Emerging Bias in the Treatment of Posttraumatic Stress Disorder

Abstract

J Clin Psychiatry 2012;73(3):304–306 (doi:10.4088/JCP.11com07055) © Copyright 2012 Physicians Postgraduate Press, Inc. T article “Declining Benzodiazepine Use in Veterans With Posttraumatic Stress Disorder” by Lund and colleagues1 comes on the heels of the recent update of the US Department of Veterans Affairs (VA) and Department of Defense (DoD) Clinical Practice Guideline for Management of Post-Traumatic Stress2 and the position taken by the National Center for PTSD3 regarding benzodiazepine use. The Guideline was first published in 2004 and updated in 2010. Dr Friedman is the executive director of the National Center for PTSD, the cochair of the workgroup that wrote the Guideline, and one of the authors of the Lund et al article. Therefore, I think that it is fair, that, as I discuss this article, I also discuss the Guideline. The authors cite scarce recent studies to arrive at the conclusion that benzodiazepines have no benefit and may cause harm. In spite of this insufficient evidence, they inform us that the 152,413 veterans (30.6% of 498,081) who are in treatment for posttraumatic stress disorder (PTSD) in the VA and are taking benzodiazepines are receiving inappropriate treatment. In fact, according to the authors, these patients are being given drugs that have no benefit and there are “long-term harms imposed by benzodiazepine use.”1(p292) They fail to present conclusive evidence to support this statement; however, they clearly imply that we are in the midst of a public health crisis as a result of benzodiazepine use. These numbers do not include the many thousands of individuals outside the VA who are being prescribed benzodiazepines for PTSD and other anxiety disorders. While there is some general agreement that benzodiazepines should have only an adjunctive role in PTSD treatment, the authors are overly biased in the negative. Even though the authors say that “determining the impact of the Guideline publication was not an objective of our analysis,”1(p295) this seems to be exactly what this study is about. It takes for granted the conclusion that benzodiazepines are not useful in the treatment of PTSD and in fact can be quite harmful and that the gradual reduction with ultimate elimination of benzodiazepines should be a national goal. They conclude that “minimizing benzodiazepine exposure will remain a vital policy issue for the VA.”1(p296) In contrast to the National Center for PTSD recommendation, the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder4 takes a more reasoned approach. It addresses the same risks as reported in the National Center for PTSD recommendations, while including benzodiazepines as a recommendation for reducing anxiety and improving sleep. In addition, it doesn’t describe them as harmful. Furthermore, a study5 of veterans treated by the VA has shown that the rationale for benzodiazepine use is usually PTSD severity and anxiety and that the negative outcomes predicted by the Guideline are not occurring. The authors of the study concluded that “among PTSD patients with comorbid substance abuse, benzodiazepine treatment was not associated with adverse effects on outcome.”5(p1) Those who were treated with benzodiazepines “were more likely to have been previously hospitalized, had more severe PTSD symptoms, and had more anxiety and overall psychiatric symptoms.” 5(p4) Lund and colleagues also state that “[c]urrently, no data support the efficacy of benzodiazepines for the treatment of core PTSD symptoms.”1(p292) They then draw the unfounded conclusion that “benzodiazepines are ineffective for core PTSD symptoms like avoidance or dissociation.”1(p292) It is illogical to conclude that, since there are not enough data, the treatment is ineffective. In addition, this statement focuses on only a subset of symptoms. The article also states that “[b]ecause benzodiazepine discontinuation is often challenging, the least problematic means to curtail use is to avoid these drugs in newly treated, benzodiazepinenaive patients.”1(p295) Discontinuation symptoms may occur in some cases but often are not a problem. All patients do not become tolerant, and some take benzodiazepines for years with continued therapeutic benefit and no problems. Although the authors state that “setting a target goal of zero benzodiazepine use is probably not realistic,”1(p295) it is implicit in the article that zero use should be the goal. Benzodiazepines have been around for at least 50 years and prior to the DSM diagnosis of PTSD. Funding for the study of new indications is generally absent for these drugs since they have long had US Food and Drug Administration approval. Conclusions should not be based on a lack of evidence. The authors claim that reducing anxiety with benzodiazepines will interfere with the psychotherapeutic treatment of PTSD. They bring to our attention that