Dr Capehart Replies

See original letter by Steenen et al

Dr Capehart Replies

To the Editor: I appreciate the comments from Steenen et al on benzodiazepines and posttraumatic stress disorder (PTSD). They appear to support avoiding benzodiazepines in routine clinical care of PTSD, correctly noting the lack of studies on benzodiazepines’ therapeutic effect in PTSD and the risk for addiction associated with benzodiazepines.

Steenen et al briefly discuss animal research on adverse memory and reconsolidation. I agree with their position on further research into medications that may improve our treatment for PTSD. That research could include benzodiazepines, d-cycloserine, propranolol, or other compounds.

There are, however, important differences between clinical care and the animal research studies cited by Steenen et al.

The article by Bustos et al1 evaluates midazolam in a rodent model of anxiety. Assuming a number of unresolved questions could be answered, Bustos et al suggest a potential future role for benzodiazepines in psychotherapy of PTSD. When animal research protocols have determined the proper dose and time frame for medications to augment psychotherapy, I would welcome a randomized, placebo-controlled clinical trial based on those animal studies.

Clinicians need novel treatment approaches for PTSD. In particular, PTSD care would benefit from treatments that integrate psychotherapy and medication to yield a greater magnitude and longer duration of clinical response. To my knowledge, there are no clinical protocols for benzodiazepines and psychotherapy in routine clinical practice. The preclinical study published by Bustos et al2 does not guide the clinician on if, how, when, or how long to prescribe a benzodiazepine for PTSD, and their findings should not be used to justify routine benzodiazepine prescribing in PTSD.

The article by Lund et al2 and my accompanying commentary3 both describe clinical practice for PTSD. Until we see results from properly controlled clinical trials that support a change in clinical practice guidelines, benzodiazepines are best avoided when treating patients with PTSD.

References

1. Bustos SG, Maldonado H, Molina VA. Disruptive effect of midazolam on fear memory reconsolidation: decisive influence of reactivation time span and memory age. Neuropsychopharmacology. 2009;34(2):446-457. PubMed doi:10.1038/npp.2008.75

2. Lund BC, Bernardy NC, Alexander B, et al. Declining benzodiazepine use in veterans with posttraumatic stress disorder. J Clin Psychiatry. 2012;73(3):292-296. PubMed doi:10.4088/JCP.10m06775

3. Capehart BP. Benzodiazepines, posttraumatic stress disorder, and veterans: good news and why we’ re not done yet. J Clin Psychiatry. 2012;73(3):307-309. PubMed doi:10.4088/JCP.11com07079

Bruce P. Capehart, MD, MBA

[email protected]

Author affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Potential conflicts of interest: None reported.

Funding/support: None reported.

J Clin Psychiatry 2013;74(8):852-853 (doi:10.4088/JCP.12lr08383b).

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