247. Patterns of benzodiazepine polypharmacy in the treatment of panic disorder and generalized anxiety disorder

Abstract

Abstract Background Panic disorder (PD) and generalized anxiety disorder (GAD) significantly impair daily functioning and cause substantial emotional distress, necessitating active and timely treatment. Although selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors are first-line pharmacotherapies, their delayed onset of action often leads clinicians to prescribe benzodiazepines (BDZs) during the acute phase. In practice, BDZ polypharmacy may occur to address diverse anxiety profiles, comorbid insomnia, and variable drug responses. However, BDZs carry risks including tolerance, dependence, misuse, cognitive impairment, and falls, and clinical guidelines generally discourage polypharmacy. Despite this, empirical data—particularly in PD and GAD—on the frequency, clinical rationale, and decision-making factors underlying BDZ polypharmacy remain scarce. Aims & Objectives This study investigated BDZ polypharmacy patterns among psychiatrists experienced in treating PD and GAD, examined their clinical reasons for prescribing multiple BDZs, and explored associations between physician characteristics and polypharmacy rates. Method A cross-sectional web-based survey was administered to lifetime members of the Korean Anxiety Disorders Association who were board-certified psychiatrists. The survey included 36 items addressing BDZ prescribing patterns, number of BDZs concurrently used, proportion of patients receiving BDZ polypharmacy, reasons for polypharmacy, and demographic and clinical-practice characteristics. Descriptive statistics summarized prescribing patterns. Chi-square tests compared PD and GAD. Spearman rank correlations examined associations between clinician age or years of specialist experience and BDZ prescription number and polypharmacy rate. Statistical significance was set at p < 0.05. Results A total of 105 psychiatrists completed the PD survey and 99 completed the GAD survey. For PD, 61.9% typically prescribed a single BDZ, 32.4% used two or more, and 5.7% did not use BDZs. Polypharmacy was most frequently reported in ≤20% of patients (44.8%). For GAD, 67.7% prescribed a single BDZ, 25.3% used two BDZs, and 7.1% used none; polypharmacy in ≤20% of patients was similarly common (46.5%). Polypharmacy reasons differed between disorders: in PD, treating comorbid insomnia (52.4%) and avoiding adverse effects from dose escalation of a single agent (49.5%) were most common; in GAD, addressing multiple anxiety symptoms was most frequently endorsed (59.6%). Using long-acting BDZs to taper short-acting agents was more common in PD (p = 0.028). Older age and longer specialist experience were associated with lower BDZ polypharmacy rates in both PD and GAD, and with fewer BDZs prescribed in PD. Discussion & Conclusions BDZ polypharmacy was practiced by a minority of psychiatrists and typically in a small proportion of patients. Patterns reflected disorder-specific clinical considerations such as comorbid insomnia in PD and heterogeneous symptom profiles in GAD. More experienced clinicians tended to prescribe fewer BDZs and had lower polypharmacy rates, possibly due to heightened awareness of long-term risks and greater use of psychosocial strategies. Although BDZ polypharmacy may be clinically justified in select cases—such as persistent insomnia, complex anxiety symptoms, or tapering strategies—it requires careful monitoring, clear treatment goals, and structured follow-up to minimize risks.