Emily is a final year medical student at the Hull York Medical School. In her latest blog she examines one of our recently published reviews about benzodiazepines for panic disorder in adults.
Panic disorder is defined as “recurrent unexpected panic attacks”1 with moments of intense fear peaking within a few minutes. It is a common problem, affecting 1-5% of the general population2. Therefore, it is important that we understand the best ways to manage it. Panic attacks can lead to fear of having another attack and avoidance of places that may trigger them1. This can lead to agoraphobia which is “a fear of being in situations where escape may be difficult or help would not be available if needed”2. The cause of panic disorder is not fully understood, but it can often be associated with other psychiatric conditions including depression, social phobia and drug dependence2. It is important for students to understand panic disorder and its management because we often come across the medications prescribed to treat it in primary care.
Management of panic disorder
Panic disorder is often treated with a combination of psychological and pharmacological methods2. Psychological therapy mainly involves cognitive behavioural therapy (CBT), a type of talking therapy3. First line pharmacological therapy involves selective serotonin reuptake inhibitors (SSRIs)4. These are often preferred as they have fewer side effects compared to other treatments including tricyclic antidepressants (TCAs). They also have fewer problems with dependence and withdrawal symptoms compared to benzodiazepines2. Another time when SSRIs may be preferred is when the patient has co-existing depression, as benzodiazepines might not be as effective at managing the depressive symptoms2. Despite not being first line, benzodiazepines are often used in the management of panic disorder5, so it is important that we study the efficacy of this medication.
A Cochrane review looked at the efficacy and acceptability of benzodiazepines compared to a placebo in the treatment of panic disorder in adults, with or without agoraphobia2.
Benzodiazepines v Placebo
The systematic review used double-blinded trials with participants over 18 years randomly allocated to benzodiazepines or a placebo, with trials lasting less than 6 months. People with serious comorbid disorders including COPD and diabetes were excluded from the study. Overall, the review looked at 24 studies with 4233 participants2.
The two primary outcomes of the study, efficacy (measured as response to treatment) and acceptability (measured as number of people dropping out of treatment), showed a possible advantage of benzodiazepines over placebo. However, authors judged the studies to be of poor quality when considering study methods and reporting. There was also an advantage of benzodiazepines for remission and social functioning at the end of the study, although this was again from low quality evidence.
Most of the studies had high risk of bias. Confidence in the validity of the findings was reduced because of high dropout rates and people being able to guess which treatment a participant was on. Therefore, there is low quality evidence that benzodiazepines are superior to placebo.
Clinical Practice and Future Research
The studies used in this review only looked at the short-term effect of benzodiazepines and placebo after following patients up for three to nine weeks, so we do not know the long-term efficacy or the risk of dependency and withdrawal. As a result, the studies have limited impact on clinical practice. Furthermore, there is a choice between benzodiazepines and SSRIs, and the decision should be based on patient preference and looking at the risks versus benefits in the long term. Further reviews comparing benzodiazepines with other medication and psychotherapies would be more valuable as guidance for clinical practice. As well as this, many studies excluded psychiatric comorbidities, but panic disorder is often associated with other psychiatric conditions so the samples used may not be representative of the population. Therefore, more studies including people with other mental health conditions would be beneficial. Finally, longer studies would be helpful to assess the long-term effects of benzodiazepines including quality of life and satisfaction with treatment.
Emily Sanger, June 2019
Find out why Emily blogs.
Read Emily's Students 4 Best Evidence blog on Family Therapy approaches for Anorexia Nervosa.
Read Emily's Students 4 Best Evidence blog on Psychological Therapies in Humanitarian Crises.
Students 4 Best Evidence (S4BE) is a growing network of students from around the world, from school age to university, who are interested in learning more about evidence-based health care. The Students 4 Best Evidence website & social media platforms are supported by Cochrane UK.
Nimh.nih.gov. (2019). NIMH » Anxiety Disorders. [online] Available at: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml [Accessed 12 May 2019].
Breilmann J, Girlanda F, Guaiana G, Barbui C, Cipriani A, Castellazzi M, Bighelli I, Davies S, Furukawa T, Koesters M. (2019). Benzodiazepines versus placebo for panic disorder in adults. Cochrane Database of Systematic Reviews.
Pompoli A, Furukawa T, Imai H, Tajika A, Efthimiou O, Salanti G. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. Cochrane Database of Systematic Reviews.
Nice.org.uk. (2019). 1 Guidance | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance#stepped-care-for-people-with-panic-disorder [Accessed 12 May 2019].
Gomez A, Barthel A, Hofmann S. (2018). Comparing the efficacy of benzodiazepines and serotonergic anti-depressants for adults with generalized anxiety disorder: a meta-analytic review. Expert Opinion on Pharmacotherapy, 19(8), pp.883-94.