Can diazepam (Benzodiazepine) be used to treat anxiety?

Diazepam for Anxiety: Appropriate for Short-Term Use Only

Diazepam can be used for anxiety, but should only be prescribed for short-term relief of anxiety symptoms (2-4 weeks maximum) due to significant risks of dependence and withdrawal. 1

Indications and FDA Approval

Diazepam is FDA-approved for:

• Management of anxiety disorders
• Short-term relief of anxiety symptoms
• NOT for everyday stress that doesn't require anxiolytic treatment 1

The FDA label specifically notes that "the effectiveness of diazepam in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies" and recommends that physicians "periodically reassess the usefulness of the drug for the individual patient." 1

Benefits of Diazepam for Anxiety

• Rapid onset of action for acute anxiety symptoms
• High efficacy in reducing anxiety symptoms
• Low toxicity at therapeutic doses 2
• Particularly effective for acute stress reactions, episodic anxiety, and fluctuations in generalized anxiety 2

Significant Risks and Limitations

Dependence and Withdrawal

• Long-term use leads to tolerance, dependence, and withdrawal effects 2
• Around half of patients prescribed benzodiazepines are treated continuously for at least 12 months, contrary to clinical guidelines 3
• Sudden cessation can lead to physical and psychological withdrawal symptoms requiring careful tapering 3

Other Adverse Effects

• Psychomotor impairment, especially in elderly patients
• Cognitive impairment
• Sedation and daytime sleepiness
• Risk of falls and fractures, particularly in older adults 3
• Occasional paradoxical excitement or agitation 2

Drug Interactions

• Dangerous respiratory depression when combined with opioids
• Increased risk of overdose death when co-prescribed with opioids (nearly quadrupled risk) 3
• Potentiation of central nervous system depression when used with other CNS depressants (muscle relaxants, hypnotics) 3

Appropriate Prescribing Protocol

1. Duration: Limit to short-term use (2-4 weeks maximum) 2

   • Single doses
   • Very short courses (1-7 days)
   • Short courses (2-4 weeks)
   • Only rarely for longer-term treatment

2. Patient Selection:

   • Appropriate for severe symptomatic distress
   • Appropriate for impaired ability to cope
   • NOT for everyday stress or anxiety 1
   • Avoid in older adults with cognitive impairment 4

3. Dosing:

   • Keep dosages minimal
   • For anxiety: Diazepam 0.5-1 mg orally four times a day as required (maximum 4 mg in 24 hours)
   • Reduce dose to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours) 3

4. Monitoring:

   • Regular reassessment of continued need
   • Monitor for signs of dependence or tolerance
   • Watch for cognitive and psychomotor impairment

Alternatives for Anxiety Treatment

For long-term anxiety management, consider:

1. First-line alternatives:

   • SSRIs (e.g., sertraline) for anxiety-dominant mixed depression 4, 5
   • SNRIs (e.g., venlafaxine) if SSRIs ineffective 5
   • Psychological treatments (CBT) 3

2. Other options:

   • Buspirone (non-benzodiazepine anxiolytic without dependence risk) 5
   • Trazodone for anxiety with sleep disturbance 4

Discontinuation Protocol

If a patient has been taking diazepam long-term:

1. Taper gradually - abrupt withdrawal can cause rebound anxiety, hallucinations, seizures, and rarely death 3
2. Reduce dose by 25% every 1-2 weeks 3
3. Consider cognitive behavioral therapy to increase tapering success 3
4. When tapering patients on both benzodiazepines and opioids, taper opioids first due to greater risks of benzodiazepine withdrawal 3

Special Considerations

• In elderly patients: Use lower doses, monitor more closely for adverse effects
• In patients with comorbid conditions: Consider drug interactions and adjusted dosing
• For patients with substance use history: Evaluate risk of abuse carefully

Remember that while diazepam can be effective for short-term anxiety relief, the risk-benefit ratio becomes unfavorable beyond 2-4 weeks of use due to dependence and other adverse effects 2, 6.