Are benzodiazepines (BZDs) considered primary mood stabilizers?

Benzodiazepines Are Not Mood Stabilizers

Benzodiazepines are not considered primary mood stabilizers and should not be used as such in the treatment of mood disorders. 1

Definition and Classification of Mood Stabilizers

True mood stabilizers are medications that:

• Treat or prevent manic episodes
• Treat or prevent depressive episodes
• Do not worsen either phase of bipolar disorder
• Do not induce cycling between mood states

The medications recognized as primary mood stabilizers include:

• Lithium
• Certain anticonvulsants (valproate, carbamazepine, lamotrigine)
• Certain atypical antipsychotics (olanzapine, quetiapine, aripiprazole, risperidone)

Role of Benzodiazepines in Psychiatric Treatment

Benzodiazepines have specific clinical applications but are not mood stabilizers:

1. Acute Agitation Management: Benzodiazepines are used for chemical restraint and rapid tranquilization in acutely agitated patients 2

2. Adjunctive Treatment: They may be used as adjuncts to mood stabilizers for:

   • Short-term management of insomnia
   • Acute anxiety symptoms
   • Severe agitation during mood episodes 2

3. Crisis Intervention: Benzodiazepines like midazolam or lorazepam may be used as crisis medications in delirious patients with severe agitation and distress 2

4. Specific Indications: They are first-line agents in the management of alcohol or benzodiazepine withdrawal 2

Evidence Against Benzodiazepines as Mood Stabilizers

Multiple guidelines explicitly clarify that benzodiazepines are not mood stabilizers:

• The American Academy of Child and Adolescent Psychiatry states that benzodiazepines are not generally recommended for chronic anxiety in children with intellectual disabilities due to potential behavioral side effects like disinhibition 2

• For bipolar disorder treatment, mood stabilizers (lithium, valproate) and atypical antipsychotics are the recommended agents, not benzodiazepines 1

• In delirium management guidelines, benzodiazepines are described as potentially deliriogenic (can cause delirium) and are not considered part of the initial strategy in delirium management 2

Limitations and Risks of Benzodiazepines

Benzodiazepines have significant limitations that make them unsuitable as mood stabilizers:

1. Tolerance and Dependence: With long-term use, tolerance, dependence, and withdrawal effects become major disadvantages 3

2. Cognitive Effects: They can cause cognitive and psychomotor impairment, especially in elderly patients 4

3. Paradoxical Reactions: Approximately 10% of patients may experience paradoxical agitation when treated with benzodiazepines 3

4. Limited Duration: Guidelines recommend limiting benzodiazepine use to 2-4 weeks maximum 3

5. No Mood-Stabilizing Properties: They do not prevent cycling between mood states or treat the underlying pathophysiology of mood disorders 1

Current Treatment Paradigm for Mood Disorders

In bipolar disorder treatment:

• Mood stabilizers and antipsychotics remain the primary treatments (72-95% of patients) 5
• Benzodiazepines are used only as adjunctive therapy (20-34% of patients) 5
• The most common treatment combination is mood stabilizer plus antipsychotic (36-44% of patients) 5

Conclusion

Benzodiazepines have specific and limited roles in psychiatric treatment as anxiolytics, sedatives, and for acute management of agitation. However, they do not meet the definition or clinical criteria of mood stabilizers. For mood disorders, particularly bipolar disorder, true mood stabilizers like lithium, certain anticonvulsants, and atypical antipsychotics should be used as primary treatments, with benzodiazepines reserved for short-term adjunctive use only.