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460 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Benzodiazepines in the treatment of psychiatric disorders Benzodiazepines have a valid place in the treatment of some forms of epilepsy and severe muscle spasm, and as premedication agents in some surgical procedures. However, the vast majority of prescriptions are written for their hypnotic and anxiolytic effects. They are also used for rapid tranquillisation and, usually as adjuncts, in the treatment of depression and schizophrenia. Benzodiazepines are commonly both prescribed and misused. A European study found that almost 10% of adults had taken a benzodiazepine over the previous year1 and a 2019 US study reported past-­year usage of 12.6% among adults.2 Generally speaking, the use of benzodiazepines in psychiatric disorders has gradually become less supportable over the past few decades.3 Benzodiazepines are sometimes divided into two groups depending on their half-­life: hypnotics (short half-­life) or anxiolytics (long half-­life), although there are many exceptions (for example, nitrazepam and alprazolam, respectively). Anxiolytic effect Benzodiazepines reduce pathological anxiety, agitation and tension. Although useful in the short-­term management of generalised anxiety disorder,4 either alone or to augment SSRIs, benzodiazepines are associated with tolerance and withdrawal. Despite awareness of this, many patients continue to take these drugs for years5 with unknown benefits and many likely harms. Most authorities agree that, where a benzodiazepine is prescribed, this should not routinely be for longer than 4 weeks.6 In the UK, NICE recommends that benzodiazepines should not be used in patients with generalised anxiety disorder except as a short-­term measure during crisis.7 Evidence is mixed in other anxiety disorders, and potential benefits should be viewed in the context of the known problems associated with benzodiazepine use. A small number of trials report the efficacy of benzodiazepines in social anxiety disorder.8 Benzodiazepines are useful in the short-­term treatment of panic disorders,9,10 but little is known about their efficacy and safety with long-­term use.10,11 Benzodiazepines are, with some exceptions, relatively ineffective in the treatment of PTSD12,13 or phobias.14 Hypnotic effect Benzodiazepines are effective hypnotics but they inhibit rapid eye movement (REM) sleep and REM rebound is seen when they are discontinued.14 There is a debate over the clinical significance of this property.15 Benzodiazepines are effective in the short term.16 RCTs support the effectiveness of Z hypnotics over a period of at least 6 months,17 but it is unclear if this holds true for benzodiazepine hypnotics. Intermittent use probably extends the period over which benzodiazepines are effective as hypnotics. Physical causes (pain, dyspnoea, etc.) or substance misuse (most commonly high caffeine consumption) should always be excluded before a hypnotic drug is prescribed. Where possible, behavioural therapies (e.g. CBT for insomnia or sleep restriction) should be offered before prescribing hypnotics.17 A high proportion of hospitalised patients are prescribed hypnotics.18,19 These drugs should not be routinely continued at discharge.