Editing Benzodiazepine (section)

===Panic disorder===
{{Further|Panic disorder}}
[[File:Lorazepam Orion.jpg|thumb|A box of Lorazepam Orion (Lorazepam) tablets]]

Benzodiazepines are usually administered orally; however, very occasionally [[lorazepam]] or [[diazepam]] may be given intravenously for the treatment of [[panic attack]]s.<ref name="BNF_2009"/>

Because of their effectiveness, tolerability, and rapid onset of [[anxiolytic]] action, benzodiazepines are frequently used for the treatment of [[anxiety]] associated with [[panic disorder]].<ref name="pmid15762816">{{cite journal | vauthors = Stevens JC, Pollack MH | title = Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents | journal = The Journal of Clinical Psychiatry | volume = 66 | issue = Suppl 2 | pages = 21–27 | year = 2005 | pmid = 15762816 | quote = The frequent use of benzodiazepines for the treatment of anxiety is likely a reflection of their effectiveness, rapid onset of anxiolytic effect, and tolerability. }}</ref> However, there is disagreement among expert bodies regarding the long-term use of benzodiazepines for panic disorder. The views range from those holding benzodiazepines are not effective long-term<ref name=cgftmamoa2004/> and should be reserved for treatment-resistant cases<ref>{{cite journal | vauthors = Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ | title = World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Posttraumatic Stress Disorders | journal = The World Journal of Biological Psychiatry | volume = 3 | issue = 4 | pages = 171–199 | date = October 2002 | pmid = 12516310 | doi = 10.3109/15622970209150621 | s2cid = 922780 | doi-access = free | title-link = doi }}</ref> to those holding they are as effective in the long term as [[selective serotonin reuptake inhibitors]] (SSRIs).<ref name=APA/>

[[American Psychiatric Association]] (APA) guidelines, published in January 2009,<ref name="APA">{{cite web |url=http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=PanicDisorder_2e_PracticeGuideline |format = PDF |title= APA Practice Guideline for the Treatment of Patients With Panic Disorder, Second Edition |publisher=Work Group on Panic Disorder |date=January 2009 |access-date=12 July 2009 }}</ref> note that, in general, benzodiazepines are well tolerated, and their use for the initial treatment for panic disorder is strongly supported by numerous controlled trials. APA states that there is insufficient evidence to recommend any of the established panic disorder treatments over another. The choice of treatment between benzodiazepines, SSRIs, [[serotonin–norepinephrine reuptake inhibitors]] (SNRIs), [[tricyclic antidepressant]]s, and psychotherapy should be based on the patient's history, preference, and other individual characteristics. Selective serotonin reuptake inhibitors are likely to be the best choice of pharmacotherapy for many patients with panic disorder, but benzodiazepines are also often used, and some studies suggest that these medications are still used with greater frequency than the SSRIs. One advantage of benzodiazepines is that they alleviate the anxiety symptoms much more quickly than antidepressants, and therefore may be preferred in patients for whom rapid symptom control is critical. However, this advantage is offset by the possibility of developing [[benzodiazepine dependence]]. APA does not recommend benzodiazepines for persons with depressive symptoms or a recent history of [[substance use disorder]]. APA guidelines state that, in general, pharmacotherapy of panic disorder should be continued for at least a year, and that clinical experience supports continuing benzodiazepine treatment to prevent recurrence. Although major concerns about benzodiazepine tolerance and withdrawal have been raised, there is no evidence for significant dose escalation in patients using benzodiazepines long-term. For many such patients, stable doses of benzodiazepines retain their efficacy over several years.<ref name=APA/>

Guidelines issued by the UK-based [[National Institute for Health and Clinical Excellence]] (NICE), carried out a systematic review using different methodology and came to a different conclusion. They questioned the accuracy of studies that were not placebo-controlled. And, based on the findings of [[placebo-controlled studies]], they do not recommend use of benzodiazepines beyond two to four weeks, as tolerance and [[physical dependence]] develop rapidly, with withdrawal symptoms including [[rebound anxiety]] occurring after six weeks or more of use.<ref name=cgftmamoa2004>{{cite web |vauthors=McIntosh A, Cohen A, Turnbull N, Esmonde L, Dennis P, Eatock J, Feetam C, Hague J, Hughes I, Kelly J, Kosky N |title=Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder |url=http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf |publisher=National Collaborating Centre for Primary Care |year=2004 |access-date=16 June 2009 |archive-date=19 February 2009 |archive-url=https://web.archive.org/web/20090219140855/http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf |url-status=dead }}</ref><ref>{{cite web |vauthors=Barbui C, Cipriani A |title=Proposal for the inclusion in the WHO Model List of Essential Medicines of a selective serotonin-reuptake inhibitor for Generalised Anxiety Disorder |url=http://who.int/selection_medicines/committees/expert/17/application/Section24_GAD.pdf |publisher=WHO Collaborating Centre for Research and Training in Mental Health |year=2009 |access-date=23 June 2009 |archive-date=5 May 2012 |archive-url=https://web.archive.org/web/20120505191411/http://who.int/selection_medicines/committees/expert/17/application/Section24_GAD.pdf |url-status=dead }}</ref> Nevertheless, benzodiazepines are still prescribed for long-term treatment of [[anxiety disorders]], although specific [[antidepressants]] and psychological therapies are recommended as the [[first-line treatment]] options with the [[anticonvulsant]] drug [[pregabalin]] indicated as a second- or third-line treatment and suitable for long-term use.<ref>{{cite journal | vauthors = Cloos JM, Ferreira V | title = Current use of benzodiazepines in anxiety disorders | journal = Current Opinion in Psychiatry | volume = 22 | issue = 1 | pages = 90–95 | date = January 2009 | pmid = 19122540 | doi = 10.1097/YCO.0b013e32831a473d | s2cid = 20715355 }}</ref> NICE stated that long-term use of benzodiazepines for panic disorder with or without [[agoraphobia]] is an unlicensed indication, does not have long-term efficacy, and is, therefore, not recommended by clinical guidelines. Psychological therapies such as [[cognitive behavioural therapy]] are recommended as a first-line therapy for panic disorder; benzodiazepine use has been found to interfere with therapeutic gains from these therapies.<ref name=cgftmamoa2004 />