Suicide attempts in high-dose benzodiazepine users

Benzodiazepine high-doses: The need for an accurate definition

OBJECTIVES

A clear definition of what we understand of high-dose misuse or of a 'markedly increased dose' (as stated by the DSM-5) is important and past definitions may be inadequate. The aim of this review is to describe the different definitions used and to test these definitions for their accuracy.

METHODS

A narrative PubMed literature review was conducted based on articles published between 1 January 1990 and 31 December 2020 describing benzodiazepines (in MeSH Terms or MeSH Major Topic) and high-dose (or high-dosage). Specific definitions were applied to a population sample to show how definitions affect high-dose benzodiazepine prevalence.

RESULTS

Multiples of an equivalent-diazepam dose or of the World Health Organization 'defined daily dosage' were used more frequently than the overstep of the recommended maximum therapeutic dosage as a cut-off point.

CONCLUSION

High-dose use is rare but the prevalence in the general population varies among studies, mainly due to different definitions, making both clinical and epidemiological comparisons between studies difficult. Defining a high-dose user as a person who takes at least a higher dose than the maximum usual therapeutic dose over a defined period of time therefore appears to be clinically more consistent.

A pharmacoepidemiological study of the association of suicide reattempt risk with psychotropic drug exposure

INTRODUCTION

Recent pharmacoepidemiological studies have suggested that consumption of certain classes of psychotropic drugs could be considered protective or risk factors for suicidal behaviour. The aim of the study was to evaluate the association between the risk of suicide reattempt within 6 and 14 months after a suicide attempt (SA) with the use of different classes of psychotropic drugs, combination pairs and treatment adequacy from inclusion through 6 and 14 months post-SA.

METHOD

A prospective observational cohort of 972 subjects from the ALGOS study from January 2010 to February 2013 was used to evaluate the association of risk of suicide reattempt within 6 and 14 months with the use of different classes of psychotropic drugs (antidepressants, anxiolytics, antipsychotics, lithium, anticonvulsants, analgesics, opioid maintenance therapy and maintenance treatment for alcohol dependence). A multivariable Cox model was performed after imputation of missing data using the multiple imputation method.

RESULTS

Our main results did not show an association between psychotropic drug use and suicide reattempt after 6 months of follow-up. We demonstrated that the use of benzodiazepines (HR = 1.87 [1.25; 2.81], p < 0.01) and hypnotics (HR = 1.49 [1.03; 2.17], p = 0.04) or a combination of both (HR = 1.80 [1.17; 2.72], p = 0.01) were associated with suicide reattempt within 14 months after a previous SA.

CONCLUSION

The early identification of a positive association between psychotropic drugs and the risk of suicidal behaviour is extremely important for prevention of suicide reattempts. Special precautions should be considered when prescribing psychotropic drugs for these subjects, particularly those at risk of suicide reattempt.

Quantitation of Benzodiazepines and Metabolites in Urine by Liquid Chromatography–Tandem Mass Spectrometry

Background

Benzodiazepines (BZDs) are central nervous system depressants that are prescribed to prevent seizures, manage anxiety, or help sleep. When misused, BZDs can lead to addiction and sometimes cause death. Measurement of BZDs in urine is used to identify their use, especially in pain management settings. LC-MS/MS is preferred for these measurements because of its high sensitivity and specificity. Here, we report an LC-MS/MS assay for measuring 7 BZDs and metabolites in urine.

Methods

Urine sample was incubated at 60 °C for 30 min after addition of internal standards and a β-glucuronidase solution. After centrifugation, the supernatant was diluted with methanol and water before being injected onto a C18 analytical column in an LC-MS/MS system for quantification. The analytical time between injections was 4.35 min. The analytes included 7-aminoclonazepam, α-hydroxyalprazolam, α-hydroxytriazolam, oxazepam, lorazepam, nordiazepam, and temazepam.

Results

The lower limit of quantification ranged from 30 ng/mL to 50 ng/mL with an analytical recovery &gt;80% for all 7 analytes. Total CV was &lt;10% for all analytes (3 concentration levels of 100, 2500, and 5000 ng/mL; n = 30 each). This method had 100% agreement with a GC-MS method offered by an independent laboratory for negative urine samples. For the positive urine samples, this method showed a strong correlation (R &gt; 0.96) with the GC-MS method.

Conclusions

The LC-MS/MS assay allows accurate and precise measurement of 7 BZDs and metabolites in a single analytical run with a short analytical run time and broad measuring ranges.

Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review

OBJECTIVE

To review the literature on the co-occurrence of anxiety with depressive disorders and the rationale for and use of combination treatment with benzodiazepines and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) for treating comorbid anxiety and depression.

DATA SOURCES

PubMed and PsycINFO were searched using terms identified as relevant based on existing practice guidelines. The primary search terms were anxiety, anxiety disorders, depression, depressive disorders, comorbidity, epidemiology, benzodiazepines, antidepressants, pharmacology, clinical trials, and pharmacotherapy. Reference lists of identified articles were also reviewed to ensure capture of relevant literature.

STUDY SELECTION

Publications were selected for inclusion in the review if they applied to adult populations and specifically addressed the comorbidity of anxiety and depression, their epidemiology, or their management. Case reports and case series were not considered for inclusion.

DATA EXTRACTION

Each author assessed the publications independently for content related to the review topics. Findings considered relevant to the clinical understanding and management of comorbid anxiety and depression were incorporated into the review.

DATA SYNTHESIS

Comorbidity is very common among patients with anxiety and depressive disorders, and, even when full criteria for 2 separate disorders are not met, subsyndromal symptoms are often present. Little controlled research has explored how benzodiazepines and SSRIs/SNRIs may be usefully combined, yet their combination is frequently employed in clinical practice. Patients with comorbidities are likely to have poorer treatment outcomes and have greater utilization of health care resources. Currently SSRIs/SNRIs are considered first-line therapy and are effective in both anxiety and depressive states. Nevertheless, many patients have only a partial response or have difficulty tolerating efficacious doses of antidepressant monotherapy. Benzodiazepines appear to improve treatment outcomes when an anxiety disorder co-occurs with depression or for depression characterized by anxious features. Specifically, they may provide benefits both in terms of speed of response and overall response.

CONCLUSIONS

Long-term management plans for anxiety disorder with or without comorbid depression should include strategies for acute or short-term care, long-term maintenance, and episodic or breakthrough symptoms. Combination therapy with benzodiazepines and antide-pressants in appropriate clinical settings may improve outcomes over monotherapy in some patients.

Characteristics of a French African Caribbean epidemiological psychiatric sample with a history of suicide attempt

Research on vulnerability factors among ethnic groups, independent of primary psychiatric diagnosis, may help to identify groups at risk of suicidal behavior. French African Caribbean general psychiatric patients (N = 362) were recruited consecutively and independently of the primary psychiatric diagnosis. Demographic and clinical characteristics and lifetime history of suicide attempts were recorded. Sixty-five patients (18%) had a history of at least one suicide attempt. Presence of professional qualifications, children, poor social contacts, treatment with benzodiazepine at inclusion, and poor treatment compliance were all associated with a lifetime history of suicide attempts.

[Antidepressants and their onset of action: a major clinical, methodological and pronostical issue]

Although antidepressant medications are effective in about 50-70% of patients with major depressive disorder (MDD), they have a delayed onset of therapeutic effect. This latency is one of the current major limitations of these medications, in that it prolongs the impairments associated with depression, leaves patients vulnerable to an increased risk of suicide, increases the likelihood that a patient will prematurely discontinue therapy, and increases medical costs associated with severe depression. It is becoming increasingly clear that differences may exist between antidepressants and some evidence suggests that some antidepressant agents may begin to work faster than others. Escitalopram, duloxetine, venlafaxine, and mirtazapine have shown statistically significant differences in some measures of antidepressant action within the first two weeks of treatment, both in placebo-controlled trials and in head-to-head comparisons with other antidepressants. Results of the current review should be regarded with certain important limitations in mind. First, differences in times to onset of antidepressant response have been shown in clinical efficacy studies not specifically designed to detect differences in onset of action (post-hoc analysis). Second, results observed in 'pure' clinical trial samples should not be directly generalized to the real clinical practice since it has been proven in clinical settings that less than one in seven depressed patients would be eligible to participate in antidepressant clinical trials. For instance, depressed patients who are suicidal or who score higher than 30 on the 17-item HAM-D are excluded from antidepressant clinical trials. Third, caution is warranted when applying these findings to clinical populations with more severe depressions with respect to the fact that among clinical populations, severity of depression coincides with comorbidity, including such psychiatric disorders as anxiety disorders, personality disorders and substance abuse. In addition, the magnitudes of the size-effects of antidepressants versus placebo are clearly higher in severely depressed patients. Fourth, specific items on depression rating scales may induce greater antidepressant/placebo differences. For instance, the 17-item HAM-D contains three questions pertaining to sleep. It questions the fact that earlier onset may appear not only via a specific antidepressant effect but also via a non-specific effect on anxiety, sleep, physical pain or other accessory symptoms. Thus, current data do not clearly support claims that one drug reduces the symptoms of depression faster than another, though the existing literature suggests that escitalopram displays some superiority in terms of rapidity of action. Given the potential benefits of early-acting antidepressant treatments, the possibility of superior speed of onset of escitalopram presented here merits further study in adequately designed, prospective clinical trials. A definitive demonstration of early onset of action awaits the results of appropriately designed and powered clinical studies, which may include (1) a prospective definition of early onset of action, (2) more focused assessments of core emotional symptoms and cognitive deficits of depression by using specific and sensitive tools, (3) a data-analytic approach capable of capturing the dynamic nature of symptomatic change (for example, survival analysis), and (4) strategies to minimize biases and heterogeneity of response.