Does long-term use of benzodiazepines (benzos) suppress manic symptoms in bipolar disorder?

Benzodiazepines in Bipolar Disorder: Effects on Manic Symptoms

Long-term benzodiazepine use is not recommended for managing manic symptoms in bipolar disorder due to the risk of triggering mania and potential for dependence. 1

Mechanism and Efficacy

Benzodiazepines can temporarily suppress manic symptoms through their sedative and anxiolytic effects, primarily by enhancing GABA inhibitory neurotransmission. However, they are not considered primary treatments for bipolar disorder for several important reasons:

• The American Psychiatric Association guidelines explicitly warn that treatment with SSRIs should be avoided in men with bipolar depression due to risk of triggering mania 2, and this caution extends to benzodiazepines as well
• Benzodiazepines may provide short-term relief of manic agitation but are not recommended as long-term monotherapy for bipolar disorder 3

Appropriate Use of Benzodiazepines in Bipolar Disorder

Benzodiazepines have a limited role in bipolar disorder management:

• They may be used as adjunctive treatment for acute manic agitation alongside mood stabilizers 4
• Lorazepam has shown efficacy similar to haloperidol as an adjunct to lithium in the early phase of manic agitation management 4
• They should be used for short durations only, as approximately 20% of bipolar patients who start benzodiazepines become long-term users 5

First-Line Treatments for Bipolar Disorder

The recommended evidence-based treatments for bipolar disorder include:

• First-line treatments for bipolar depression: monotherapy with lamotrigine, quetiapine, or lithium; or combination therapy with lithium + lamotrigine, lithium/valproate + aripiprazole, or olanzapine-fluoxetine 1
• First-line treatment for bipolar disorder with psychotic features: combination of an antipsychotic medication with a mood stabilizer 1
• Maintenance therapy: lithium or valproate for at least 2 years after the last episode 1, 6

Risks of Long-Term Benzodiazepine Use in Bipolar Disorder

Long-term benzodiazepine use in bipolar patients carries significant risks:

• Tolerance develops after weeks of therapy, reducing effectiveness 7
• High risk of dependence and withdrawal symptoms 7
• A 2018 study found that 29% of bipolar patients initiated benzodiazepine/Z-drug treatment, with one in five becoming long-term users 5
• Clonazepam and alprazolam were associated with the highest odds of long-term use (adjusted odds ratios 3.78 and 2.03, respectively) 5
• Polytherapy with multiple benzodiazepines/Z-drugs significantly increased the risk of long-term use (aOR 2.46) 5

Important Clinical Considerations

When managing bipolar patients with a history of benzodiazepine use:

• Monitor for rebound symptoms: When discontinuing benzodiazepines, carefully watch for rebound anxiety or insomnia that might be mistaken for bipolar symptoms 7
• Assess for dependence: Regular evaluation for signs of dependence is essential
• Consider safer alternatives: For anxiety symptoms in bipolar disorder, consider non-benzodiazepine options like certain atypical antipsychotics
• Be cautious with abrupt discontinuation: Benzodiazepines should be tapered gradually to avoid withdrawal symptoms

Summary of Management Approach

For patients with bipolar disorder currently on long-term benzodiazepines:

1. Evaluate for dependence and tolerance
2. Consider gradual tapering while introducing evidence-based mood stabilizers
3. Focus on first-line treatments like lithium, valproate, lamotrigine, or atypical antipsychotics 1, 6
4. Incorporate non-pharmacological approaches like psychoeducation, cognitive behavioral therapy, and maintenance of regular sleep patterns 1

Remember that bipolar disorder requires comprehensive management focused on long-term mood stabilization rather than symptomatic treatment with benzodiazepines, which may ultimately worsen the course of illness.