The Truth About Benzodiazepines in an Age of Anxiety

Anxiety and its treatment are characterized by conflicting views. Most recently, an international task force of experts, including those from U.S. institutions such as Yale University School of Medicine, Washington University School of Medicine, University of Pennsylvania, and Tufts University School of Medicine to name a few, have argued that some “medical propagandists” have popularized a negative view of benzodiazepine medications (e.g., Ativan, Klonopin, Valium) which has penetrated into general medical opinion and resulted in “non-data-based” recommendation of selective serotonin reuptake inhibitors (SSRIs such as Zoloft and Lexapro) as the first-line treatment choice for panic disorder (PD) (Nardi et al., 2018).

The authors (Nardi et al., 2018) remind us that such recommendations are purely based on “the opinions of some experts” and are lacking evidence from direct drug comparisons of benzodiazepines and SSRIs in the treatment of PD. Indeed, Nardi and colleagues (2018) argue that such a stance deprives many patients with an anxiety disorder of “potentially valuable treatment with benzodiazepines.”

Why should this conflicting view matter to you? Well, it is safe to say that we live in an Age of Anxiety. If political instability, climate change, or the pandemic have not yet rattled you, chances are that all these events affected someone you know, maybe even someone you care about, and how they are treated should matter to you.

Over the past two decades, medical providers prescribing benzodiazepines to patients suffering from anxiety disorders have operated under a cloud of suspicion even though studies show that only a small percentage of patients who use benzodiazepines abuse these medications, and when they do, it almost always occurs in the context of another addiction (e.g., Uhlenhuth et al., 1999) and/or personality disorder.

Indeed, the media commonly reports about people who overdosed on “heroin and Valium.” Of course, in this example, Valium (or any other benzodiazepine) is mostly only guilty by association. Mentioning Valium in the context of a heroin overdose, or any other opiate and hard drug for that matter, is like reporting that a person passed out after drinking whiskey and chamomile tea. The problem is that years of such reporting has likely contributed to a negative view of benzodiazepine medications.

People diagnosed with anxiety disorders are usually treated by front-line interventions such as cognitive-behavioral therapy (CBT) and SSRIs, but only 60 percent of them respond to these treatments (e.g., Bystritsky, 2006). What do we do with 40 percent of people with treatment-resistant anxiety disorders? While drug comparison studies are sparse, there is some evidence that suggests that treatment with a benzodiazepine (i.e., Clonazepam), in a six-year post-treatment follow up of individuals treated for Panic Disorder, predicts lower recurrence than treatment with an SSRI (i.e., Paroxetine) (Freire et al., 2017). Further, those treated with clonazepam monotherapy were less likely to experience recurrence of panic attacks and had safer withdrawal phases of treatment than those treated with paroxetine (Freire et al., 2017).

There are numerous reasons why benzodiazepines have a bad reputation. For one, they have been around for a long time, are all available in generic form, and are very cheap. The pharmaceutical industry may thus have had an interest in pushing newly patented SSRIs in the 1990s and 2000s. Also, media coverage played a significant role in the perception of benzodiazepines in the United States. Juicy exposes on “Valium addiction” in early 1980s America have also popularized negative views of benzodiazepines. Countries like France, where there was no benzodiazepine backlash, continued with high benzodiazepine consumption rates and society continues to function perfectly well (Tone, 2005).

We live in a very stressful world, and for many of those living on the margins of society, it is a world of dread and fear. It is important to understand that in such a world people need to be supported and that sometimes may mean “palliated” through bouts of enormous pain or severe anxiety. The recent tragic death of Dr. Susan Moore illustrates dangers inherent in a dogmatic stance often used within a medical context—refusing seriously ill COVID-19 patient adequate pain medications, and in the midst of a pandemic, is reflective of both systemic racism as well as dogmatic and myopic “all pain medications are bad all the time” stance often taken by healthcare providers.

One of the most dangerous things about the current medical model of care in the US is that it assumes the worst about most people—it communicates to the patient that the provider's doubts about potential abuse outweigh the patient's suffering. What makes it worse is that it is often, as is the case with benzodiazepines, “non-data-based” and only a matter of opinion.

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As a psychologist, I am first to recognize the limitations of medications in the treatment of psychiatric disorders, but we also need a more balanced, person-centered approach that looks at the unique needs of each patient as well as the context in which they live their daily lives. After suspending prevalent attitudes about benzodiazepines, and finding a sympathetic physician, in talking about people who are worried, looking tired and who cannot sleep, a 59-year-old woman told a London reporter “I think, you stupid wallies—take a Valium and it’ll all look different in the morning (Tone, 2005, p.379). For some people, sometimes, that may be the most valuable treatment option.