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Letters to the Editor   |    
The Role of Benzodiazepines in Treating Social Anxiety Disorder
Edward K. Silberman, M.D.
Am J Psychiatry 2014;171:795. doi:10.1176/appi.ajp.2014.14010048
View Author and Article Information

The author reports no financial relationships with commercial interests.

From the Department of Psychiatry, Tufts Medical Center, Boston.

Copyright © 2014 by the American Psychiatric Association

Accepted April , 2014.

To the Editor: The article by Pollack et al. (1) in the January issue of the Journal is a welcome demonstration of the benefits of using benzodiazepines in the treatment of social anxiety disorder. However, the lack of a clonazepam monotherapy arm in the study demonstrates how entrenched, in the absence of evidence, the assumption has become that benzodiazepines should not be used as first-line therapy for anxiety disorders (2). Despite evidence that benzodiazepines alone may be effective for social anxiety disorder (and other anxiety disorders) (3), misunderstanding about their potential for abuse and dependency is now a common barrier to appropriate prescription of these highly effective medications. While they are not for everyone, the systematic literature is virtually unanimous in finding that benzodiazepines have a low potential for abuse in patients who are not currently abusing other substances (4), even if the patients have a past history of substance abuse (5). In addition to potentially greater efficacy for treating anxiety disorders, benzodiazepines have the advantages of immediate onset of action, fewer side effects compared with antidepressants, and a high therapeutic index. Long-term controlled trials of benzodiazepine monotherapy, including monitoring of efficacy, tolerability, and abuse in the treatment of social and other anxiety disorders, may be difficult to fund, but would be a great service to patients who suffer from these often undertreated conditions.

Pollack  MH;  Van Ameringen  M;  Simon  NM;  Worthington  JW;  Hoge  EA;  Keshaviah  A;  Stein  MB:  A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder.  Am J Psychiatry 2014; 171:44–53
[CrossRef] | [PubMed]
 
Berney  P;  Halperin  D;  Tango  R;  Daeniker-Dayer  I;  Schulz  P:  A major change of prescribing pattern in absence of adequate evidence: benzodiazepines versus newer antidepressants in anxiety disorders.  Psychopharmacol Bull 2008; 41:39–47
[PubMed]
 
Davidson  JR;  Potts  N;  Richichi  E;  Krishnan  R;  Ford  SM;  Smith  R;  Wilson  WH:  Treatment of social phobia with clonazepam and placebo.  J Clin Psychopharmacol 1993; 13:423–428
[CrossRef] | [PubMed]
 
Woods  JH;  Winger  G:  Current benzodiazepine issues.  Psychopharmacology (Berl) 1995; 118:107–115, discussion 118, 120–121
[CrossRef] | [PubMed]
 
Posternak  MA;  Mueller  TI:  Assessing the risks and benefits of benzodiazepines for anxiety disorders in patients with a history of substance abuse or dependence.  Am J Addict 2001; 10:48–68
[CrossRef] | [PubMed]
 
References Container
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References

Pollack  MH;  Van Ameringen  M;  Simon  NM;  Worthington  JW;  Hoge  EA;  Keshaviah  A;  Stein  MB:  A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder.  Am J Psychiatry 2014; 171:44–53
[CrossRef] | [PubMed]
 
Berney  P;  Halperin  D;  Tango  R;  Daeniker-Dayer  I;  Schulz  P:  A major change of prescribing pattern in absence of adequate evidence: benzodiazepines versus newer antidepressants in anxiety disorders.  Psychopharmacol Bull 2008; 41:39–47
[PubMed]
 
Davidson  JR;  Potts  N;  Richichi  E;  Krishnan  R;  Ford  SM;  Smith  R;  Wilson  WH:  Treatment of social phobia with clonazepam and placebo.  J Clin Psychopharmacol 1993; 13:423–428
[CrossRef] | [PubMed]
 
Woods  JH;  Winger  G:  Current benzodiazepine issues.  Psychopharmacology (Berl) 1995; 118:107–115, discussion 118, 120–121
[CrossRef] | [PubMed]
 
Posternak  MA;  Mueller  TI:  Assessing the risks and benefits of benzodiazepines for anxiety disorders in patients with a history of substance abuse or dependence.  Am J Addict 2001; 10:48–68
[CrossRef] | [PubMed]
 
References Container
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Response to Silberman. Am J Psychiatry 2014;171(7):795-6.