Are benzodiazepines (BZDs) contraindicated in post-traumatic stress disorder (PTSD)?

Benzodiazepines in PTSD Treatment

Benzodiazepines are contraindicated in PTSD treatment due to their ineffectiveness for PTSD management and their potential to worsen long-term outcomes. 1, 2

Evidence Against Benzodiazepine Use in PTSD

Guideline Recommendations

• The VA/DoD Clinical Practice Guidelines strongly recommend trauma-focused psychotherapy as first-line treatment for PTSD, with pharmacotherapy (specifically SSRIs and SNRIs) as adjunctive options, not benzodiazepines 1
• The American Academy of Child and Adolescent Psychiatry explicitly states that benzodiazepines are not generally recommended for chronic anxiety in vulnerable populations due to potential heightened sensitivity to behavioral side effects such as disinhibition 3
• The WHO guidelines for mental health disorders do not recommend benzodiazepines for PTSD symptoms 3

Research Evidence

• A systematic review and meta-analysis of 18 clinical trials with 5,236 participants found that benzodiazepines are ineffective for both PTSD treatment and prevention 2
• The risks associated with benzodiazepine use in PTSD patients tend to outweigh potential short-term benefits 2
• Specific problems associated with benzodiazepine use in PTSD patients include:
  • Worse overall symptom severity
  • Significantly increased risk of developing PTSD when used after recent trauma
  • Poorer psychotherapy outcomes
  • Increased aggression, depression, and substance use 2

Clinical Implications

Negative Impact on Treatment

• A prospective study found that early administration of benzodiazepines (clonazepam or alprazolam) to trauma survivors did not have beneficial effects on illness course 4
• In this study, 9 out of 13 benzodiazepine-treated subjects met PTSD criteria at 6 months compared to only 3 out of 13 controls 4
• Benzodiazepines may interfere with the natural recovery process after trauma exposure 2

Impact on Exposure Therapy

• While one study suggested benzodiazepines may not reduce the effectiveness of prolonged exposure therapy 5, the overall evidence suggests caution
• Patients taking benzodiazepines showed poorer maintenance of therapeutic gains from present-centered psychotherapy 5
• A 2020 systematic review found mixed evidence regarding benzodiazepine impact on exposure-based interventions, with some studies showing reduced efficacy at follow-up 6

Alternative Treatment Approaches

First-Line Pharmacological Options

• SSRIs such as sertraline (50-200 mg/day) and paroxetine (20-60 mg/day) are first-line pharmacological treatments with 53-85% of patients classified as treatment responders 1
• Venlafaxine (an SNRI) is an alternative option if SSRIs are ineffective 1

First-Line Non-Pharmacological Options

• Trauma-focused psychotherapies including:
  • Prolonged exposure therapy
  • Cognitive processing therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • These approaches have shown 40-87% of participants no longer meeting PTSD criteria after treatment 1

Sleep-Specific Interventions

• For PTSD-related sleep disturbances, consider trazodone rather than benzodiazepines 3, 1
• Prazosin may be beneficial for PTSD-related nightmares 1
• Non-pharmacological approaches like Imagery Rehearsal Therapy for nightmares 3

Special Considerations

Suicide Risk

• PTSD patients have an increased risk of suicide compared to the general population 7
• Some research suggests differential risks among benzodiazepines if they must be used, with alprazolam and midazolam potentially associated with fewer suicide-related behaviors compared to clonazepam and lorazepam 7
• However, this does not override the general contraindication of benzodiazepines in PTSD

Tapering Considerations

• For patients already taking benzodiazepines, gradual tapering is recommended rather than abrupt discontinuation
• Concurrent initiation of evidence-based treatments (SSRIs/SNRIs and trauma-focused psychotherapy) is advised during tapering

In conclusion, the evidence strongly supports avoiding benzodiazepines in PTSD treatment, with clear guidelines recommending trauma-focused psychotherapy and specific antidepressants as the evidence-based approaches for improving mortality, morbidity, and quality of life outcomes.