Benzodiazepines versus placebo for panic disorder in adults

Breilmann, Johanna; Girlanda, Francesca; Guaiana, Giuseppe; Barbui, Corrado; Cipriani, Andrea; Castellazzi, Mariasole; Bighelli, Irene; Davies, Simon; Furukawa, Toshi A; Kösters, Markus

doi:10.1002/14651858.cd010677.pub2

Cited by 33 publications

(29 citation statements)

References 166 publications

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Section: Discussionmentioning

confidence: 99%

“…Multiple options exist for the treatment of panic disorder; however, previous evidence has been mainly limited to placebo comparisons 828. Previous systematic reviews and meta-analyses reported benzodiazepines as the most efficacious in reducing panic attack frequency and anticipatory anxiety symptoms 8. Despite this clear evidence of benefit, benzodiazepines have not been recommended as the primary treatment option for panic disorder owing to potential adverse events (sedation, impaired memory and cognitive function, and increased risk of falling, especially in elderly people) and long term risks of dependency and withdrawals 29.…”

Section: Discussionmentioning

confidence: 99%

“…Several drug treatments are available for panic disorder, including tricyclic antidepressants, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and serotonin-noradrenaline reuptake inhibitors (SNRIs) 6. Findings from previous systematic reviews and direct meta-analyses suggest these treatments are more effective in reducing panic symptoms than placebo, but tricyclic antidepressants and benzodiazepines are linked with a significantly higher risk of adverse events 78. As a result several guidelines recommend SSRIs as the primary treatment owing to their preferable long term safety over benzodiazepines and tricyclic antidepressants 6910.…”

Section: Introductionmentioning

confidence: 99%

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Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

Chawla

Anothaisintawee

Charoenrungrueangchai

et al. 2022

BMJ

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Objective To identify drug classes and individual selective serotonin reuptake inhibitors (SSRIs) with high rates of remission and low risk of adverse events in the treatment of panic disorder with or without agoraphobia. Design Systematic review and network meta-analysis. Data sources Embase, Medline, and ClinicalTrials.gov from inception to 17 June 2021. Eligibility criteria for study selection Randomised controlled trials that included adults aged ≥18 years with a diagnosis of panic disorder, compared drugs used to treat the panic disorder, and measured the outcomes of interest, including remissions, dropouts, and adverse events. Methods Risk of bias in the included studies was assessed using the revised Cochrane risk of bias tool for randomised trials. Direct meta-analyses were performed using random effects models. A two stage network meta-analysis with surface under the cumulative ranking curve (SUCRA) was used to estimate the comparative efficacy of drug classes and individual SSRIs. Results 87 studies including a total of 12 800 participants and 12 drug classes were eligible for inclusion. Almost all the studies (86/87) had some concern or were at high risk of bias. Network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs, and serotonin-noradrenaline reuptake inhibitors (SNRIs) were associated with significantly higher remission rates than placebo, with risk ratios of 1.39 (95% confidence interval 1.26 to 1.54), 1.47 (1.36 to 1.60), 1.30 (1.00 to 1.69), 1.38 (1.26 to 1.50), and 1.27 (1.12 to 1.45), respectively. SUCRAs identified benzodiazepines (84.5%, mean rank=2.4), tricyclic antidepressants (68.7%, 3.8), and SSRIs (66.4%, 4.0) as the top three best treatments for remission. However, tricyclic antidepressants, benzodiazepines, and SSRIs were also significantly associated with increased risk of adverse events compared with placebo, with risk ratios of 1.79 (1.47 to 2.19), 1.76 (1.50 to 2.06), and 1.19 (1.01 to 1.41), respectively. Consistency assumption of adverse events was upheld but could still be present on removal of studies with high percentages of women participants and those with agoraphobia. A SUCRA cluster ranking plot considering both remission and adverse events among all drug classes indicated that SSRIs were associated with high remission and low risk of adverse events. Among individual SSRIs, sertraline and escitalopram provided high remission with an acceptable risk of adverse events. Conclusion The findings suggest that SSRIs provide high rates of remission with low risk of adverse events for the treatment of panic disorder. Among SSRIs, sertraline and escitalopram were associated with high remission and low risk of adverse events. The findings were, however, based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported. Systematic review registration PROSPERO CRD42020180638.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

Chawla

Anothaisintawee

Charoenrungrueangchai

et al. 2022

BMJ

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“…Although 69.7% of the psychiatrists agreed with Q2 (efficacy of anxiolytics for anxiety), there is only low-quality evidence concerning the superiority of BDZs over a placebo for the short-term treatment of panic disorders. 18 As first-line treatment for panic disorder, selective serotonin reuptake inhibitors are recommended in several guidelines. 19–22 However, a study conducted in Japan showed a high prescription rate for BDZs, especially in the absence of concomitant antidepressant treatment, among patients with neurosis.…”

Section: Discussionmentioning

confidence: 99%

Different Attitudes of Patients and Psychiatrists Toward Benzodiazepine Treatment

Kawamata¹,

Sugawara²,

Ishioka³

et al. 2021

NDT

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Background Concern regarding the benefit/risk ratio of the long-term use of benzodiazepines (BDZs) and Z-drugs is increasing. To prevent the risk of dependence in BDZ long-term use, it is essential to understand the attitudes of patients and psychiatrists toward BDZ treatment. The aims of this investigation were to 1) obtain information on patients’ attitudes with long-term BDZ use and their referring psychiatrists’ attitudes toward BDZ treatment, including their perception of the difficulty of reducing the dose of BDZs, and 2) identify discrepancies between patients’ and psychiatrists’ perceptions. Methods A brief questionnaire was constructed to investigate the attitudes of patients receiving BDZ treatment and their referring psychiatrists. Our sample comprised 155 patients who received BDZ treatment for more than one year and their referring eight psychiatrists. Both the patients and their psychiatrists completed our questionnaire between August 2017 and December 2017. Results Of the patients, 13% felt that it was more difficult to reduce the dose of BDZs than their referring psychiatrists (type A discrepancy), while 25% felt that it was less difficult (type B discrepancy). In the multivariate logistic regression analysis, the female sex and both the patients’ (“psychotherapy plus BDZs was necessary” and “it was necessary to increase the dose of BDZs”) and psychiatrists’ beliefs (“short-term prescription was justified”) were associated with type A discrepancies. Type B discrepancies were associated with psychiatrists’ beliefs that the patient’s wishes justified the use of BDZs and that the cessation of treatment with BDZs would lead to the deterioration of their rapport with their patients. Conclusion To overcome the discrepancies in the attitudes of patients and psychiatrists toward the cessation of BDZ treatment, it is necessary to promote patient-centered care involving patient psychoeducation and practice guidelines for the decision-making process. Further studies investigating the promotion of patient-centered care to reduce BDZ use are needed.

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“…Meta-analyses indicate the efficacy of benzodiazepine anxiolytics in some patients with certain anxiety disorders [4][5][6], but tolerability and safety concerns should limit their use in routine clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Clinical management of withdrawal from benzodiazepine anxiolytic and hypnotic medications

Baldwin

2021

Addiction

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Benzodiazepines continue to be prescribed widely in the management of patients with insomnia or anxiety disorders, despite the availability and acceptability of alternative pharmacological and psychological treatments. Many patients will experience adverse effects during treatment and considerable distress when the dosage is reduced and stopped. Management of benzodiazepine withdrawal includes measures to prevent the development of dependence, careful attention to underlying medical conditions, medication consolidation and gradual dosage reduction, accompanying psychological interventions, occasional prescription of concomitant medication, and relapse prevention with on-going support to address psychosocial stressors. There are needs for easier patient access to services with refined expertise and for further research to optimise strategies for preventing dependence and facilitating withdrawal.

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Benzodiazepines versus placebo for panic disorder in adults

Abstract: Trusted evidence. Informed decisions. Better health.

Cited by 33 publications

References 166 publications

Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials

Different Attitudes of Patients and Psychiatrists Toward Benzodiazepine Treatment

Clinical management of withdrawal from benzodiazepine anxiolytic and hypnotic medications

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