Which patients presenting with clinical anxiety will abuse benzodiazepines?

Although benzodiazepines represent much safer alternatives to the old generation of sedative-hypnotics, in contemporary practice a minority of patients still abuse them. Many physicians are leery of prescribing benzodiazepines for fear of inadvertently contributing to such abuse. In the present investigation of a stratified sample of 134 adult patients from anxiety and chemical dependency clinics in two university medical centers were systematically evaluated in semi-structured interviews based on a modification of Washington University criteria. Sedative (mostly benzodiazepines) abuse was significantly associated with such indicators of long-term maladjustment as antisocial personality and somatization hysteria, labile moods, temper outbursts, unstable interpersonal relationships, alcoholism, and a history of suicide attempts. Family history of alcoholism was not significant when controlled for familial antisocial personality. Neither depression, nor its chronicity or family history for depression, had any bearing on abuse of benzodiazepines. Logistic regression identified unstable tempestuous relationships and family history of antisocial behavior as the most powerful predictors; in particular, absence of such history correctly classified 80 per cent of those who did not abuse these drugs. Our data can help physicians decide which clinically anxious patients can be prescribed benzodiazepines with relative peace of mind. Apart from the foregoing patient characteristics, physicians must consider pharmacokinetic factors which suggest that benzodiazepines with longer half-lives are least likely to result in dependence. Finally, non-benzodiazepine anxiolytic agents—such as hydroxyzine and SSRIs—should receive serious consideration as less problematic agents in the clinical management of anxiety disorders. Whenever available, brief psychotherapeutic approaches should also be provided. Copyright © 1999 John Wiley & Sons, Ltd.