We were given permission by Dr. Dodds to publish this review. It evaluates the literature of suicide risk associated with benzodiazepines. Some highlights of his findings:
In the National Comorbidity Study Replication, the use of sleeping pills or other sedatives, many of which act on GABAA receptors, was associated with a 3-fold higher risk of suicide attempt even after adjusting for insomnia, substance use, anxiety, and mood disorder
Rebound or withdrawal symptoms also may contribute to suicide risk. While benzodiazepines are intended to treat anxiety and insomnia, discontinuation, reduction in dosage, or missed doses may lead to emergence or exacerbation of these same symptoms. Abruptly stopping alprazolam, for example, has been shown to impair sleep onset and quality in healthy volunteers after as little as 2 weeks of daily use. More research is needed to clarify the safest manner in which to taper benzodiazepines in patients at risk of suicide.
Of note, clinical impressions of individuals’ responses to benzodiazepines may be misleading, with some patients reporting benefit but then going on to behave more aggressively toward themselves or others.
Indeed, effects of benzodiazepines on aggression, impulsivity, and suicide do appear to be dose dependent. In 1 study, for example, increased suicide risk in patients with schizophrenia was only statistically significant at daily dosages equivalent to more than 15 mg of diazepam. (Note: that is .75 mg of Xanax or Klonopin, or 1.5 mg of Ativan)
Nonpharmacologic approaches, such as attending to sleep hygiene, are important for clinicians to consider. Future research should also seek to identify safer medications for the acute management of insomnia and anxious distress in suicidal patients.
