Benzo Madness and the Tragedy of Chris Cornell's Suicide

Aight. Time to drop some knowledge and bust some myths.

A few days following the report of Chris Cornell's death by suicide, a connection has already been suggested between the suicide and Chris' use of a common benzodiazepine, Lorazepam (Ativan). Specifically, it's being strongly alleged that Lorazepam, or perhaps Chris' particular prescription, or the particular dose he took in the hours leading up to his death, was the cause of his suicidal thoughts and subsequent suicide -- and that therefore the drug itself was at least mostly to blame in Chris' suicide.

As a mental health professional with a specialization in addiction/substance abuse, and a college professor in addictions courses, including Psychopharmacology (i.e. the study of how psychoactive drugs impact the central nervous system, which involves in-depth examination of up-to-date information on toxicity, dependence potential, side-effects, etc.), I feel I'm in a position to say few important things about this issue. Judging from how much attention these cases get, and how much egregious nonsense gets spewed about them, I think I'll consider doing it more often.
Let's start with the drug itself. Lorazepam is a common benzodiazepine within the family of sedative-hypnotic drugs, which are in turn within the family of central nervous system depressants (drugs which decrease activity in the central nervous system). In pharmacological terms, a drug is considered a "sedative" when its therapeutic indication is to relieve anxiety (sometimes also known as 'anxiolytic' ), and it's considered "hypnotic" when its therapeutic indication is to induce sleep. All benzodiazepines fall on the sedative-hypnotic spectrum, but it's main use is as a sedative, i.e. to relieve or mitigate the effects of anxiety, and in some cases, to help prevent a full-blown panic episode from developing once initial symptoms appear. It's also used as an anti-convulsant in the treatment of epilepsy. It's also widely used (along with other benzodiazepines such Diazepam, i.e. 'Valium') in the treatment of alcohol withdrawal syndrome, given the fact that it shares cross-tolerance with alcohol. In fact, benzodiazepines save lives in this context, as they can prevent increased severity of life-threatening withdrawal symptoms, especially delirium tremens and alcohol-induced seizures.

  While increased suicidal ideations have been reported as a side-effect of benzodiazepines in some cases, the cases are statistically extremely rare, and even in those cases, there's absolutely no evidence indicating that the use of benzodiazepines caused the emergence of suicidal ideations in an individual who had otherwise never experienced suicidal ideations. Indeed, multi-factorial analysis tends to reveal the confluence of numerous factors contributing to increased suicidal ideations, rather than the use of a psychoactive drug alone.

A more likely causal pathway is what's known as the unmasking effect: in someone who is already disposed to harbour suicidal thoughts, urges, and/or impulses a central nervous system depressant might, 'unmask' these thoughts, urges, and impulses which normally wouldn't be seriously considered, let alone acted upon. Not only to benzodiazepines (like all depressants) reduce impulse control and behavioural inhibition, they reduce anxiety, especially in the form of worry and fear. That's a potentially dangerous combination in the mind of someone who has been considering suicide: not only would you be more willing to take your life due to disinhibition, you might be far less worried and fearful about the short and long-term consequences of your decision.

Of course, benzodiazepines are undeniably implicated in many suicides, especially in combination with alcohol and other drugs. But this is due to their effects on the central nervous system as depressants, not on their purported ability to cause otherwise non-suicidal people to suddenly want to commit suicide. Sufficiently high doses of any depressant -- or worse, when depressants are taken in combination, e.g. alcohol and benzodiazepines -- can cause an overdose. So, benzodiazepines can be used by someone intending to die by suicide. 

That being said, in addition to the fact they can be used to cause death via central feverous system depression (e.g. respiratory depression), there are many other problems associated with benzodiazepines such as Lorazepam. 

First, they're massively overprescribed, especially for sub-clinical cases of anxiety, i.e. cases in which someone doesn't suffer from a diagnosable anxiety disorder. Second, they're often prescribed in unnecessarily large doses and/or for unnecessarily long periods of time. Third, and related to the first problem. they're often immediately prescribed (especially by physicians with little training psychopathology and mental health) before considering other possible responses to life's challenges, e.g. lifestyle changes (exercise, diet, sleep), psychotherapy, support groups, stress reduction strategies, etc. Fourth, like most psychoactive substances, they have physical and psychological dependence liability -- i.e. it's possible to become 'addicted' to them.

Now, don't get me wrong, these drugs can be used to effectively to treat a number of serious conditions, and they do help people, provided the drugs are used responsibly and as part of a broader, holistic approach to addressing one's mental health, which involves non-pharmacological strategies like those mentioned above (e.g. lifestyle changes, therapy, support groups, stress management, etc.) But I'm under no illusions that they're perfect cure-alls to mental health problems which carry no risk of harm to those taking them --- especially to those who are already at risk of suicidal thoughts and behaviour.