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Short- and Long-Term Use of Benzodiazepines in Patients with Generalized Anxiety Disorder: A Review of Guidelines

Last updated: July 28, 2014
Project Number: RC0567-000
Product Line: Rapid Response
Research Type: Drug
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
Generalized anxiety disorder (GAD) is a chronic and disabling disorder characterized by excessive anxiety and uncontrollable worry about everyday life. For a definitive diagnosis, patients will also have at least three of the following symptoms: restlessness, difficulty concentrating, sleep disturbances, irritability, muscle tension, and becoming easily fatigued. More common in women, the lifetime prevalence of GAD is estimated to be as high as 6.6%. GAD is often seen together with other conditions such as panic disorder, phobias, obsessive compulsive disorder, depression, and health anxiety. Medication is the primary treatment modality for GAD and may be accompanied by psychological treatment such as cognitive behavioural therapy.

Technology
Selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine and noradrenaline reuptake inhibitors (SNRIs) are first-line drugs for the treatment of GAD. While effective, they can produce adverse events and have a slower onset of action during which anxiety may increase. Benzodiazepines (BZDs) are a class of drugs commonly used to treat anxiety disorders that work to decrease nerve activity in the brain. Although they work quickly to treat anxiety in the short-term, they may result in adverse events, dependency, and substance abuse over the long-term.

Issue
A review of systematic reviews and evidence-based clinical practice guidelines on the short- and long-term use of BZDs in patients with GAD will help to inform decisions about GAD therapy.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 316 citations, 10 of which were deemed potentially relevant. An additional 6 articles were identified from other sources. Of these 16 reports, 6 met the criteria for inclusion in this review: 2 systematic reviews and 4 evidence-based guidelines.

Key Messages
Short-term BZDs for GAD is recommended:

  • for patients taking antidepressants but not yet responding
  • for patients in acute crisis
  • for patients whose anxiety has increased.

Long-term BZD use in GAD is not recommended unless:

  • patients cannot tolerate or do not respond to first-line pharmacotherapies.

The maximum daily dose for long-term BZD therapy in GAD is uncertain.

Caution is advised for the elderly, children, and for pregnant or breastfeeding woman.

Question

  1. What are the guidelines associated with the short- and long-term use of benzodiazepines for patients with generalized anxiety disorder (GAD)?

Key Message

The short-term use of benzodiazepines for the treatment of generalized anxiety disorder is recommended as adjunctive therapy to antidepressants until their effectiveness is apparent or in times of acute crisis or increased anxiety. One guideline specified a daily dosage of alprazolam ranging between 1.5 mg and 6 mg when used to control the anxiety associated with first-line use of antidepressants. Long-term use of benzodiazepines is only recommended in patients who do not respond to or cannot tolerate numerous first-line therapies. No recommendations were provided on the maximum daily doses for long-term BZD treatment for GAD. For special populations, the guidelines generally advise against the use of BZDs in the elderly (or to use at lower adult doses if required), to use them sparingly in children and adolescents, and to use them with caution during the first and third trimesters of pregnancy, during labour and delivery, and when breastfeeding.