I was immediately skeptical when I saw a tweet announcing an upcoming episode of Braincast, a U.K. podcast sponsored by Maudsley Learning (part of a series geared to mental-health professionals that’s promoted as “a weekly 30-minute conversation with inspiring people from all around the world sharing their love about the most fascinating thing that happened to your head . . . your brain”).
Hosted by neuropsychiatrist Sotiris ”Pospo” Posporelis, this episode focused on benzodiazepines and featured Professor Edward K. Silberman. Knowing Dr. Silberman’s history, I was concerned that the podcast might result in spreading misinformation to prescribers and stigmatizing harmed patients. While the interview did get some important things right, my suspicions were ultimately confirmed.
I truly hope that this podcast wasn’t an indication that the U.K. is losing its way.
This was disappointing, as many in the benzodiazepine-harm community have long viewed the U.K., with its guidelines and government-funded withdrawal charities, as decades ahead of America in addressing prescribed benzodiazepine issues. The U.K. was home to two of the most highly respected benzodiazepine experts: Professor Heather Ashton, author of the Ashton Manual, who ran her own benzodiazepine withdrawal clinic, and Professor Malcolm Lader, a psychopharmacologist and researcher who began studying benzodiazepine harm before I was even born. I truly hope that this podcast wasn’t an indication that the U.K. is losing its way.
Who is Dr. Edward Silberman?
Dr. Edward Silberman is an attending psychiatrist and professor at Tufts University School of Medicine. More importantly, he is a member of the International Task Force on Benzodiazepines. The Task Force is a group of physicians and researchers sharing a belief that SSRIs are mostly ineffective, and that benzodiazepines are underutilized and should be prescribed more. They believe that the risks of benzodiazepines have been overblown.
These five Task Force members use the journal to write analyses, citing each other and themselves, about the benefits of benzodiazepines for almost anything.
Dr. Silberman, along with two other Task Force members, is on the editorial board of the medical journal Psychotherapy and Psychosomatics. Another Task Force member is an associate editor, and yet another, Dr. Giovanni A. Fava, serves as editor-in-chief. These five Task Force members use the journal to write analyses, citing each other and themselves, about the benefits of benzodiazepines for almost anything. In particular, they advocate for the use of benzodiazepines in place of antidepressants.
Dr. Silberman’s faith in the effectiveness of benzodiazepines appears to be unwavering. He and another Task Force member have testified against a patient-initiated bill in Massachusetts—a bill that was designed to ensure that the informed consent process, the pillar of ethical medical treatment, is followed when patients begin a benzodiazepine prescription. After heralding the safety of benzodiazepines, while misrepresenting the possible benefits—in a room filled with benzodiazepine-harmed patients—the psychiatrists opposed to the bill were asked by the Massachusetts Committee on Mental Health and Substance Use Recovery to stay and hear patients testify about their own experiences. Instead, they chose to leave.
What the Podcast Got Right
There are plenty of positive things I could say about this podcast. Its host, “Pospo,” is very likeable and seems genuinely concerned about patients and evidence. He raised many good points about the importance of listening to patients, mentioned the concerns posed by rising prescriptions, and noted that after announcing this podcast, his feed was busier (with input from benzodiazepine-harmed patients) than it was when he announced he became a father. Pospo also asked some really important questions about how to prevent patient harm, and how to identify who is at risk of being harmed. The podcast ended with him referring to a recent paper about the role of the patient voice and how patients feel when their withdrawal syndromes are dismissed or misdiagnosed. He called for psychiatrists to do better.
Dr. Silberman did acknowledge that physical dependence is not the same as addiction, an important distinction. He pointed out that antidepressants can have limited effectiveness, along with their own nasty withdrawal syndrome.
Most of the views I found myself nodding in agreement with were ones that align with the most current evidence. Dr. Silberman did acknowledge that physical dependence is not the same as addiction, an important distinction. He pointed out that antidepressants can have limited effectiveness, along with their own nasty withdrawal syndrome. When asked about the indications for benzodiazepines, he noted that they have some use in anesthesia, are a first-line treatment for alcohol withdrawal, and are also a first-line treatment for catatonia (although I discovered a recent Cochrane review that found evidence issues related to the latter).
When Pospo asked about benzodiazepine contraindications, Dr. Silberman immediately answered that benzodiazepines are contraindicated in the elderly, which came as a relief to me. (Another Task Force member, Dr. Carl Salzman, was quoted in MDEdge Psychiatry in a piece titled “Misguided fear is keeping benzodiazepines from elderly” as saying just the opposite: he declared benzodiazepines to be “wonderful” for geriatric anxiety and insomnia—and claimed that elderly patients would gladly trade their short-term memories for the anxiolytic and soporific effects of the drugs.)
A “Preoccupation with Control”
In the podcast, Dr. Silberman shared his tapering philosophy for benzodiazepines, which I was largely in agreement with, although it was vague when it came to details. He didn’t discuss specific safe-tapering techniques, though he did understand that the size of the reductions over the course of a taper needs to get incrementally smaller, an important concept. And he understood that patients should be in charge of the tapering process, a crucial approach for minimizing harm. But he said his rationale for a slow and flexible taper was that patients experiencing anxiety have a “preoccupation with control.”
Patients who have been harmed by benzodiazepines simply want to avoid being further harmed, as what they are experiencing, in some cases, feels like torture.
I disagree with this sort of reasoning and find such classification pejorative and short-sighted. It also misses the point. “These are very anxious people,” Dr. Silberman stressed. My knee-jerk response is to say, yes, because the benzodiazepine is not working for them! Due to tolerance and interdose withdrawal, such patients are now likely to be far more anxious than on day one of their treatment. And if people undergoing benzodiazepine withdrawal are controlling, it may be because they are leery after being falsely assured that their medication was safe. Or that they’re apprehensive of the pain and debilitation potentially awaiting them after their next reduction. Patients who have been harmed by benzodiazepines simply want to avoid being further harmed, as what they are experiencing, in some cases, feels like torture.
Anxiety Disorder Effectiveness?
In his interview, Dr. Silberman asserted that benzodiazepines can have indications in a variety of anxiety disorders, citing literature that supports their use in generalized anxiety disorder, panic disorder, and social anxiety disorder. He said some studies suggest that benzodiazepines are at least as effective, if not more effective, for anxiety disorders than antidepressants, particularly for panic disorder and somatic manifestations of anxiety. Later in the podcast he recommended a “standing prescription,” meaning daily use, of benzodiazepines, instead of as-needed, one-off use.
But when one looks at what evidence exists, standing, long-term benzodiazepine prescriptions have been shown in many cases to be a disaster and to result in poor outcomes for patients. To dismiss all the available evidence for this is akin to practicing pseudoscience.
I find such statements misleading and dangerous. When it comes to benzodiazepines, the daily prescription idea is a dated concept that has proven disastrous in many cases, leading a significant cohort of patients to worse outcomes, long-term disability, and, for some, suicide. Most contemporary guidelines in 2021 discourage daily use of benzodiazepines for anxiety: For example, the VA strongly recommends against benzodiazepines for PTSD, the New York City Department of Health and Mental Hygiene recommends only short term, sporadic use, and the 2015 Prescribing Guidelines for Pennsylvania warns that continuing this class of drug beyond four to six weeks will likely result in loss of efficacy and the development of tolerance and physical dependence. With nearly every other guideline echoing the same sentiments, there is sufficient evidence that patients on long-term benzodiazepines (aka a standing prescription) not only don’t improve, but often get worse. This has been known for decades.
That is not to say that there isn’t some benefit in one-off, short-term benzodiazepine use. But when one looks at what evidence exists, standing, long-term benzodiazepine prescriptions have been shown in many cases to be a disaster and to result in poor outcomes for patients. To dismiss all the available evidence for this is akin to practicing pseudoscience.
In his podcast, Pospo commented that it is well known that benzodiazepines can be notoriously difficult to stop, and that withdrawal symptoms are not uncommon. He noted that the guidelines issued by the U.K.’s National Institute for Health and Care Excellence (NICE) recommend that uninterrupted benzodiazepine usage should not exceed four weeks. He added that this warning is not reflected in reality, with a quarter-million people in England taking benzos far beyond the recommended time frame.
Dr. Silberman responded, to my surprise, that there was “absolutely no evidence” to support the guidelines in question.
Dr. Silberman responded, to my surprise, that there was “absolutely no evidence” to support the guidelines in question. He went on to say that the U.K. guidelines were based on concerns about tolerance to benzodiazepines’ anxiolytic (anxiety-reducing) effects, which he believed to be unfounded. He insisted that tolerance exists only to the drugs’ sedating effects.
Dr. Silberman did not cite any evidence to support his statements, and I find his reasoning extremely misguided and contradictory to observable patient outcomes. According to psychopharmacologist Heather Ashton, perhaps the world’s leading benzodiazepine expert, whose specialized knowledge included helping more than 300 patients discontinue benzodiazepines over the course of twelve years running a withdrawal clinic:
Tolerance to the anxiolytic effects develops more slowly, but there is little evidence that benzodiazepines retain their effectiveness after a few months. Many patients find that anxiety symptoms gradually increase over the years despite continuous benzodiazepine use, and panic attacks and agoraphobia may appear for the first time after years of chronic use. Such worsening of symptoms during long-term benzodiazepine use is probably due to the development of tolerance to the anxiolytic effects, so that “withdrawal” symptoms emerge even in the continued presence of the drugs.
As for studies, one review of the literature found several that described tolerance to anti-anxiety effects, including one of Upjohn’s own clinical trials for Xanax, in which the treated group gradually worsened as they became tolerant to their dose, while the placebo group improved (read about the controversial trial here). There is also research led by the Task Force’s own Dr. Giovanni Fava, who published “Fading of therapeutic effects of alprazolam in agoraphobia,” a review of case studies discussing the “fading” of therapeutic effects (aka tolerance) in some individuals. In it he states that “the fading of psychotropic effects is a relatively common phenomenon in clinical practice.” Perhaps there is some evidence of tolerance to anti-anxiety effects after all.
During the interview, Dr. Silberman acknowledged that “there is unquestionably a withdrawal or discontinuation syndrome for benzodiazepines,” in some cases severe enough to result in seizures.
But after citing several benzodiazepine withdrawal symptoms, his strategy was to deflect, pointing out (in a kind of “what-aboutism”) that many patients have similar withdrawal problems with antidepressants. While I wouldn’t argue, his next assertion—that withdrawal from benzodiazepines is “not nearly as severe as it is made out to be”—is where I couldn’t more strongly disagree.
He questioned what it means for people on benzodiazepines to be dependent (“it’s a word with inevitably pejorative connotations”) and wound up with a quip about being dependent on his glasses.
Dr. Silberman went on to interject that the literature surrounding benzodiazepine withdrawal is a mess, as it says virtually nothing about the original indications for which the medication was prescribed. He questioned what it means for people on benzodiazepines to be dependent (“it’s a word with inevitably pejorative connotations”) and wound up with a quip about being dependent on his glasses.
How Serious are Benzodiazepine Tolerance, Physical Dependence, and Withdrawal?
Dr. Silberman is right in observing that the literature surrounding withdrawal is a mess—a sorry indicator that medicine neither understands benzodiazepine withdrawal nor takes it seriously. But he appears to be blinded to the severity of benzodiazepine withdrawal syndromes: in fact, they are much more severe than they are made out to be. And because of doctors’ lack of training about benzodiazepine risk and discontinuation, patients are forced to survive it alone.
The message is that physicians have been unprepared for these withdrawal disorders and are unable to treat or even guide patients through complicated withdrawal from these substances.
In 2018, three psychiatrists, Dr. Josef-Witt Doerring, Dr. Daryl Shorter, and Dr. Thomas Kosten, took a look at some of the vast communities of harmed patients, such as BenzoBuddies, that can be found online, largely unhelped by the medical world. As the authors shared in their Psychiatric Times article, Online Communities for Drug Withdrawal: What Can We Learn?:
While it might initially seem that these communities and video blogs are simply artifacts of the internet culture, a closer look at the stories told on these forums suggests a different message. The message is that physicians have been unprepared for these withdrawal disorders and are unable to treat or even guide patients through complicated withdrawal from these substances.
The authors believe that this lapse in physician education and appropriate response occurs because withdrawal syndromes are so difficult to assess in the six-to-twelve-week randomized control trials the FDA requires for approval. The studies can show no more than relative safety and efficacy in such a short duration, which is not sufficient time to even develop significant physical dependence and withdrawal syndromes. After benzodiazepines were released in 1960, it wasn’t until 1988 that dependence issues were acknowledged. Even now, in 2021, medicine remains largely uninformed about true benzodiazepine risk.
Ling grew to suspect that her own father was being harmed by benzodiazepine tolerance to prescribed Klonopin: he was severely ill, had been misdiagnosed with dementia, and was recommended for palliative care. Since stopping the drug, he has fully recovered.
In 2019,CNN released an episode of “This Is Life with Lisa Ling” titled The Benzos Crisis. In the episode, Ling followed several patients harmed by benzodiazepines, including our own Krissy Tyrrell, who shared the story of her near loss of life and slow, self-directed, multi-year benzodiazepine taper. Ling also interviewed the grieving family of Jonathan Wagner, who had taken his life due to unbearable akathisia induced by benzodiazepine withdrawal. Like Tyrrell and others appearing in the show, he had been unable to find useful medical help. During the course of filming the episode, Ling grew to suspect that her own father was being harmed by benzodiazepine tolerance to prescribed Klonopin: he was severely ill, had been misdiagnosed with dementia, and was recommended for palliative care. Since stopping the drug, he has fully recovered (Ling’s husband, Dr. Paul Song, a radiation oncologist, blogged about the experience here).
In his testimony related to the Massachusetts benzodiazepine bill, Dr. Silberman said that in forty years of practice he had never seen or read in the literature about a single patient who had suffered long-term cognitive consequences from taking these drugs. Had Dr. Silberman taken the time to stay and listen to patient testimony at the hearing, he would have heard such patient stories firsthand, reflecting outcomes of a severity similar to those relayed on Lisa Ling’s program. The reality of patients left alone to support each other online, in many cases disabled, some who take their lives, should not be trivialized with a joke about being dependent on your glasses.
At one point in the broadcast, Dr. Silberman claimed that he’d never had any trouble getting a patient off benzodiazepines. Only moments later, he turned that assertion on its head when he spoke about two of his patients, neither of them initially treated for anxiety (one for muscle relaxation after a car accident, the other for insomnia), who were “exquisitely sensitive” to benzodiazepines and were having terrible trouble coming off them. What sense can be made of this sort of contradiction?
While I can’t believe it needs to be said, patients who develop physical dependence and withdrawal symptoms are not personality disordered or suffering from unreasonable expectations. Patients are harmed by careless prescribing and deprescribing. They need useful medical research and help.
Confirming that we have close to zero understanding of why certain patients are harmed by benzodiazepines, Dr. Silberman admitted that he didn’t know how to identify that cohort in advance. Instead, he postulated that those who are harmed may have a personality pathology combined with bad prescribing experience and unreasonable expectations. Not only is this reasoning stigmatizing, it’s just plain strange. While I can’t believe it needs to be said, patients who develop physical dependence and withdrawal symptoms are not personality disordered or suffering from unreasonable expectations. Patients are harmed by careless prescribing and deprescribing. They need useful medical research and help.
It’s important to note that the aforementioned Dr. Carl Salzman, also a member of the International Task Force on Benzodiazepines, found (in his position as chair of the American Psychological Association’s Benzodiazepine Dependence Task Force) that a significant number of all patients prescribed benzodiazepines—an estimated 40% to 80%—experience withdrawal. Professor Heather Ashton, whose work Dr. Silberman spoke of positively, estimated that of those patients who are physically dependent on benzodiazepines, some 10% to 15% will experience a protracted withdrawal syndrome, with damage lasting years, or in some cases permanently.
Considering that an estimated 92 million benzodiazepine prescriptions are dispensed annually in America, with even more worldwide—a number that is only rising—the potential for even more patient harm is alarming.
The Road Ahead
Benzodiazepine Information Coalition (BIC) was created to educate patients and medical professionals about the potential adverse effects of benzodiazepines taken as prescribed. Among our aims is to correct misinformation when we see it, and to advocate for those who have been harmed. Sometimes our hard work pays off: In September 2020, the FDA, in response to roughly 300,000 accounts of patient adverse experiences and a reporting drive led by our organization, instituted a black box warning about physical dependence, tolerance, and withdrawal related to benzodiazepines. The announcement states:
The current prescribing information for benzodiazepines does not provide adequate warnings about these serious risks and harms associated with these medicines.
The FDA went on to warn about severe withdrawal symptoms that can last from weeks to years.
It’s clear that my work at BIC and Dr. Silberman’s are at odds. From his remarks on the podcast, his approach to benzodiazepines strikes me as lacking full respect for the patient experience—ignoring, avoiding, deflecting, and dehumanizing a harmed population instead of placing responsibility where it belongs: on the drugs. The last thing I want is for more physicians to be influenced by Dr. Silberman’s knowledge base.
What I want is a medical field well-enough educated that patients aren’t forced to manage benzodiazepine withdrawal and protracted syndromes entirely alone.
The approach of simply ignoring bad outcomes from prescribed benzodiazepines is what has led patients to their deaths by suicide, and more to long-term disability. This is unacceptable. What is needed instead is a reduction in casual prescribing, an increase in patient informed consent, prescriptions that follow established guidelines (and an updating of guidelines with new findings), and physicians who are fully trained regarding both risks and safer methods of cessation. What I want is a medical field well-enough educated that patients aren’t forced to manage benzodiazepine withdrawal and protracted syndromes entirely alone.
After listening to and responding to the podcast, I have to admit that I remain unsure of its aims. Most prescribers need no help in becoming more confused than they already are about benzodiazepines. Was the purpose of the interview to increase benzodiazepine prescribing? If so, why? Was it to stigmatize harmed patients by calling them control freaks and personality disordered? If so, sadly, that mission was accomplished.
But more importantly, what will the outcome be? Did anyone learn anything accurate or helpful toward safer prescribing from this interview? Thanks to this podcast, are there now even more misinformed benzodiazepine prescribers, falsely reassured of benzodiazepine safety with pseudoscientific claims? Will they, consequently, take this information and go on to harm and disable some of their patients?
There are a lot of strong views that we certainly can’t ignore, as the significant majority are from people with lived experience. I was genuinely sad to see tweets from people saying how their lives were ruined.
As Pospo said to Dr. Silberman during the podcast, “There are a lot of strong views that we certainly can’t ignore, as the significant majority are from people with lived experience. I was genuinely sad to see tweets from people saying how their lives were ruined.”
I’ll end with the first comment that was posted in response to the Braincast podcast on YouTube. It’s from a lone patient who was harmed by benzodiazepines and is asking for help. I think that says it all.