Acute Crisis: Diazepam

Anxiety disorder with short-term diazepam use 

Confirm diagnosis and baseline measures 

• Explain the diagnosis of GAD clearly and give written information (for example the NICE “Treating generalised anxiety disorder and panic disorder in adults” booklet and the NHS GAD page). 

• Record baseline severity with GAD-7 (or similar), current functioning, alcohol and drug intake, sleep pattern, physical symptoms and any comorbid depression or other anxiety disorders. 

• Agree a plan for active monitoring, typically every 2–4 weeks while treatment is being adjusted. 

Follow the stepped-care model 

• Step 1: Psycho-education, self-help resources, lifestyle advice (exercise, sleep hygiene) and watchful waiting if symptoms are mild. 

• Step 2: Offer a low-intensity psychological intervention (individual guided self-help, non-facilitated CBT materials, or a psycho-educational group) if there is insufficient improvement. 

• Step 3: 

  • High-intensity CBT or applied relaxation is first choice for marked functional impairment. 

  • Start pharmacological treatment with an SSRI (sertraline usually first). Explain delayed onset and early side-effects. Review at 2–4 weeks, then at three-monthly intervals once stable. 

  • Diazepam or another benzodiazepine should be reserved for acute crises only: use the smallest effective dose for the shortest possible time (usually 2–5 mg up to three times daily for a maximum of 2 weeks). 

  • Do not initiate benzodiazepines without simultaneously arranging a longer-term therapy such as CBT or an SSRI. 

• Step 4: Refer to mental-health services for complex, treatment-refractory cases or high suicide risk. 

Safe, short-term prescribing of diazepam in primary care 

• Indication: acute escalation of anxiety causing significant distress or functional collapse (for example, a crisis that prevents attendance at an essential police interview). 

• Screen before prescribing: rule out significant respiratory disease, severe hepatic impairment, myasthenia gravis, alcohol or drug dependence, pregnancy (relative contra-indication), and high risk of falls or cognitive impairment. 

• Dose and duration: start 2 mg orally up to three times daily; increase to 5 mg tds only if necessary. Prescribe for 7–10 days and supply no more than 14 days total. 

• Driving and safety: advise the person not to drive, operate machinery or sign legal documents while taking diazepam. Warn about additive sedation with alcohol or other CNS depressants. 

• Follow-up: review in person or by phone within 1 week. Confirm adherence, check for daytime sedation, disinhibition or paradoxical agitation, and reinforce the stop date. 

• Withdrawal: after short courses (<2 weeks) abrupt cessation is usually tolerated; if used longer, taper the dose over a further week. 

• Documentation: record justification for diazepam, dose, quantity supplied, counselling given, and agreed review date. 

Parallel longer-term management 

• Continue or initiate an SSRI (or alternative first-line drug) unless contraindicated, ensuring the person understands the delayed benefit. 

• Offer or re-refer for CBT if not already in place. 

• Address comorbidities (for example depression, substance misuse) and encourage lifestyle interventions (exercise, regular sleep-wake schedule, reduction of caffeine). 

• Provide clear safety-netting: instruct the patient to seek urgent help if suicidal thoughts emerge, anxiety worsens despite medication, or troubling side-effects develop. 

Ongoing monitoring and relapse prevention 

• Re-assess GAD-7 or other validated scale at each review to gauge progress. 

• Once symptoms are controlled, continue the SSRI for at least 12 months to reduce relapse risk, with gradual dose tapering thereafter. 

• Reinforce self-management strategies and give written relapse-signs advice; encourage rapid GP contact if warning signs return. 

Applying the above to our case

First ask: does this episode meet the definition of a “crisis”? 

• The anxiety is so severe that Ms Hodge cannot leave the house, yet she must attend a police interview in 48 hours; failure could jeopardise both the investigation and her career. 

• NICE expressly allows a benzodiazepine only as a short-term measure during crises in generalised anxiety disorder nice.org.uk. 

• On that basis the presentation satisfies the “crisis” exception. 

Check for contraindications and practical risks 

• Medical factors 

  • First-degree AV block: diazepam has minimal effect on atrioventricular conduction, so it is safer than a beta-blocker in this context. 

  • No respiratory disease, pregnancy, substance misuse or cognitive impairment. 

• Legal and functional factors 

  • She must be warned that diazepam impairs driving; she will need a trusted adult to accompany her to the station. 

  • She is at low suicide risk, but paradoxical disinhibition is always mentioned. 

• Dependence potential 

  • The plan must limit supply, set a firm stop date and arrange review within one week. 

Non-pharmacological or alternative pharmacological options 

• Rapid access psychological help (e.g. a single session of applied relaxation, breathing work, crisis helpline). Useful but unlikely on a 48-hour timescale. 

• Propranolol could dampen autonomic symptoms, but any beta-blocker is relatively contra-indicated in an AV conduction delay and would not treat the cognitive component of panic. In addition, propranolol is falling out of favour in most guidelines.

• Short-acting antihistamine (promethazine) offers some sedation but little evidence for crisis management of GAD. 

• Starting an SSRI now will not deliver benefit for several weeks and therefore does not address the immediate barrier to attendance, though it should be discussed as part of the longer-term plan. 

If prescribing diazepam, do so within strict parameters 

• Dose: 2 mg orally three times daily as needed, with the option to increase to 5 mg t.d.s. only if the initial dose fails; this is within NHS-endorsed advice for acute anxiety nhs.uk. 

• Quantity: supply seven to nine tablets (two to three days’ cover); annotate the prescription “no repeat”. 

• Administration advice: try the first 2 mg when someone is present, then a single 2 mg 30–60 minutes before leaving for the interview. 

• Counselling points: no alcohol, no driving, avoid signing legal documents when under the influence, possible daytime drowsiness, paradoxical agitation. 

• Follow-up: telephone or face-to-face review within one week to confirm cessation, check for residual anxiety, and begin/continue first-line long-term therapy (SSRI plus CBT). Document the indication, dose, quantity, discussion and review date. 

Shared-decision outcome 

After explaining all of the above, I would say to Ms Hodge: 

“Because this is an acute, short-lived crisis and other options cannot work quickly enough, a very small supply of diazepam is clinically justifiable. It should only be taken for a couple of days around the interview, and we will review you immediately afterwards. At the same time we’ll start measures that tackle the anxiety long-term, such as sertraline and urgent CBT.” 

If she accepts these terms, I would prescribe diazepam exactly as outlined. If she declines or expresses concern about sedation or dependency, I would explore the alternative strategies and arrange urgent psychological support instead. 

In summary: Yes, diazepam is appropriate here, but only as a tightly controlled, temporary bridge while the definitive treatments and wider psychosocial support are put in place.