Current estimates suggest the lifetime prevalence of anxiety disorders in the U.S. ranges from 16% to 34%, with evidence to suggest these numbers may be worse post-COVID-19.1 When a patient presents in obvious distress or is reporting significant anxiety, it is clinically and ethically appropriate to address the patient’s discomfort.
However, in the case of benzodiazepines, the immediate and short-term benefits do not outweigh the moderate- and long-term risks. In fact, a growing body of research documents the negative effects of benzodiazepine use, including mild cognitive impairments, decreased coordination and associated increase in motor vehicle accidents, emergency room visits, tolerance leading to higher doses, psychological and physiological dependence, withdrawal if abruptly or inappropriately discontinued (e.g., agitation, seizures, possible death), rebound anxiety post-discontinuation, risk for abuse, unintentional and intentional overdose, and mortality.2–7
In fact, in 2020, the U.S. Food and Drug Administration (FDA) updated the requirements for box warnings on benzodiazepines to include abuse, addiction and other serious risks.8 Despite significant risks associated with use, prescriptions for benzodiazepines have increased in recent decades with an estimated 30.5 million adults per year using benzodiazepines.9 The most frequent prescribers are non-behavioral health clinicians.10
From an ongoing historical perspective, there are many disturbing similarities between the opiate epidemic and ongoing patterns of benzodiazepines. The surge in benzodiazepine prescriptions cannot be solely attributed to medical necessity or their potent effects, but also to the marketing strategies of Arthur Sackler (1913-1987), a psychiatrist and the patriarch of the family behind Purdue Pharma. Sackler’s aggressive approach to pharmaceutical marketing techniques played a role in promoting both benzodiazepines and opiates.11
Paired with the drugs’ inherently rapid and rewarding effects, the aggressive marketing approach led to blockbuster sales with devastating repercussions. In the 1970s, benzodiazepines became one of the most prescribed class of medications.12 Sackler’s direct outreach to physicians served as inspiration for many others to follow suit in promoting their own drugs. This blueprint for benzodiazepine promotion could possibly have even laid the groundwork for the subsequent opioid crisis.13,14
Though regulations have since curbed many of these marketing practices, the aftermath remains – benzodiazepines, like opioids, have been prescribed in a dangerous manner.10 While the detrimental effects of opioids have been more readily apparent, the effects of benzodiazepines linger, stressing the urgent need for vigilant oversight and informed prescribing practices.
How Should We Treat Anxiety Disorders?
First, accurately determining whether the patient meets criteria for an anxiety disorder and which anxiety disorder is essential to identifying the targeted, empirically supported intervention. In many cases, that may not mean medication.
If medication is needed, balancing the benefits with the tolerability of side effects is crucial. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) remain the first-line medications for most anxiety disorders, although medications like buspirone and hydroxyzine can also be effective, but additional long-term risks should be considered.15
Clinicians often rely on medications with off-label indications for the symptoms of anxiety, such as quetiapine and gabapentin. Because of the lack of FDA approval, this may expose clinicians to issues concerning liability and patients to unpredictable adverse reactions.16
Determining which medications are indicated, for how long and for whom is complex, especially given the presence of pharmaceutical marketing, which, though curtailed, remains influential. This produces a challenging undertaking for non-behavioral healthcare physicians.17
Psychotherapeutic approaches have shown positive effects in addressing anxiety symptoms and disorders. Psychotherapy also provides patients the opportunity to learn adaptive coping strategies for anxiety, which medications cannot.
In some cases, medications to treat anxiety could perpetuate anxiety. Rather than learning strategies to manage their anxiety, patients may receive the message that their only option to control their anxiety is pharmaceutical.
The psychotherapeutic modality with arguably the largest body of evidence is cognitive behavioral therapy (CBT). CBT has shown significant positive effects on patient-reported anxiety, anxiety disorder symptoms, reducing other comorbid mood related symptoms and improving overall quality of life. It has few to no significant long-term negative side-effects and may be more cost-effective than psychopharmacology.18–21 CBT has also shown potential effectiveness in helping patients tapering off benzodiazepines.22
Newer psychotherapeutic treatment modalities also showing positive impacts on anxiety symptoms include acceptance and commitment therapy (ACT)23 and mindfulness-based therapy (MBT),24 though additional research is still needed for long-term outcomes.
The Benefits of Integrated Behavioral Healthcare
Studies have repeatedly shown that non-behavioral health clinicians are the highest prescribers of benzodiazepines and that, when symptoms are comprehensively assessed, patients prescribed benzodiazepines often do not meet full criteria for anxiety or other psychiatric disorders.25,26
Inappropriate treatment or diagnosis of anxiety disorders can lead to costly consequences over time. This is exemplified by the number of patients taking benzodiazepines long term. Also not surprisingly, general practitioners report significant ambivalence, uncertainty and low confidence in prescribing benzodiazepines.27,28
This highlights the need for behavioral health integration. Behavioral health integration involves incorporating mental health professionals, such as psychologists, social workers and/or psychiatrists, into primary care and specialty medical practices. This can be done in a variety of ways to target a specific population of a healthcare system.29 Through behavioral health integration, mental healthcare professionals can offer expertise in assessing and treating mental health conditions, ensuring patients receive care that addresses physical, mental and psychological needs.
By integrating behavioral health services into medical settings, patients with anxiety disorders could benefit from accurate diagnoses and approaches to treatment combining evidence-based medication management with psychotherapy, lifestyle interventions and supportive services. In addition, some integrated behavioral health programs include a teaching component for non-behavioral health physicians, which results in them being better equipped to tackle behavioral health concerns.30
Behavioral health integration removes the archaic siloes between mental health and medical care, fostering communication and collaboration among providers to optimize patient care. This collaborative model could promote early intervention, continuity of care and enhanced access to mental health services, ultimately improving the overall quality of care for individuals with anxiety disorders.
References
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