Researchers Identify Patterns in Antidepressant and Long-Term Benzodiazepine Use

A new study, published in JAMA Psychiatry, examines patterns of benzodiazepine use in people also prescribed antidepressants. The researchers found that, of those who were initially prescribed both antidepressants and benzodiazepines, approximately 12% went on to engage in long-term benzodiazepine use.

“Benzodiazepines have been prescribed for short periods to patients with depression who are beginning antidepressant therapy to improve depressive symptoms more quickly, mitigate concomitant anxiety, and improve antidepressant treatment continuation,” the authors write. “However, benzodiazepine therapy is associated with risks, including dependency, which may take only a few weeks to develop.”

Benzodiazepines, such as Ativan, Xanax, Klonopin, and Valium, are controversial due to the risk of dependency and abuse, adverse effects, and the potential for increased aggression and suicide risk—all of which are more concerning after long term use.

Clinical practice guidelines, which are developed by numerous organizations and governments in order to provide clinicians with best practices for prescriptions, advise prescribing benzodiazepines only for short-term use. In fact, the authors write that “The United Kingdom National Institute for Health and Care Excellence depression guideline cautions against using a benzodiazepine for more than 2 weeks when prescribed to patients also taking antidepressants, noting further that it remains unclear whether starting benzodiazepine therapy at antidepressant therapy initiation produces desirable effects in efficacy or tolerability.”

The current study examined prescriptions for 765,130 American adults between 2001 and 2014. Participants were chosen because they received their first prescription for an antidepressant during this time period. The researchers found that 81,020 (10.6%) received their first prescription for a benzodiazepine at the same time as their antidepressant prescription. Of these, 12.3% went on to use benzodiazepines long-term (at least six months). Comorbid anxiety and sleep disorders were associated with more benzodiazepine prescriptions.

Among people taking antidepressants who were prescribed benzodiazepines, several risk factors increased the likelihood that they would engage in long-term benzodiazepine use. These risks include having a longer supply of benzodiazepines in the first prescription; being initially prescribed a long-acting benzodiazepine; and previous prescription opioid use.

Previous articles on madinamerica.com have reported extensively on the benzodiazepine controversy, such as evidence that benzodiazepine use increases dementia risk. A previous article focused on “as-needed” prescriptions, which are associated with far higher risk of benzodiazepine abuse. Benzodiazepines are also linked to the development of treatment-resistant depression—suggesting that they may exacerbate depressive symptoms. Due to side effects and lack of evidence of efficacy, benzodiazepines also appear on the 2015 Beers list of inappropriate medications for older adults—yet studies have shown that benzodiazepine prescription rates actually rise for older patients.

According to the authors of the current study,

“When prescribed carefully in appropriate patients, benzodiazepines are considered to be useful medications. Still, the decision to simultaneously initiate benzodiazepine therapy at antidepressant therapy initiation and the preference for short-term treatment are influenced by concerns about benzodiazepines, including dependency, emergency department visits, and increased risk of fractures, motor vehicle crashes, and overdose.”

They recommend that initial prescriptions for benzodiazepines include a supply of benzodiazepines that last less than 1 week, and that providers forgo the use of long-term benzodiazepine agents. These two changes represent easy ways to reduce the risk for long-term use.

****

Bushnell, G. A., Stürmer, T., Gaynes, B. N., Pate, V., & Miller, M. (2017). Simultaneous antidepressant and benzodiazepine new use and subsequent long-term benzodiazepine use in adults with depression, United States, 2001-2014. JAMA Psychiatry, 74(7), 747-755. doi:10.1001/jamapsychiatry.2017.1273 (Link)