risk of withdrawal symptoms including rebound anxiety, hallucinations, seizures, and in rare cases, death, as recommended by The Lancet Psychiatry 5
A gradual tapering approach is recommended, typically reducing the dose by 25% every 1-2 weeks, as suggested by The Lancet Psychiatry 5

In children and adolescents with intellectual disabilities, benzodiazepines are generally not recommended for chronic anxiety due to concerns about potential heightened sensitivity to behavioral side effects such as disinhibition, according to the American Academy of Child and Adolescent Psychiatry 6
When benzodiazepines are co-prescribed with opioids, there is a near quadrupling of risk for overdose death compared to opioid prescription alone, as reported by the Centers for Disease Control and Prevention 7