2. Duration of Therapy

Anxiety disorders are considered chronic disorders with low spontaneous remission rates and high rates of relapse. Pharmacotherapy for generalized anxiety disorder (GAD) in adults includes antidepressants, benzodiazepines, buspirone, hydroxyzine and pregabalin. Treatment duration for GAD ranges from 3 to 12 months to accomplish treatment goals of symptom remission and improvement in quality of life. Although antidepressants are now considered drugs of choice for managing GAD, benzodiazepines are used frequently for short-term management of anxiety, as an adjunct to initiating antidepressant therapy, or improvement in sleep disturbances associated with GAD and/or antidepressant therapy. Benzodiazepines provide symptom improvement more rapidly than antidepressants and are more effective in managing somatic complaints rather than psychic symptoms. Although longer-term use is considered relatively safe and effective for benzodiazepines, the potential for abuse, dependence and withdrawal does exist 18-19.

In pediatric patients, selective serotonin reuptake inhibitors (SSRIs) are agents of choice to manage childhood anxiety disorders, with serotonin norepinephrine reuptake inhibitors (SNRIs) being recommended as another treatment option. The most recent guidelines published by the American Academy of Child & Adolescent Psychiatry state that there is insufficient evidence to draw conclusions about the benefits or harms of benzodiazepine therapy in pediatric patients with anxiety disorders20.

Panic disorder (PD) is a chronic, recurring condition requiring drug therapy suitable for prolonged use. The acute treatment phase for PD lasts approximately 12 weeks, and most patients require an additional 12 to 18 months of therapy to optimize treatment response and prevent relapse. SSRIs are the agents of choice to manage PD, although benzodiazepines are frequently prescribed as well, usually in combination with antidepressant therapy18. While benzodiazepines are effective in the short-term treatment of panic disorder due to rapid onset of action, long-term treatment may be less desirable due to the potential for dependence. Unlike anxiety disorder patients, patients with panic disorder are less successful at discontinuing benzodiazepine therapy. Additionally, there is a high prevalence of comorbid depression and/or bipolar disorder in patients with panic disorder. Benzodiazepines are less effective than other available agents when panic disorder coexists with other mood disorders. Therefore, patients with panic disorder and other psychiatric comorbidities may benefit from short-term therapy with a benzodiazepine, with chronic management incorporating mood stabilizing or antidepressant agents that are also effective in panic disorder19. Alprazolam has been studied more than other available benzodiazepines for the treatment of panic disorder, although clonazepam, lorazepam, and diazepam have also been evaluated. Most studies evaluating benzodiazepine use in panic disorder have been short-term studies (less than 8 weeks in duration). A few long-term panic disorder studies evaluating alprazolam have demonstrated sustained reductions in panic attack frequency when alprazolam has been administered for 6 to 8 months21. Benzodiazepines should be tapered when discontinued, as patients may experience a withdrawal syndrome if therapy is discontinued abruptly. Benzodiazepine elimination half-life and seizure history for the patient also influence the taper duration. Patients receiving benzodiazepines in lower doses for shorter times periods (less than six months) may be effectively tapered over two to eight weeks, while patients receiving benzodiazepines with a short elimination half-life, in higher doses, and/or for a longer duration (six months or longer) may require a slow taper over two to four months18,19,21.

Benzodiazepines should be prescribed on a short-term basis to manage anxiety disorders. Benzodiazepine doses should be tapered rather than discontinued abruptly to avoid withdrawal symptoms. Patients receiving benzodiazepines for up to 6 months should be tapered over 2 to 8 weeks, while patients treated with benzodiazepines for up to 12 months should be tapered over 2 to 4 months18,19,21<.

While concerns for benzodiazepine tolerance and withdrawal exist, patients may benefit from long-term use of benzodiazepines in panic disorder to minimize symptom recurrence. Additionally, significant problems with benzodiazepine dose escalation have not surfaced with chronic use for panic disorder18,19,21.

The use of benzodiazepines as an anti-epileptic is not limited in duration.