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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: J Psychiatr Res. 2020 May 24;128:33–37. doi: 10.1016/j.jpsychires.2020.05.020

Benzodiazepine Misuse among Adults Receiving Psychiatric Treatment

R Kathryn McHugh a,b, Andrew D Peckham a,b, Thröstur Björgvinsson a,b, Francesca M Korte a, Courtney Beard a,b
PMCID: PMC7483788  NIHMSID: NIHMS1601729  PMID: 32516628

Abstract

Benzodiazepines are among the most commonly prescribed psychiatric medications and have the potential for misuse. People with psychiatric disorders may have a heightened liability to the reinforcing effects of benzodiazepines. Yet, the prevalence of benzodiazepine misuse in psychiatric care settings is not well characterized. The aim of the current study was to characterize the prevalence and correlates of benzodiazepine misuse in a sample of adults receiving psychiatric treatment (N = 589). The majority of participants reported a lifetime history of benzodiazepine prescription (68%) and 26% reported a lifetime history of misuse (defined as use without a prescription or at a dose or frequency higher than prescribed). Multivariable analyses indicated that history of a benzodiazepine prescription and drug use problems were significantly associated with lifetime benzodiazepine misuse. People with a history of benzodiazepine prescription had four times higher odds of misusing benzodiazepines and the primary source of misused benzodiazepines was from family or friends. Results suggest that benzodiazepine misuse is not exclusive to substance use disorder populations. The misuse of benzodiazepines should be assessed in psychiatric settings. Further research is needed to understand the impact of benzodiazepine misuse in this population and to develop tools to identify those at risk for misuse.

Keywords: benzodiazepines, prescription drug misuse, anxiety, substance misuse

Benzodiazepines are among the most commonly prescribed psychiatric medications, with more than 1 in 20 adults in the United States filling benzodiazepine prescriptions each year (Agarwal and Landon, 2019; Olfson et al., 2015). Both the frequency and potency of benzodiazepine prescriptions have substantially increased since the mid-1990s (Bachhuber et al., 2016). For example, the number of prescriptions for benzodiazepines increased 67% from 1996–2013 and the dose of prescriptions increased 140% of that time period (Bachhuber et al., 2016).

Benzodiazepines can also be misused (i.e., taken at a frequency or dose higher than prescribed or without a prescription). People with substance use or other psychiatric disorders appear to be more susceptible to the reinforcing properties of benzodiazepines and are more likely than people without these disorders to be exposed to benzodiazepines via prescription (see Licata and Rowlett, 2008). Despite the fact that benzodiazepines are more commonly misused than cocaine (Center for Behavioral Health Statistics and Quality, 2019), their misuse remains understudied. Understanding the scope of benzodiazepine misuse is particularly important because of the many health and mental health consequence of misuse (see Votaw et al., 2019a), including a highly distressing and potentially fatal withdrawal syndrome. Furthermore, benzodiazepines are a growing contributor to drug overdose deaths (Bachhuber et al., 2016), particularly among women (VanHouten et al., 2019).

In the general population in the United States, the estimated past-year prevalence of benzodiazepine misuse is approximately 2% (Center for Behavioral Health Statistics and Quality, 2019), and increases to over 7.5% in people with significant psychiatric distress (Substance Abuse and Mental Health Services Administration [SAMHSA]’s public online data analysis system [PDAS], 2020). Misuse is much more prevalent in people with substance use disorders; for example, approximately 27% of people with alcohol use disorder and 70% of people with opioid use disorder have misused benzodiazepines in their lifetime (Votaw et al., 2019b). Research has indicated that psychiatric disorders and symptoms are associated with increased risk for benzodiazepine misuse in people with substance use disorders (see Votaw et al., 2019a). However, very few studies have examined misuse in samples with psychiatric disorders (de las Cuevas et al., 2003; de las Cuevas et al., 2000; Yen et al., 2015). People receiving psychiatric treatment may be at a particularly heightened risk for misuse due to their higher likelihood of receiving a prescription, and thus being exposed to benzodiazepines. However, the prevalence of benzodiazepine misuse in psychiatric patients is unknown.

The few studies in psychiatric samples published to date have focused exclusively on samples of patients who have been prescribed benzodiazepines and only one has examined benzodiazepine misuse. Two studies examined dependence on benzodiazepines (e.g., worry about a missed dose, desire to stop use) and found that dependence is common, with estimates in the range of 29–47% (de las Cuevas et al., 2003; de las Cuevas et al., 2000; Yen et al., 2015). One study specifically assessed benzodiazepine misuse (i.e., taking benzodiazepines at a frequency or dose higher than prescribed); this study of elderly people receiving inpatient psychiatric hospitalization found that 7.9% misused benzodiazepines (Yen et al., 2015). However, these estimates only include people receiving benzodiazepines and do not consider other types of misuse (i.e., recreational use or use of someone else’s prescription).The paucity of studies investigating the prevalence or correlates of benzodiazepine misuse in people with psychiatric disorders is a significant gap in the literature. In particular, estimates of the prevalence of benzodiazepine misuse in this population are needed to inform the need for screening and treatment for this issue in psychiatric treatment settings. Characterizing the scope of benzodiazepine misuse in psychiatric settings may be particularly important to informing prescribing practices.

The overarching aim of this study is to characterize the prevalence and correlates of benzodiazepine misuse in adults presenting for psychiatric treatment. Our first aim is to characterize the prevalence of benzodiazepine prescription, length of prescription, and frequency of misuse. Our second aim is to examine correlates of misuse, based on prior literature in substance use disorders, including sociodemographic and clinical correlates. We hypothesized that history of a benzodiazepine prescription, younger age, female sex, sexual orientation, anxiety symptom severity, and other substance use severity would be significantly associated with benzodiazepine misuse, consistent with findings from studies of people with substance use disorders (Votaw et al., 2019a).

Methods

This paper reports a planned analysis of an ongoing naturalistic study of adults receiving acute care (partial hospitalization) for psychiatric disorders.

Participants

Participants were adults presenting for acute psychiatric care at a partial hospital program within a private psychiatric hospital in the Northeastern United States. Participants were adults 18 years of age or older, who were referred from inpatient, community, or outpatient levels of care for brief psychiatric treatment. Adults with primary substance use disorders were not admitted and were instead referred to clinics focusing on treatment for substance use. Primary diagnoses for participants in this sample included major depressive disorder or other mood disorders (63%), bipolar disorder (22.6%), or an anxiety disorder (5.8%); the remaining participants had primary diagnoses of psychotic disorders (4.2%), obsessive-compulsive disorder (3.2%), or another diagnosis (1.2%). Participants completed self-report measures as part of routine clinical care and were invited to consent for their clinical data to be used for research purposes (89% of patients in the program provided consent). For the present study, participants were included in analyses if they provided informed written consent to research and were undergoing their first admission to this program.

The sample included 589 participants (57.6% female) who completed a measure assessing benzodiazepine use. The mean age of the sample was 33.7 years (SD =13.9, range = 18 to 75). The sample self-identified race as White (88.6%), Asian (2.9%), Black (2.7%), not listed (1.2%), more than one race (3.4%), and don’t know (0.3%); race data were missing for 0.8% of participants. The majority of the sample self-identified as non-Hispanic/Latinx (94.7%). The majority of the sample reported that their sexual orientation was heterosexual (79%). More than half of the sample had completed a college education or other advanced degree (58.9%), with 35.6% completing some college, 5.3% high school or equivalent and 0.2% less than high school. Most of the sample reported that they were never married (61.4), followed by married (25.4%). Employment status was 16.2% part-time employed, 35.9% full-time employed and 47.9% unemployed (41.4% of those who were unemployed were students). More than half (55.6%) of participants reported at least one prior inpatient hospitalization.

Procedures

Self-report measures were administered to participants on their day of admission to the program and on their day of discharge. Measures were administered on a computer via Research Electronic Data Capture (REDCap; Harris et al., 2009). Data collection for this project occurred between September 2017 and October 2018.

Measures

All participants completed a battery of self-report measures. Measures included in this secondary analysis are described below. Demographic information was collected via a standardized questionnaire.

Anxiety symptom severity was measured using the Generalized Anxiety Disorder 7-Item Scale (GAD-7; Spitzer et al., 2006). The GAD-7 is a brief, well-validated self-report measure of anxiety symptoms in the past two weeks. Items are rated on a 0 (“not at all”) to 3 (“nearly every day”) scale and summed. The total score values range from 0 to 21, with higher scores reflecting more severe anxiety. The admission value on the GAD-7 was used for this analysis.

The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) was used as a measure of depression symptoms. The PHQ-9 is a 9-item scale assessing symptoms of depression in the past two weeks. Each item is rated on a 0 (“Not at all”) to 3 (“Nearly all the time”) scale, with total scores ranging from 0 (minimal depression symptoms) to 27 (severe depression symptoms). The PHQ-9 is a well-validated measure with good psychometric properties in partial hospital settings (Beard et al., 2016). The admission value on the PHQ-9 was used for this analysis.

Substance-related problems were measured using the Alcohol Use Disorder Identification Test-Consumption questions (AUDIT-C; Bush et al., 1998) and the Drug Abuse Screening Test-10 item version (DAST-10; Skinner, 1982). The AUDIT-C is a screening measure for hazardous drinking that includes 3 questions assessing the frequency of alcohol consumption in the past year. The DAST-10 is a screening measure that assesses the severity of drug use problems during the past year, with 10 items answered in a “yes/no” format. The 10-item version used in the present study has good psychometric properties (Yudko et al., 2007). Participants only completed the full DAST-10 measure if they endorsed drug use in the past year, using a single-item screening measure (“How many times in the past year have you used an illegal drug or a prescription medication for non-medical reasons?”) validated in previous studies, including partial hospital settings (Hearon et al., 2015; Smith et al., 2010). For the purpose of this analysis, participants with no drug use in the past year were coded as a “0” on the DAST. The AUDIT-C and DAST-10 were administered at admission.

We developed a brief questionnaire of benzodiazepine use and misuse for this study using questions adapted from a prior study of prescription drug misuse (Weiss et al., 2010). The questions assessed the following domains relevant to prescription history: lifetime history of benzodiazepine prescription, indication for the prescription, source of the prescription, and information received about the prescription (expected duration of prescription). Participants were also asked about misuse (In your lifetime how often have you used benzodiazepines without a prescription to you or at a higher dose or more frequently than prescribed?). Response options included never, rarely (<5 times in your life), sometimes (a few times per year but less than once per month), often (once per month), very often (once per week or more). The benzodiazepine questionnaire was administered at discharge to mitigate participant concern about the impact of disclosure of misuse at treatment entry. Data on reasons for misusing benzodiazepines were collected in a smaller subset of participants (n = 41) due to a measure administration error.

Data Analysis

We first used descriptive statistics to quantify the prevalence of benzodiazepine prescription, length of prescription and frequency of misuse in our sample (Aim 1). Subsequently, we compared people with and without a history of misuse on correlates of interest (Aim 2). We used logistic regression to examine correlates of misuse; bivariate associations were also calculated using t-tests and chi-square tests for descriptive purposes.

Results

Benzodiazepine Prescriptions

The majority of the sample reported a lifetime history of benzodiazepine prescription 67.8%). Of those with a history of benzodiazepine prescription, the most common indication was anxiety (81.2%), followed by sleep (11.3%), other psychiatric condition (5.6%), and pain or medical condition (2%). There was significant variability in the length of the longest benzodiazepine prescription; however, more than half of participants (54.6%) reported a duration of at least one year and 13.4% reported duration of more than 10 years. Most participants reported that benzodiazepines had been described by their prescriber as short-term treatment for acute symptoms (55.4%). The most common currently prescribed benzodiazepines were clonazepam (30.3%), lorazepam (28.6%), alprazolam (5.9%) and diazepam (3.4%); 32% of those with a lifetime history of benzodiazepine prescription did not have a current prescription. Most participants with a current prescription received it from a psychiatrist (72.3%), followed by primary care physician (14.3%).

Benzodiazepine Misuse Prevalence

Benzodiazepine misuse was reported by 26% of the sample (n = 153). Most participants in this subgroup reported that misuse was rare (n = 67% of people who reported lifetime misuse). Others reported misusing more than a few times but less than monthly (n = 32), once per month (n = 8) and weekly or more (n = 11). Of note, 21 participants who denied misuse reported that they had taken a benzodiazepine from someone other than a doctor at some time. Although this would meet our criteria for misuse, we did not include these participants in our misuse group because we could not verify that this was inconsistent with a prescriber’s recommendation.

Of the participants who reported a history of benzodiazepine misuse (n = 113 due to some missing data), 66.6% reported that they obtained misused benzodiazepines from friends or family, 12.5% reported stealing and 1% reported purchasing on the internet. A small subset of people who reported a history of benzodiazepine misuse also answered questions about reasons for misuse (n = 41). In this group, the most commonly reported reason for misuse was anxiety (85.4%). Other motives for misuse included depression (43.6%), sleep (31.6%), out of curiosity (22%), to relieve bad memories (18.4%), recreationally/to get high (12.5%), because someone offered them (12.2%), to increase the effects of alcohol (10.3%), to increase a stimulant effect (5.3%), and a small percentage (2.6%) reported each of the following: misusing for pain, to decrease a stimulant effect, to increase an opioid effect, to relieve opioid withdrawal, to relieve mania, and to commit suicide.

Correlates of Benzodiazepine Misuse

Results from bivariate analyses are presented in Table 1. These analyses indicated that people with a history of benzodiazepine misuse were younger, had higher alcohol and drug problem scores, and were more likely to have a history of benzodiazepine prescription. There were no differences in anxiety or depression severity at admission between those with and without a history of benzodiazepine misuse. There was also no significant sex difference in the prevalence of misuse.

Table 1.

Sociodemographic and clinical variables by benzodiazepine misuse status.

Misuse
(n=153)		 No Misuse
(n=436)		 χ2/t p-value
Age (mean, SD) 31.2 (11.2) 34.6 (14.6) 2.57 .01
Female, % 54.9 58.5 0.60 .44
Heterosexual, % 79.1 79.5 0.01 .92
Lifetime benzodiazepine Rx, % 84.3 61.9 26.01 <.001
Alcohol use problems, AUDIT (mean, SD) 3.7 (2.7) 2.8 (2.3) −3.30 .001
Drug use problems, DAST (mean, SD) 2.0 (2.5) 0.7 (1.6) −6.08 <.001
Anxiety, GAD-7 (mean, SD) 11.5 (5.4) 10.9 (5.4) −1.11 .27
Depression, PHQ-9 (mean, SD) 14.7 (5.6) 14.5 (5.5) −0.35 .73
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Note.

AUDIT = Alcohol Use Disorder Identification Test; DAST = Drug Abuse Screening Test; GAD-7 = Generalized Anxiety Disorder-7 Item Scale; PHQ-9 = Patient Health Questionnaire-9

Results from the logistic regression indicated that benzodiazepine prescription (OR = 4.08; 95% CI = 2.39, 6.97 p < .001) and drug use problems (OR = 1.30; 95% CI = 1.17, 1.44; p < .001) were significantly associated with benzodiazepine misuse (Figure 1). In an exploratory analysis, we ran these models separately for males and females; however, there were no substantive differences in the pattern or magnitude of effects (i.e., prescription and drug use problems were the only significant correlates of misuse), suggesting that sex did not moderate these associations.

Figure 1.

Figure 1.

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Forest plot of factors associated with benzodiazepine misuse in adjusted analyses. Unstandardized Odds Ratios and 95% Confidence Intervals are presented.

Discussion

Benzodiazepines are among the most commonly prescribed medications and are also among the most commonly misused drugs (Agarwal and Landon, 2019; Center for Behavioral Health Statistics and Quality, 2019; Olfson et al., 2015). Research in populations with substance use disorders has found that benzodiazepine misuse is highly prevalent; however, relatively little attention has been paid to people with psychiatric disorders, who are also commonly exposed to benzodiazepines (see Votaw et al., 2019a). In this study, we found that 1 in 4 adults receiving acute psychiatric treatment reported a lifetime history of benzodiazepine misuse. For two-thirds of these participants, misuse was not common, however, one-third reported more frequent misuse.

These results should not be interpreted as population estimates, as our sample reflects a single treatment center and an acute level of care (partial hospitalization). Indeed, our estimate is substantially higher than the estimate among adults with significant psychiatric distress in the National Survey of Drug Use and Health (approximately 7.5%; SAMHSA’s PSAS, 2020). This difference highlights the importance of the assessment of benzodiazepine misuse in people who are receiving treatment, for whom exposure to benzodiazepines due to prescription are high. Indeed, more than two-thirds of our sample had a prior history of benzodiazepine prescription. Nonetheless, representative surveys with greater geographic distribution and greater representation across levels of care and sociodemographic factors are needed to estimate the prevalence of benzodiazepine misuse in people in psychiatric treatment. Our study highlights the importance of this future research direction.

Consistent with hypotheses, history of a benzodiazepine prescription and drug use problems were associated with a higher likelihood of misuse.Specifically, people with a lifetime benzodiazepine prescription had a more than 4 times higher odds of reporting a history of misuse. For each 1-unit increase in DAST score there was a 30% higher odds of misuse. This is consistent with the literature in other populations, predominantly people with substance use disorders (Votaw et al., 2019a). The strong association between benzodiazepine prescription and misuse likely reflects a heightened exposure to the medication. Nonetheless, it cannot be ruled out that people with a vulnerability toward benzodiazepine misuse are more likely to be prescribed this medication type or that some people sought out prescriptions with the intention of misuse.

Other hypothesized correlates of benzodiazepine misuse, including younger age and alcohol symptom severity were associated with misuse only in bivariate analyses. Contrary to hypotheses, female sex and minority sexual orientation were not associated with misuse. Studies have been equivocal with respect to the association between sex and benzodiazepine misuse (Votaw et al., 2019a); this study further suggests that there may not be substantive sex differences in the prevalence of benzodiazepine misuse. Sexual orientation findings may reflect the relatively small representation of participants who did not identify as heterosexual (approximately 20%), and thus replication is needed.

Additionally, contrary to hypotheses, anxiety symptom severity was not associated with misuse. The finding that coping motives were the primary reason for misuse without a corresponding association between psychiatric symptom severity and misuse was unexpected. This represents a distinction from the substance use disorder literature, where psychiatric severity in general and anxiety in particular are associated with benzodiazepine misuse (see Votaw et al., 2019a). Importantly, anxiety was not associated with benzodiazepine misuse in bivariate analyses, which suggests that this is not simply attributable to overlap with other variables (e.g., prescription). Of note, the most common primary diagnosis in the sample was depression; these findings may have differed in a sample with a different diagnostic profile. Furthermore, the use of the GAD-7 rather than a measure more focused on panic disorder symptoms may have impacted these results. For example, several studies in substance use disorder samples have used measures of anxiety sensitivity, which have shown strong links to benzodiazepine misuse (e.g., McHugh et al., 2017; 2018). Future studies are needed to determine whether this is a reliable finding.

Taken together, these findings have several clinical implications. Most notably, these results demonstrate that benzodiazepine misuse is not limited to people in substance use disorder treatment and should be assessed in psychiatric treatment settings. Nonetheless, people with other substance-related problems may be at heightened risk of misusing benzodiazepines. These findings also highlight the importance of education on safe medication storage and disposal. The majority of participants who misused benzodiazepines acquired them from family or friends.

Although these findings demonstrate that benzodiazepine misuse is prevalent in this sample, they do not provide insight into the clinical impact of misuse. Although benzodiazepine misuse has been associated with myriad health, mental health and other functional consequences (Votaw et al., 2019a), little is known about what level of misuse is risky. Indeed, this is not well characterized for prescription drugs in general, where the impact of occasional use without a prescription or in a manner different than prescribed is not well understood. Several research groups have recommended research on subgroups of this population, such as distinguishing between those who occasionally use extra medications in a way that is inconsistent with a prescription (e.g., taking extra medication during a symptom exacerbation) from those who misuse more frequently or with the intention of feeling euphoric (Barrett et al., 2008; Boyd and McCabe, 2008). Yet, it remains unclear how such groups should be derived and based on which factors. Indeed, misusing benzodiazepines to achieve a therapeutic effect (e.g., to relieve anxiety or to help sleep) was the most common motive in this sample, consistent with studies of people in substance use disorder treatment. Further empirical work is needed to identify meaningful subgroups, particularly those that are associated with negative consequences (e.g., craving, social or functional impairment).

This study has several limitations. First, questions were all assessed via self-report and were not complemented with clinician-administered or objective (e.g., urine drug screen) measures. Second, the sample was homogeneous with respect to race, ethnicity and clinical severity; thus, these findings cannot be assumed to generalize to other samples. Similarly, these findings represent a single treatment setting and thus provide only a local estimate of the prevalence of benzodiazepine misuse. Representative surveys would be needed to provide more precise estimates of the prevalence of benzodiazepine misuse in this population. Finally, this study was cross-sectional and thus temporality cannot be assumed. Longitudinal studies of benzodiazepine use and misuse—particularly studies that investigate predictors of benzodiazepine misuse among new recipients of prescriptions—are sorely needed to develop risk stratification tools that can be applied in clinical settings.

Benzodiazepine misuse remains understudied and research has typically focused on populations with substance use disorders (see Votaw et al., 2019a). The results of this study provide support for the heightened prevalence of benzodiazepine misuse in psychiatric populations and suggest that additional attention should be paid to understanding this issue. Providing education to patients on the potential for abuse of these medications as well as education about safe medication storage and disposal should be standard practice when prescribing these medications. Future studies designed to investigate the consequences of different levels of benzodiazepine misuse will help to clarify the public health impact of these findings.

Highlights.

  • 26% of people receiving acute psychiatric care reported lifetime benzodiazepine misuse.

  • History of benzodiazepine prescription was associated with misuse.

  • Other subsance problems were associated with misuse.

  • Most people who misused did so to cope with psychiatric symptoms.

  • However, anxiety and depression symptoms were not significantly associated with misuse.

Declaration of Interest

The authors have no conflicts of interest to report. Effort for this work was supported by the National Institutes of Health (F32MH115530) and the Sarles Young Investigator Award.

Footnotes

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