Benzodiazepines Are Not Recommended for PTSD Treatment
Benzodiazepines should not be used for the treatment or prevention of PTSD, as they are ineffective for core PTSD symptoms and are associated with worse outcomes, including increased PTSD severity, higher rates of PTSD development after trauma, and significant risks of dependence and substance abuse. 1
Strong Guideline Recommendations Against Benzodiazepines
The most recent and authoritative guidance comes from the 2023 VA/DoD Clinical Practice Guideline, which provides a strong recommendation against the use of benzodiazepines for PTSD treatment. 1 This represents one of only six strong recommendations in the entire guideline, underscoring the strength of evidence against their use.
Additional guideline support includes:
- WHO guidelines explicitly state that benzodiazepines should not be used for initial treatment of individuals with depressive symptoms or trauma-related conditions. 1
- Benzodiazepines are contraindicated for acute stress reactions following recent trauma, as they may worsen outcomes and increase the risk of developing chronic PTSD. 2
- For perioperative management of patients with PTSD history, avoidance of benzodiazepines is specifically recommended to prevent emergence delirium and complications. 1
Evidence of Harm and Inefficacy
The evidence demonstrates that benzodiazepines are not merely ineffective—they actively worsen PTSD outcomes:
Prevention Studies Show Harm
- Early administration of benzodiazepines after trauma increases PTSD risk: In one study, 63% of trauma survivors receiving benzodiazepines (clonazepam or alprazolam) within one week of trauma met criteria for PTSD at 6 months, compared to only 23% receiving placebo. 1, 3
- Prospective research confirms no beneficial effect on PTSD course or symptom severity when benzodiazepines are given early after trauma. 3
Treatment Studies Show Multiple Problems
A comprehensive systematic review and meta-analysis of 18 studies with 5,236 participants found: 4
- Worse overall PTSD severity in patients using benzodiazepines
- Worse psychotherapy outcomes when benzodiazepines are used concurrently
- Increased aggression, depression, and substance use in PTSD patients taking benzodiazepines
- No efficacy for core PTSD symptoms across multiple studies
Specific Risks in PTSD Population
- High comorbidity with substance use disorders makes benzodiazepine dependence particularly problematic in PTSD patients. 5
- Benzodiazepines are not recommended as monotherapy or adjunctive treatment according to the 2010 VA/DoD guidelines. 5
What Should Be Used Instead
First-line treatments for PTSD include: 1
- Manualized trauma-focused psychotherapies (prolonged exposure, cognitive processing therapy, or EMDR) are strongly recommended over pharmacotherapy
- SSRIs (paroxetine, sertraline) or SNRI (venlafaxine) if pharmacotherapy is chosen
- Prazosin specifically for PTSD-related nightmares 5
Common Clinical Pitfalls to Avoid
- Do not use benzodiazepines to "bridge" until antidepressants take effect in PTSD patients—this practice lacks evidence and may worsen outcomes. 4
- Do not prescribe benzodiazepines for sleep or anxiety symptoms in PTSD—while these symptoms are distressing, benzodiazepines interfere with trauma processing and psychotherapy effectiveness. 4
- Avoid the misconception that "some patients need them"—the evidence shows harm across PTSD populations, not just in subgroups. 4
- Do not confuse PTSD with panic disorder—benzodiazepines may have a role in panic disorder but are contraindicated in PTSD. 6
Rare Exceptions Requiring Extreme Caution
While guidelines recommend against benzodiazepines, some clinicians have suggested very limited adjunctive use may be considered for severe anxiety or sleep disturbance in carefully selected patients without substance use history. 7 However, this view contradicts the strongest evidence and guideline recommendations. The safest approach is complete avoidance given the preponderance of evidence showing harm. 1, 4