Benzodiazepine drugs are widely used in patients with posttraumatic stress disorder (PTSD), but available evidence suggests that they are not effective—and may even be harmful, concludes a systematic review and meta-analysis in the July Journal of Psychiatric Practice. The journal is published by Wolters Kluwer.
"Benzodiazepines are ineffective for PTSD treatment and prevention, and risks associated with their use tend to outweigh potential short-term benefits," write Dr. Jeffrey Guina and colleagues from Wright State University, Dayton, Ohio. They also find evidence to suggest that using benzodiazepines in patients with recent trauma can even increase the risk of developing PTSD.
Benzodiazepines Are 'Relatively Contraindicated' for PTSD
The researchers performed a systematic review to identify clinical trials or observational studies concerning the use of benzodiazepines in patients with PTSD, or in patients with recent trauma evaluated for possible PTSD. The study was the first comprehensive review and meta-analysis (pooled data analysis) to focus on this issue.
Benzodiazepines are a "common and controversial" treatment for PTSD. Some mental health professionals argue that benzodiazepines can reduce anxiety, insomnia, and irritability associated with PTSD. Others suggest that benzodiazepines may actually prolong and worsen the disorder. "With all the news stories today pertaining to the inadequate treatment and mistreatment of military veterans with PTSD, it is important that the health care community continues to analyze what we are doing," Dr. Guina comments.
The review identified 18 studies including more than 5,200 participants who survived one or more traumas, including physical injuries, life-threatening medical conditions, combat-related trauma, sexual trauma, and disasters. Based on evidence from these studies, benzodiazepines were associated with no improvement in or worsening of overall severity, psychotherapy outcomes, aggression, depression, and substance use in PTSD patients.
Twelve studies provided data sufficient for a meta-analysis. The results suggested that benzodiazepines were associated with no improvement in PTSD-related outcomes, and that using benzodiazepines in patients with recent trauma actually increased PTSD risk. "Those studies providing sufficient data suggest that the risk of developing PTSD is two to five times higher in groups receiving benzodiazepines than in control groups," Dr. Guina and coauthors write.
Benzodiazepines have some efficacy for other anxiety disorders—so why are they unhelpful, or even harmful, in PTSD? It may be because anxiety in PTSD develops differently than in other anxiety disorders. "Benzodiazepines might be effective if they selectively inhibited the stress and anxiety centers of the brain that are often hyperactive in PTSD," Dr. Guina comments. "Instead, they indiscriminately target the entire brain—including areas that are already hypoactive in PTSD, such as the cognitive and memory centers."
Because benzodiazepines have ongoing effects on memory, they may hinder patients from learning how to cope with PTSD symptoms. "Evidence-based trauma-focused psychotherapies require that patients experience and then master anxiety," Dr. Guina and colleagues write. "Benzodiazepines can impair that experience by numbing emotions, decreasing learning efficiency, and inhibiting memory processing of material learned in therapy."
Given that just four randomized trials have been performed to date, the authors conclude that more studies are needed to conclude that benzodiazepines consistently worsen PTSD.
In the meantime, based on little evidence of efficacy and stronger evidence of potential risks, Dr. Guina and colleagues conclude that benzodiazepines are "relatively contraindicated" in trauma patients. They emphasize that there are now many different evidence-based treatments for PTSD—including psychotherapy, antidepressants, and adrenergic inhibitors—"all of which should be exhausted before benzodiazepines are considered."
Article: "Benzodiazepines for PTSD: A Systematic Review and Meta-Analysis" (doi: 10.1097/PRA.0000000000000091)
About Journal of Psychiatric Practice
Journal of Psychiatric Practice®, a peer reviewed journal, publishes reports on new research, clinically applicable reviews, articles on treatment advances, and case studies, with the goal of providing practical and informative guidance for clinicians. Mental health professionals will want access to this journal—for sharpening their clinical skills, discovering the best in treatment, and navigating this rapidly changing field. John M. Oldham, MD, is the editor in chief and past president of the American Psychiatric Association.
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