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Psychother Psychosom 2013;82:351-352

Should Benzodiazepines Be Replaced by Antidepressants in the Treatment of Anxiety Disorders? Fact or Fiction?

Rickels K.
Department of Psychiatry, Mood and Anxiety Disorders Treatment and Research Program, University of Pennsylvania, Philadelphia, Pa., USA
email Corresponding Author



In this issue of Psychotherapy and Psychosomatics, Offidani et al. [1] address the important clinical question of the role of benzodiazepines (BZs) in the treatment of anxiety disorders and whether there exists evidence in the literature that the BZs should be replaced by the newer antidepressants (ADs).

Experts today recommend the use of newer ADs as first-line treatments for anxiety disorders [2], replacing the BZs; yet what is the evidence for this recommendation? Prescribing patterns in US outpatients for mood and anxiety disorders in the year 2007 do not seem to support this recommendation [3]. For example, 136 million prescriptions were written for ADs and 85 million for BZs and the 10 most frequently prescribed medications for either an anxiety or depression diagnosis include 7 ADs and 3 BZs, alprazolam, lorazepam and diazepam (clonazepam was not included in this survey as its use was coded under ‘convulsive disorders'). This 2007 prescribing pattern is very similar to the one reported by Stahl [4 ] for 2001.

Controlled studies of BZs and ADs in anxiety disorders have been few and far apart as has been pointed out by Offidani et al. [1]. In fact, no evidence for the superiority of the newer ADs over BZs, both in terms of efficacy or safety, exists for either short-term or long-term treatment. BZ toxicity, adverse events, and withdrawal symptoms, not better efficacy, are usually cited in support of the use of ADs over BZs in anxiety disorders. Yet ADs are not better tolerated than BZs and they also cause withdrawal symptoms [5,6]. Therefore, gradual, not abrupt, taper is indicated after treatment with BZs and ADs [7,8], and a distinction between withdrawal symptoms and a return of anxiety, often a most difficult task, is critical for clinical management.

A well-conducted comparison trial of a BZ and a newer AD simply does not exist, neither for acute nor chronic treatment. In fact, when in the late 1970s the National Institute of Mental Health (NIMH) made the decision to withdraw largely from supporting clinical trials of new drugs, turning new drug development over to industry, many clinically important trials, such as a comparison of BZs versus selective serotonin reuptake inhibitor ADs in anxiety disorders for example, were simply not done. It is therefore time that such comparison trials are conducted if possible under other sponsorship than that of the industry.

 goto top of outline References
  1. Offidani E, Guidi J, Tomba E, Fava GA: Efficacy and tolerability of benzodiazepines versus antidepressants in anxiety disorders: a systematic review and meta-analysis. Psychother Psychosom 2013;82:355-362.
  2. Baldwin D, Anderson I, Nutt D, Bandelow B, Bond A, Davidson JRT, den Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen H-U: Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005;19:567-596.
  3. IMS Health, IMS National Prescription Audit 01/2007-12/2007, extracted February 2008.
  4. Stahl S: Don't ask, don't tell, but benzodiazepines are still the leading treatments for anxiety disorder. J Clin Psychiatry 2002;63:756-757.
  5. Fava M, Mulroy R, Alpert J, Nierenberg AA, Rosenbaum JF: Emergence of adverse events following discontinuation of treatment with extended-release venlafaxine XR. Am J Psychiatry 1997;154:1760-1762.
  6. Strocchi F, Nordera G, Jokinen RH, Lepola UM, Hewitt K, Bryson H, Iyengar MK: Efficacy and tolerability of paroxetine for the long-term treatment of generalized anxiety disorder. J Clin Psychiatry 2003;64:250-258.
  7. Rickels K, Garcia-Espana F, Mandos LA, Case GW: Physician Withdrawal Checklist (PWC-20). J Clin Psychopharmacol 2008;28:447-451.
  8. Rickels K, DeMartinis N, Rynn M, Mandos L: Pharmacologic strategies for discontinuing benzodiazepine treatment. J Clin Psychiatry 1999;19(suppl 2):12S-16S.

    External Resources

 goto top of outline Author Contacts

Prof. Karl Rickels, MD
Department of Psychiatry, Mood and Anxiety Disorders Treatment and
Research Program, University of Pennsylvania
3535 Market Street, Suite 670, Philadelphia, PA 19104 (USA)

 goto top of outline Article Information

Received: June 5, 2013
Accepted: June 6, 2013
Published online: September 20, 2013
Number of Print Pages : 2
Number of Figures : 0, Number of Tables : 0, Number of References : 8

 goto top of outline Publication Details

Psychotherapy and Psychosomatics

Vol. 82, No. 6, Year 2013 (Cover Date: October 2013)

Journal Editor: Fava G.A. (Bologna)
ISSN: 0033-3190 (Print), eISSN: 1423-0348 (Online)

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