What does data on adverse reactions reveal about benzodiazepines and suicide-related risk?: A disproportionality analysis using FDA FAERS pharmacovigilance data

Benzodiazepines (BZDs) are widely used in the treatment of psychiatric disorders, but their association with suicidal/self-injurious behavior is conflicting. This study investigated the relationship between BZDs and suicidal and self-injurious behavior, by analyzing data from the FDA Adverse Event Reporting System. We analyzed FDA Adverse Event Reporting System data from January 2004 and March 2025, to analyze adverse events (AEs) associated with suicidal and self-injurious behavior in BZDs. Thirty-eight BZDs were initially identified via the WHO Anatomical Therapeutic Chemical Code System. After excluding 26 BZDs with insufficient psychiatric disorder-related AEs (<50 reports), 12 (diazepam, chlordiazepoxide, oxazepam, potassium clorazepate, lorazepam, bromazepam, clobazam, alprazolam, flurazepam, triazolam, temazepam, and midazolam) were retained for disproportionality analysis using zolpidem as a control. Reporting odds ratios (RORs) were calculated, and subgroup analysis assessed risk variations by age and gender. Among 52,767 psychiatric disorders AEs, 9474 (17.95%) involved suicidal and self-injurious behaviors. Compared to zolpidem, diazepam (ROR = 1.38), chlordiazepoxide (ROR = 1.62), oxazepam (ROR = 2.14), lorazepam (ROR = 1.11), alprazolam (ROR = 1.64), flurazepam (ROR = 3.26) triazolam (ROR = 1.68), and temazepam (ROR = 1.72) showed significantly elevated risks, while clobazam (ROR = 0.46) and midazolam (ROR = 0.37) demonstrated protective effects. Subgroup analyses revealed higher risks in females using diazepam, oxazepam, lorazepam, alprazolam and temazepam. Adults <65 years who used potassium clorazepate, lorazepam, clobazam, alprazolam, or triazolam faced a significantly higher suicide-related risk than those ≥65 years. Compared to zolpidem, BZDs demonstrate varied suicide-related risks, which necessitated personalized risk-benefit evaluations and increased monitoring for high-risk agents such as flurazepam and alprazolam.