Benzodiazepines May Influence Suicide Risk in Anxiety Disorders Depending on Duration of Use

Colorful pills on a spoon.
Pills and capsules on spoon.
Benzodiazepines are considered a third-line treatment for the management of anxiety and sleep disorders, after antidepressant medications and psychotherapy.

The odds of death by suicide are higher in patients with anxiety disorder who receive benzodiazepines as monotherapy, according to study results published in General Hospital Psychiatry. However, there was a reduced risk for suicide in patients with anxiety with short- to moderate-duration treatment and concomitant psychotherapy or antidepressants. Benzodiazepines are considered a third-line treatment for the management of anxiety and sleep disorders, after antidepressant medications and psychotherapy.

The investigators examined health and claims information for patients who were part of the Treatment Utilization Before Suicide retrospective study, which was conducted in 8 healthcare systems throughout the United States. The study included data from patients who died by suicide between 2001 and 2013, along with matched controls. The investigators selected all patients aged ≤89 years who had at least 1 medical or mental health visit for anxiety or sleep disorder during the year prior to the index date. Analyses were limited to patients who filled at least 1 benzodiazepine prescription between 45 and 245 days prior to their index date.

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Patients were considered to be in concordance if they were <65 years of age, had ≤8 filled benzodiazepines during the study timeframe, and had evidence of at least 3 psychotherapy sessions for sleep and anxiety disorders or antidepressant medication treatment for anxiety disorders only. The final sample included 6960 patients with anxiety disorders (2363 receiving at least 1 dispensing of benzodiazepine) and 6215 patients with sleep disorders (1237 receiving at least 1 dispensing of benzodiazepine).

In adjusted models, the odds for death by suicide were 39% lower in patients with anxiety disorders who met benzodiazepine guidelines (odds ratio [OR], 0.611; 95% CI, 0.392-0.953; P =.03). In the sleep disorder group, the association of benzodiazepine guideline concordance and a decreased risk for suicide death did not meet statistical significance (OR, 0.413; 95% CI, 0.154–1.11; P =.08). Patients with anxiety disorders and <65 years of age who received 3 to 8 benzodiazepine fills as monotherapy (OR, 2.75; P <.01) and patients with long benzodiazepine duration (≥9 fills) (OR, 1.67; P =.05) had higher odds of death by suicide compared with patients receiving 1 or 2 benzodiazepine fills and concomitant antidepressant or psychotherapy.

The researchers noted that the lack of information about sleep disturbance symptoms and whether patients participated in evidence-based therapies may have contributed to the lack of significant association results in the sleep disorder group. They also acknowledged that patients with a sleep disorder diagnosis are generally associated with a lower suicide risk than patients with anxiety.

“This study shows that about one-fifth of individuals filled benzodiazepines [prescriptions] for sleep and anxiety outside recommended guidelines and this discordance is associated with suicide death,” the investigators wrote. “We hope that this study provides an impetus to physicians and health systems to carefully monitor benzodiazepine prescribing practices that are discordant per anxiety and sleep disorder guidelines and to consider screening patients who are treated with benzodiazepines for suicide risk.”


Boggs JM, Lindrooth RC, Battaglia C, et al. Association between suicide death and concordance with benzodiazepine treatment guidelines for anxiety and sleep disorders.

Gen Hosp Psychiatry. 2019;62:21-27.