Understanding Benzodiazepines: Clinical Use, Risks, and Mind-Body Alternatives for Older Adults

Benzodiazepines (BZDs) remain one of the most widely prescribed classes of psychoactive drugs in the United States. Known for their sedative, anxiolytic, and muscle-relaxing effects, these medications have helped millions manage symptoms of anxiety, insomnia, and seizures. Long-term use presents serious risks, especially in older adults, including cognitive decline, falls, and dependence. In response, the Substance Abuse and Mental Health Services Administration (SAMHSA) recently issued a Dear Colleague Letter urging providers to engage in patient-centered, evidence-informed conversations about benzodiazepine use in this population (SAMHSA, 2025).

This article explores the clinical mechanisms of BZDs, their role in mental health treatment, the risks of chronic use—particularly for older adults—and the growing relevance of mind-body medicine as a safer alternative.

Why BZDs Became So Popular—and Why That Matters

BZDs rose to fame in the 1960s and 1970s, with drugs like Valium (diazepam) earning celebrity status. Promoted as solutions for “nerves” and sleeplessness, they became staples in American medicine cabinets. Today, amid rising rates of anxiety and sleep disorders, BZDs remain a fixture in mental health care.

They are still frequently used for:

But this popularity comes with a cost: widespread, long-term use has led to increasing rates of dependence, withdrawal syndromes, and cognitive decline.

How Benzodiazepines Work: A Neuroscience Snapshot

BZDs are central nervous system (CNS) depressants that enhance the action of gamma-aminobutyric acid (GABA)—the brain’s primary inhibitory neurotransmitter. They bind to specific sites between the alpha and gamma subunits of the GABA-A receptor, intensifying GABA’s calming effects.

There are six known isoforms of the GABA-A receptor’s alpha subunit, each producing different effects:

Alpha-1: Sedation, anterograde amnesia, some anticonvulsant effects

Alpha-2: Anxiolysis and muscle relaxation

Because of their high lipid solubility, BZDs distribute quickly through the body and into the brain. They’re metabolized by the liver and eliminated via conjugation, which is why caution is advised when prescribing them to older adults, individuals with liver impairment, or those who smoke.

Withdrawal, Dependence, and the Risks for Older Adults

While BZDs provide rapid symptom relief, their long-term use—especially in older adults—can lead to serious consequences. Chronic users may become physiologically dependent, and abrupt cessation can trigger withdrawal symptoms, including:

Risk factors that influence withdrawal severity include:

One study found a 40% withdrawal rate among those using long-acting BZDs for six or more months who abruptly stopped (Ogbonna & Lembke, 2017). Among older adults, BZD use also increases the risk of falls, balance issues, gait instability, and lowered seizure threshold. As a result, more individuals are now seeking treatment for complications related to BZD dependence than ever before.

Mind-Body Alternatives: Safer Strategies for Anxiety and Insomnia

Given these risks, mental health providers are encouraged to explore non-pharmacologic, mind-body approaches as first-line or complementary treatments—especially in older adults.

Evidence-based alternatives include:

Clinical Guidance and Moving Forward

SAMHSA and the American Society of Addiction Medicine (ASAM) recommend reassessing BZD use at least every 3 months and integrating shared decision-making into treatment planning. For providers, this means using transitional care visits, wellness appointments, or prescription refills as opportunities to open respectful, patient-centered conversations.

Benzodiazepines are powerful tools—but they require careful stewardship. As mental health professionals, we have a responsibility to weigh the benefits and risks, empower our patients with education, and lean into holistic strategies that support long-term health and well-being.

Resources for Providers and Patients:

• ASAM Clinical Guideline on Benzodiazepine Tapering
• CDC Guideline for Prescribing Opioids (includes BZD considerations)
• VA Provider Guide for BZD Use in Older Adults
• EMPOWER Patient Brochure on Sedatives