To the Editor: We thank Mr Steenen and colleagues for their thoughtful comments concerning our examination of benzodiazepine prescribing trends among veterans with posttraumatic stress disorder (PTSD). We agree that the breadth of effective treatment options for PTSD is woefully sparse and that the evidence base supporting any individual treatment is less than optimal. Mr Steenen and colleagues describe a set of preclinical animal studies examining the effect of systemic midazolam administration on reconsolidation memory. It is unknown at this time whether this intriguing line of scientific inquiry will ultimately lead to a clinically effective human treatment for PTSD, either to prevent the development of PTSD following traumatic exposure or to reduce symptom burden among individuals with existing PTSD. However, it is unclear how the animal studies described could be used to support guideline-discordant benzodiazepine prescribing for veterans with PTSD. The animal protocols involve one-time benzodiazepine administration, rather than the chronic daily treatment observed in our work. In addition, there are alternative agents under investigation, such as propranolol and hydrocortisone, which may achieve the same effect on memory reconsolidation with a less imposing risk profile. We are not in a position to speak for the Management of Post-Traumatic Stress Working Group, which is responsible for the recommendations contained in the PTSD clinical practice guideline. However, if new clinically relevant evidence emerged supporting the effectiveness of benzodiazepines in this population, we feel confident that the PTSD clinical practice guidelines would be updated to reflect that practice.
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