What are the alternatives to benzodiazepines (BZD)?

From the Guidelines

Benzodiazepines should be avoided in favor of non-benzodiazepine benzodiazepine receptor agonists (BZRAs) or sedating antidepressants for the treatment of insomnia due to their lower risk of dependency and adverse effects. For anxiety disorders, SSRIs like sertraline (50-200mg daily) or escitalopram (10-20mg daily) are first-line options, typically requiring 2-4 weeks for full effect but offering long-term benefits without dependency risks 1. Buspirone (15-30mg daily in divided doses) specifically targets anxiety without sedation or addiction potential.

Non-Pharmacological Approaches

Non-pharmacological approaches are equally important, including:

• Cognitive behavioral therapy (CBT), which addresses underlying thought patterns contributing to anxiety or insomnia, typically through 8-12 weekly sessions 1.
• Regular exercise, mindfulness meditation, and sleep hygiene practices can significantly reduce symptoms without medication risks.
• Stimulus control, relaxation training, and sleep restriction are also effective therapies for insomnia 1.

Pharmacological Alternatives

For insomnia, non-benzodiazepine sleep medications like:

• Zolpidem (5-10mg at bedtime) or
• Eszopiclone (1-3mg at bedtime) have shorter half-lives and less dependency risk, though they should still be used short-term 1.
• Trazodone (25-100mg at bedtime) offers sedating effects without significant dependency concerns.
• Low-dose doxepin (3 or 6 mg) is also an option for patients who are unable or unwilling to receive CBT-I 1.

These alternatives are preferred because benzodiazepines, while effective short-term, carry risks of tolerance, dependence, cognitive impairment, and withdrawal symptoms when used regularly beyond 2-4 weeks 1.

From the Research

Benzodiazepine Alternatives

Benzodiazepines are commonly used to treat anxiety disorders, but they can have negative side effects and lead to dependence. Fortunately, there are alternative treatments available. Some of these alternatives include:

• Cognitive Behavioral Therapy (CBT) 2, 3, 4
• Mindfulness-Based Interventions (MBIs) such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) 2, 5, 3, 4
• Acceptance and Commitment Therapy (ACT) 2
• Behavioral treatments for insomnia, such as Sleepwell, which promotes non-pharmacological insomnia management and benzodiazepine receptor agonist deprescribing 6

Effectiveness of Alternatives

Research has shown that these alternatives can be effective in reducing anxiety and depression symptoms. For example:

• CBT and MBIs have been shown to be equally effective in reducing anxiety and depression in adults with autism spectrum disorders 4
• MBIs have been found to be effective in reducing anxiety and depression symptom severity in a range of individuals 5
• Adapted MBSR has been shown to be effective in reducing principal disorder severity and worry in individuals with anxiety disorders 3
• Sleepwell has been found to be an acceptable and useful tool for promoting BZRA deprescribing and non-pharmacological insomnia management 6

Delivery Modes

These alternatives can be delivered in various modes, including:

• Traditional face-to-face therapy 2, 3, 4
• Therapist-guided Internet-delivered CBT (iCBT) 2
• Digitalized mindfulness- and acceptance-based interventions 2
• Direct-to-patient interventions, such as Sleepwell 6