Sedatives still used for PTSD treatment despite warnings

Almost a third of veterans being treated for PTSD are prescribed benzodiazepines, such as Valium or Xanax, according Dr. Nancy Bernardy, a clinical psychologist with the VA’s National Center for PTSD.


By WYATT OLSON | STARS AND STRIPES Published: April 8, 2013

Department of Veterans Affairs doctors are continuing to prescribe tranquilizers such as Valium and Xanax to veterans diagnosed with post-traumatic stress disorder — despite VA guidelines advising against their use for the condition.

Almost a third of veterans being treated for PTSD are prescribed benzodiazepines, a class of sedatives commonly used to treat insomnia, anxiety, seizures and other conditions, according Dr. Nancy Bernardy, a clinical psychologist with the VA’s National Center for PTSD.

Benzodiazepine prescriptions by VA doctors for PTSD patients declined from 37 percent to 30 percent between 1999 and 2009, Bernardy and fellow researchers found in an earlier study. But it remained at 30 percent through 2012, Bernardy said, citing data that will be published soon.

The current clinical practice guidelines for managing PTSD, co-authored by the VA and Department of Defense, caution medical providers against using benzodiazepines “due to lack of efficacy data and growing evidence for the potential risk of harm,” Bernardy wrote in the PTSD center’s current newsletter.

The VA health-care system experienced a huge increase in the number of veterans being treated for PTSD, increasing three-fold in 10 years to about a half-million patients in 2009, Bernardy wrote.

Benzodiazepines have been around since the 1960s, when they became the sedative of choice and replaced barbiturates, which carried a high risk of overdose and abuse. Benzodiazepines became the preferred PTSD drug treatment because of their usefulness in managing anxiety and insomnia.

Studies, however, have not shown benzodiazepines as effective treatment for what are called the core PTSD symptoms of avoidance, hyperarousal, numbing and dissociation.

In fact, the drugs may impede other effective treatments for PTSD.

Studies on animals and humans suggest that benzodiazepines interfere with the “first-line recommended” PTSD treatment called “prolonged exposure therapy,” by which patients are exposed to trauma-related thoughts and situations in order to reduce their power to cause panic, Bernardy wrote.

She concluded that “mounting evidence suggests that the long-term harms imposed by benzodiazepine use outweigh any short-term symptomatic benefits in patients with PTSD.”

A 1990 study that compared the use of a benzodiazepine called alprazolam and a placebo for alleviating PTSD symptoms found that the slight reduction of anxiety was offset by withdrawal symptoms after only five weeks of use.

The use of benzodiazepines is especially problematic in PTSD patients who also have substance-abuse disorders or mild traumatic brain injuries. The DOD/VA guidelines especially caution their use with patients suffering from combat-related PTSD because more than half of such patients abuse alcohol or drugs.

“Once initiated, benzodiazepines can be very difficult, if not impossible, to discontinue due to significant withdrawal symptoms compounded by the underlying PTSD symptoms,” the VA/DOD guidelines state.

Most of the VA prescriptions for benzodiazepines for PTSD patients are made by mental health providers – rather than primary care physicians – who likely should be more aware of the VA/DOD guidelines, according to a study published last month in the journal Psychiatric Services.

The study, of which Bernardy was a co-author, analyzed VA prescription records from 2009 of 357,000 veterans with PTSD. It found that 37 percent had been prescribed benzodiazepines for the condition; just over two-thirds of those prescriptions were made by mental health providers.

The finding suggests that these particular providers contribute considerably to “the misalignment between guideline-based care and actual practice.”

The study did not determine the causes of such a misalignment but offered a few possible reasons.

“Many mental health providers ‘inherit’ patients who previously received benzodiazepines from other clinicians, creating an immediate tension as the clinician seeks to balance individual patient factors with the need to provide guideline-supported care,” the study stated.

The majority of PTSD patients in the study were Vietnam War-era vets, who perhaps began taking benzodiazepines years before guidelines were in place, the study said.

The authors concluded that further study was needed to determine whether the high prescription rates for benzodiazepine were due to ignorance about the guidelines.