Post-Traumatic Stress Disorder (PTSD) was first recognized by the American Psychiatric Association in 1980. Before that, it went by various unofficial names, including “combat neurosis” and “shell shock.”
One of the most commonly prescribed treatments when PTSD became an official medical diagnosis were benzodiazepines. These drugs included Xanax (alprazolam), Klonopin (clonazepam), and Valium (diazepam). However, today, the U.S. Department of Veterans Affairs recommends against using benzodiazepines for PTSD treatment, noting that, “The evidence is mounting on the harms associated with chronic benzodiazepine use in patients with PTSD.”
So what changed? And how is it that, per the V.A., 30 percent of its PTSD patients had a prescription for benzodiazepines in 2012?
“Trauma—with or without the diagnosis of PTSD—is ubiquitous in mental healthcare,” says Dr. Jeffrey Guina, MD, Clinical Assistant Professor of Psychiatry at the Wright State University Boonshoft School of Medicine. “Trauma is a risk factor for virtually all mental disorders, including psychotic, mood, anxiety, and addictive disorders.”
That’s why, in the 1960s following a string of high-profile celebrity deaths (including Elvis Presley, Marilyn Monroe, and Judy Garland) at the hands of barbiturates, benzodiazepines were developed with the hope that they’d be a less harmful alternative to these and other sedatives.
“They quickly became one of the most prescribed medications in the world,” Guina says. “Since trauma often resulted in anxiety and insomnia, well-meaning clinicians attempted to calm anxiety and induce sleep using sedatives.”
In the 1980s and 1990s, Guina says the conversation around benzodiazepines changed as research began to show that they were capable of some of the same harmful side effects as barbiturate use—addiction, coma, and death among them. “[This period] also saw the advent of selective serotonin reuptake inhibitors and trauma-focused psychotherapies, both safer and more effective treatments for PTSD,” he says.
Guina says he saw first-hand the effects of benzodiazepines on patients with PTSD when he first saw new patients who had prescriptions from other providers.
“Most of these patients started the appointment by asking for refills and some were surprised—and frequently resistant—when I asked them to talk about their lives and their traumas before discussing a treatment plan,” Guina remembers. “Despite describing numerous functional impairments (such as unemployment, dependency on government assistance, multiple divorces, estrangement from family, and difficulty leaving the home), most claimed that their benzodiazepines were ‘the only thing that works.’”
He says the discrepancy—that someone could say a medication was working despite continuing to suffer significant occupational, interpersonal, and general life dysfunction—perplexed him, but fairly quickly, he realized these patients were “defining success as a measure of sedation.” In other words, as long as their anxiety—and to a certain extent, emotion altogether—was absent, they were happy with benzodiazepines as treatment and didn’t want to explore other options.
“By discussing, thinking about, and processing trauma and its effects, individuals often experience a short-term worsening of anxiety, but through repeated exposure and cognitive processing, the brain literally changes and anxiety improves in the long-term,” Guina says. He explained this to some of his patients who depended on benzodiazepines for treatment. He added that avoidance, which sedatives inherently fostered, had the exact opposite effect, reducing anxiety in the short-term but, in the long-term, worsening it. A long term prescription for benzodiazepines lets the ability to manage anxiety go unpracticed and the capacity to cope with unavoidable stressors are reduced.
This eventually led Guina to pursue the subject in a scientific context. He and a number of colleagues published a paper in 2015 in the Journal of Psychiatric Practice based on a systematic review and meta-analysis of benzodiazepine use for PTSD patients. They found that “benzodiazepines are associated with specific problems in patients with PTSD: worse overall severity, significantly increased risk of developing PTSD with use after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use.”
He says the decision by the V.A. to change its views on treatment via benzodiazepines is based primarily on a sudden abundance of convincing scientific research. However, just because one organization has announced a policy change doesn’t mean there isn’t work for clinicians to do.
“The gold standard treatment for PTSD is trauma-focused psychotherapies,” Guina says, including Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing Therapy (EMDR).
Additionally, medications can be an important reinforcing treatment. “Serotonergic agents (antidepressants) increase the activity of serotonin, which is a chemical in the brain related to one’s sense of well-being and emotional and behavioral regulation,” Guina says. “Unlike sedatives, which globally inhibit the entire brain, serotonin selectively inhibits the amygdala (the stress center of the brain which tends to be hyperactive in PTSD) while enhancing the prefrontal cortex and hippocampus (the cognitive and memory centers of the brain which tend to be hypoactive in PTSD). By normalizing stress-induced changes in these areas, serotonergic agents can reduce distress, improve cognitive processing and improve learning of new coping skills.”