Benzodiazepine Monotherapy Often Used for Depression Contrary to Guidelines

Benzodiazepine monotherapy continues to be used to treat depression despite American Psychiatric Association guidelines, and even in cases of concomitant opioid use.

Although psychiatrists were significantly less like to prescribe benzodiazepine monotherapy compared with practitioners in other specialties, benzodiazepine monotherapy was used in nearly 1 in 10 office visits involving patients treated for depression, according to a nationwide study published in the Journal of Clinical Psychiatry. This is despite American Psychiatric Association guidelines that state benzodiazepines can be used adjunctively for comorbid anxiety and insomnia, but should not be used instead of antidepressants.

Investigators analyzed data from the National Ambulatory Medical Care Survey, a probability sample survey conducted annually involving office-based providers and providers at community health centers. The survey asked participants to provide detailed information on patient care trends over the previous year. Investigators used data from encounters involving adult patients (≥18 years) receiving treatment for depression. The primary outcome measure was the prevalence of benzodiazepine monotherapy, defined as initiation or continuation of a benzodiazepine medication in the absence of any antidepressant medication. A multivariate logistic regression model was created to identify variables associated with benzodiazepine monotherapy, including patient and provider characteristics.

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A total of 9426 patients were eligible for inclusion during the 2012 to 2015 survey period, among whom 70.1% were women and 81.1% were non-Hispanic whites. Patients were of mean age 53.7 years and taking an average of 6.3 medications.

Benzodiazepine monotherapy had a calculated prevalence rate of 9.3% (95% CI, 8.2-10.6%). The most commonly prescribed benzodiazepine monotherapies were alprazolam (42.1%), lorazepam (27.7%), clonazepam (20.3%), and diazepam (13.8%).

In the adjusted model, benzodiazepine monotherapy was significantly increased among patients age 45 to 64 years (odds ratio [OR], 1.39; 95% CI, 1.01-1.91) and patients with Medicare (OR, 1.40; 95% CI, 1.01-1.94) compared with those age 25 to 44 years and those with private insurance, respectively.

Additional predictors of benzodiazepine monotherapy included epilepsy-related office visit (OR, 5.34; 95% CI, 1.39-20.44), anxiety-related office visit (OR, 1.67; 95% CI, 1.23-2.27), underlying pulmonary disease (OR, 1.43; 95% CI, 1.09-1.87), and concomitant opioid prescribing (OR, 2.86; 95% CI, 2.01-4.06). A number of these variables contradict known concerns about benzodiazepines and their risk of dependence and delirium, especially with concomitant opioids.

Psychiatrists were significantly less likely to prescribe benzodiazepine monotherapy than were other providers (OR, 0.42; 95% CI, 0.29-0.61).

In addition, the following variables had no association with benzodiazepine monotherapy prescribing: sex, race/ethnicity, history of substance use disorder, chronic kidney disease, being seen by neurology specialists, and total number of chronic conditions.

A key limitation of the study was the inability to assess the duration of benzodiazepine monotherapy in this patient population.

For patients treated for depression, it is likely that benzodiazepine monotherapy continues to be used despite guidelines. “Educational or technological interventions to minimize benzodiazepine monotherapy utilization should be implemented to raise the awareness of the impact of this treatment modality on patients with [major depressive disorder],” concluded the researchers.


Soric MM, Paxos C, Dugan SE, et al. Prevalence and predictors of benzodiazepine monotherapy in patients with depression: a national cross-sectional study. J Clin Psychiatry. 2019;80(4):18m12588.