The place of benzodiazepines in psychiatric practice

A multi-center, double-blind, randomised study of the Lavender oil preparation Silexan in comparison to Lorazepam for generalized anxiety disorder

Generalized and persistent anxiety, accompanied by nervousness and other symptoms (Generalised Anxiety Disorder, GAD) is frequent in the general population and leads to benzodiazepine usage. Unfortunately, these substances induce sedation and have a high potential for drug abuse, and there is thus a need for alternatives. As the anxiolytic properties of lavender have already been demonstrated in pharmacological studies and small-scale clinical trials, it was postulated that lavender has a positive effect in GAD. A controlled clinical study was then performed to evaluate the efficacy of silexan, a new oral lavender oil capsule preparation, versus a benzodiazepine. In this study, the efficacy of a 6-week-intake of silexan compared to lorazepam was investigated in adults with GAD. The primary target variable was the change in the Hamilton Anxiety Rating Scale (HAM-A-total score) as an objective measurement of the severity of anxiety between baseline and week 6. The results suggest that silexan effectively ameliorates generalized anxiety comparable to a common benzodiazepine (lorazepam). The mean of the HAM-A-total score decreased clearly and to a similar extent in both groups (by 11.3+/-6.7 points (45%) in the silexan group and by 11.6+/-6.6 points (46%) in the lorazepam group, from 25+/-4 points at baseline in both groups). During the active treatment period, the two HAM-A subscores "somatic anxiety" (HAM-A subscore I) and "psychic anxiety" (HAM-A subscore II) also decreased clearly and to a similar extent in both groups. The changes in other subscores measured during the study, such as the SAS (Self-rating Anxiety Scale), PSWQ-PW (Penn State Worry Questionnaire), SF 36 Health survey Questionnaire and Clinical Global Impressions of severity of disorder (CGI item 1, CGI item 2, CGI item 3), and the results of the sleep diary demonstrated comparable positive effects of the two compounds. In conclusion, our results demonstrate that silexan is as effective as lorazepam in adults with GAD. The safety of silexan was also demonstrated. Since lavender oil showed no sedative effects in our study and has no potential for drug abuse, silexan appears to be an effective and well tolerated alternative to benzodiazepines for amelioration of generalised anxiety.

Benzodiazepines prescription in Dakar: a study about prescribing habits and knowledge in general practitioners, neurologists and psychiatrists

Benzodiazepines are relatively well-tolerated medicines but can induce serious problems of addiction and that is why their use is regulated. However, in developing countries like Senegal, these products are used without clear indications on their prescription, their dispensation or their use. This work focuses on the prescription of these medicines with a view to make recommendations for their rational use. Benzodiazepine prescription was studied with psychiatrists or neurologists and generalists in 2003. Specialist doctors work in two Dakar university hospitals and generalists in the 11 health centres in Dakar. We did a survey by direct interview with 29 of 35 specialists and 23 of 25 generalists. All doctors were interviewed in their office. The questionnaire focused on benzodiazepine indications, their pharmacological properties, benzodiazepines prescribed in first intention against a given disease and the level of training in benzodiazepines by doctors. Comparisons between specialists and generalists were made by chi-square test. Benzodiazepines were essentially used for anxiety, insomnia and epilepsy. With these diseases, the most benzodiazepines prescribed are prazepam against anxiety and insomnia and diazepam against epilepsy. About 10% of doctors do not know that there is a limitation for the period of benzodiazepine use. The principal reasons of drugs choice are knowledge of the drugs, habit and low side effects of drugs. All generalists (100%) said that their training on benzodiazepines is poor vs. 62.1% of specialists, and doctors suggest seminars, journals adhesions and conferences to complete their training in this field. There are not many differences between specialists and generalists except the fact that specialists prefer prazepam in first intention in the insomnia treatment where generalists choose bromazepam. In addition, our survey showed that specialists' training in benzodiazepines is better than that of generalists. Overall, benzodiazepine prescription poses problems particularly in training, and national authorities must take urgent measures for rational use of these drugs.

The impact of hospitalisation on the initiation and long-term use of benzodiazepines

BACKGROUND

Inappropriate (long-term) use of benzodiazepines (BZDs) is a reason for concern. Several studies have suggested that hospitalisation may be a determinant for initiation of BZD use as well as for long-term use. However, the available evidence is conflicting.

OBJECTIVE

To determine whether hospitalisation induces initiation of BZD use and subsequent long-term use.

METHODS

A retrospective follow-up study was conducted. Randomly, 10,000 patients who had been hospitalised were selected (index date). Non-hospitalised patients, matched on age and gender, were sampled from the same living region and assigned the same index date as the corresponding hospitalised patient. Patients were included if adequate medication data were available from 18 months before to 18 months after the index date. Initiation of BZD use was defined as a prescription for a BZD or BZD-related hypnotic without a prescription for any of these drugs during the prior 6 months. Long-term use was defined as a period of consecutive use for at least 6 months following initiation.

RESULTS

In this study, 8,681 hospitalised patients and an equal number of non-hospitalised patients were finally included. Overall, the relative risk for initiation of BZD use was almost twice as high [IDR 1.97 (95%CI 1.84-2.10)] among hospitalised patients as in non-hospitalised patients. This relative risk was most clearly elevated during the time window from 3 months before to 3 months after hospitalisation [IDR 4.81 (95%CI 4.08-5.67)]. The relative risk for long-term use during the entire 36-month observation period was not higher [IDR 1.04 (95%CI 0.95-1.13)] among hospitalised patients than among non-hospitalised patients. Within the time window of 3 months before and after hospitalisation, the relative risk for long-term use was significantly lower for the hospitalised group [RR 0.82 (CI 0.69-0.98)].

CONCLUSION

Our results confirm that hospitalisation is associated with an increased risk for initiation of BZD use; the risk is highest during the 3 months just before and after hospitalisation. However, hospitalisation appeared not to be a determinant for long-term use of BZDs.

Pharmacoeconomic evaluation of a patient education letter aimed at reducing long-term prescribing of benzodiazepines

OBJECTIVE

To determine the economic implications of sending an educational letter to patients, aimed at reducing long-term BDZ prescribing.

METHOD

Letters were sent to 242 patients from 2 general medical practices. BDZ usage and costs were compared in the years before and after intervention using numbers of defined daily dosages (DDDs) prescribed. The cost of intervention implementation was estimated using pharmacist, GP and administrative staff time, plus postage costs.

MAIN OUTCOME MEASURES

Number of BDZ DDDs prescribed during the 12-month periods before and after intervention. The cost implications of intervention.

RESULTS

Mean patient age was 67 years, 75% were female and the mean duration of BDZ usage was 19 years. A mean of 337 benzodiazepine DDDs per patient were prescribed during the baseline year. Overall BDZ usage at baseline was increasing by 13%. After receiving the letter, 31% of patients discussed BDZ usage with their GP and 10% had their drug or strength changed. During the year after intervention, a significant reduction of 17% in benzodiazepine usage was observed compared to baseline; 5% of patients ordered no more benzodiazepine prescriptions after receiving the letter. Mean BDZ costs reduced by 1.20 Pounds per patient after intervention. The cost of intervention implementation was 5.54 Pounds per patient, giving a net cost of 4.34 Pounds per patient, or 86.80 Pounds to obtain one BDZ discontinuation.

CONCLUSION

This intervention is effective, simple, and inexpensive. Its minimal cost could be justified given the morbidity associated with the long-term prescribing of benzodiazepines, particularly in the elderly.

A cross-sectional audit of benzodiazepine use among general practice patients

In order to assess how many general practice patients take benzodiazepines for long periods, a cross-sectional audit of clinical practice was conducted. During a 3-day census period, 26 general practitioners in the area of Bergamo, Italy, entered into the study every patient who was taking benzodiazepines. The prevalence of use of this class of drugs was 14.0% (CI 12.5-15.7), while the prevalence of daily use for 12 months or more was 4.7% (CI 3.8-5.8). Finally, the prevalence of very long-term use of benzodiazepines, i.e. those taking these drugs for more than 10 years, was 0.65% (CI 0.34-1.14). Compared to non-long-term users, long-term users were older (OR 2.38, CI 1.39-4.08) and had a lower level of education (OR 2.40, CI 1.04-5.54). In addition, insomnia was associated with long-term use of this class of drugs (OR 1.82, CI 1.02-3.24). These findings provide evidence that the long-term use of benzodiazepines is an important issue in everyday general practice and that this calls for precise management tactics.

The Undertreatment of Anxiety: Overcoming the Confusion and Stigma

1. The patient, the nurse, and organizational variables all interact in a dynamic and complex manner, which all have an impact on decisions about intervention. 2. The numbers and variety of agents ordered as PRN indicate the responsibility for treatment placed by physicians on nurses and their reliance on appropriate and accurate nursing assessment. 3. Much of the stigma surrounding symptoms of anxiety and their treatment is based not only on the nature of the illness, but on the perceptions and beliefs concerning the use of anti-anxiety agents.

Fatal poisonings attributed to benzodiazepines in Britain during the 1980s

The fatal toxicity indices of benzodiazepines during the 1980s were calculated from national prescribing data and mortality statistics. The overall rate was 5.9 deaths per million prescriptions for benzodiazepines taken alone or with alcohol only, anxiolytics being less toxic than hypnotics. Diazepam appeared more toxic than average among anxiolytics (P < 0.05), and flurazepam and temazepam more toxic than average among hypnotics (both P < 0.001). It was shown that the finding for diazepam was probably explained by concurrent use of alcohol, which implies that other anxiolytics may be safer in cases where there is alcohol misuse; but the greater toxicity of flurazepam and temazepam remained unexplained. Benzodiazepines are indeed much less toxic than the barbiturates they superseded, but they are not innocuous and temazepam in particular requires further evaluation.

Long-term drug treatment of panic disorder

Drug treatment of panic disorder with benzodiazepines and antidepressants has been established as efficacious in the short-term (6-8 weeks). The efficacy of medications during long-term (i.e., continuous) treatment has not often been addressed and a review of the evidence is presented. Most data exists for the long-term effectiveness of benzodiazepines. Experience with the triazolobenzodiazepine, alprazolam, is reviewed together with some other high potency drugs, e.g., clonazepam. Tricyclic antidepressants are also effective in the long-term treatment of panic and the relevant studies are presented. Long-term efficacy for monoamine oxidase inhibitors is not as clearly established. The issue of relapse following drug withdrawal is addressed and some strategies for patient management in long-term therapy are discussed.

Physical dependence on benzodiazepines: differences within the class

Concern about physical dependence seems to be the major limiting factor in the long-term treatment with benzodiazepines (BZD). The severity of the withdrawal syndrome is determined by multiple factors, e.g. dose, duration of use, frequency of dose interval, mode of discontinuation, the pharmacologic characteristics of the BZD, personality and previous or concurrent use of cross-dependent drugs and/or alcohol. There is evidence that BZD with a short elimination half-life cause a more severe withdrawal syndrome than those with a long elimination half-life. Besides pharmacokinetic properties, pharmacodynamic factors such as potency may also covary with the liability of a BZD to induce physical dependence. There is an increasing body of literature indicating that quickly eliminated, high potency BZD such as alprazolam and lorazepam may be more likely to cause severe withdrawal reactions than slowly eliminated compounds such as diazepam or less potent derivatives such as oxazepam. Alprazolam seems to play an exceptional role, insofar as relatively soon after its introduction to the market a number of case reports of withdrawal psychoses, seizures and intense rebound anxiety were published. Data reviewed from the literature correspond well with the results of interviews conducted with 31 clinicians across the United States with experience in detoxifying patients dependent on BZD, 84% of these physicians mentioning alprazolam as especially problematic with respect to the intensity and/or duration of the withdrawal syndrome.

Psychotropic drug use in medical and surgical wards of a teaching hospital in northern Nigeria

The overall prescription rate of psychotropic drugs in a Nigerian teaching hospital was 33.1%. This was slightly higher among surgical than medical patients. It is suggested that more attention needs to be paid to psychotropic drug education in developing countries in order to ensure a more rational use of these drugs.

A double-blind comparison of the effects of gradual withdrawal of lorazepam, diazepam and bromazepam in benzodiazepine dependence

Using a double-blind procedure, 68 patients with putative benzodiazepine dependence were randomly allocated to one of three groups given lorazepam (n = 22), diazepam (n = 23) or bromazepam (n = 23) in doses equivalent to those of the patients' original benzodiazepine. After four weeks the dosage was reduced in 25% quantities until no further benzodiazepines were taken. A total of 23 patients dropped out during the study, ten on lorazepam (one of whom committed suicide), seven on diazepam and six on bromazepam. There were few differences in withdrawal symptoms between the three groups but, despite the higher dropout rate, these symptoms were somewhat less marked in the lorazepam group. Withdrawal symptoms were greater in patients who had taken a benzodiazepine for greater than 5 years and were most marked in those with personality disorders, predominantly dependent ones.

Benzodiazepines: abuse and new use

Both abuse and new uses for benzodiazepines are reviewed. The pharmacology of benzodiazepines is summarized and statistics regarding their general use are given. The question of benzodiazepine abuse is reviewed in some detail and the question of rebound, recurrence of symptoms and physiological withdrawal is differentiated. Benzodiazepines are regarded as a very safe class of drugs and the abuse potential is felt to be negligible provided that they are prescribed for appropriate conditions and monitored carefully. The dangers of alternatives to benzodiazepines such as alcohol or barbiturates is emphasized. New uses for benzodiazepines are reviewed including the use of benzodiazepines in panic disorder, as well as an adjunct in the therapy of mania and some psychotic states. Rational prescribing of benzodiazepines is encouraged and the attitude that these are dangerous and addictive drugs is discouraged and put into perspective.

Benzodiazepines, putative anxiolytics and animal models of anxiety

Anxiety is a complex state that includes a broad range of classified symptoms. Anxiolytic treatment has been dominated by the use of benzodiazepine drugs (BZs), which is often prolonged. However, the multiplicity of anxiety states and the lack of BZ specificity preclude the potent targeting of the drugs to different states, and point to the problem of drug dependence. Furthermore, animal models of anxiety give different results when challenged with apparently similar drugs. The search for alternative drugs with a higher specificity has led to 5-HT receptor subtypes. In this review, Simon Green describes how recent research might have dual benefits: in improving drug therapy of anxiety in humans, and in analysing and categorizing more clearly the concept of anxiety itself.

Diazepam (Valium): its dependency liability

Reports of the withdrawal syndrome following discontinuation of diazepam and drug dependence fears have contributed to diazepam's displacement as the most popular anxiolytic agent. Reports of the withdrawal syndrome, the factors involved in withdrawal, and the remedies proposed for diazepam withdrawal symptoms are reviewed.

To which neurotic patients do psychiatrists prescribe medication?

Of 318 newly referred neurotic patients, 43% were prescribed medication by their psychiatrist. Medication was more likely to be prescribed to patients who are older, who are married, who have lengthy illnesses and who do not have a history of deliberate self-harm. These findings are discussed in the context of current debate about optimal treatment methods for patients with neurotic disorders.

Psychopharmacology of the psychiatric disorders of childhood and adolescence

The literature on the psychopharmacology of child and adolescent psychiatric disorders is reviewed. The scanty epidemiological data suggest that psychotherapeutic drugs are utilized more widely than research findings would warrant, especially in preschool-age children. With the exception of hyperactivity, the disorders of childhood and adolescence for which the use of psychopharmacological agents is well-established are rare. This highlights the need for careful prescribing, in which the child's rights, problems with compliance and developmental and behavioural adverse effects are important considerations.

Short-acting versus long-acting benzodiazepines: discontinuation effects in panic disorders

An increasing body of evidence suggests that benzodiazepines--which have long been considered the drugs of choice in the treatment of various anxiety disorders due to their relative lack of side effects, lack of adverse drug reaction, their safety, and increased efficacy over other agents--are effective in the treatment of panic disorders. Originally, the benzodiazepines were believed to be devoid of dependence-inducing properties, even at high doses. Recent evidence, however, suggests that discontinuation of both high and normal doses of both short- and long-acting benzodiazepines generally results in similar withdrawal symptoms, including anxiety and sleep and perceptual disturbances. This article presents a brief review of benzodiazepine withdrawal, with an emphasis on the discontinuation of these drugs following treatment of panic disorders. In particular, short-acting and long-acting drugs may present different features following long-term treatment and withdrawal. Preliminary results from a study comparing alprazolam and diazepam are presented to illustrate this point in contrast to expectations: the problems associated with withdrawal of both agents were comparable.

Kuwait drug addiction scene: a changing pattern?

Sociocultural considerations and persistence of indiscriminate prescription habits for addicts may have contributed in shifting the pattern of misused drugs from traditional alcohol and illicit drugs to predominantly iatrogenic dependence on benzodiazepines. The clinical profile and the rationale for the long-adopted detoxification treatment of 120 patients were studied. Multiple-drug misusers were found to suffer significantly more anxiety-type symptoms suggestive of benzodiazepine withdrawal. Poor correlation of detoxification medication with patient variables suggests that such treatment lacks the rationale for its continuation and should be replaced by treatments based on proper physical and psychiatric evaluation. Benzodiazepine dependence should be recognized as a clinical entity requiring relevant treatment strategies.

Mania induced by lorazepam withdrawal: a report of two cases

Although depression is a well recognised component of the benzodiazepine withdrawal syndrome there have, as yet, been no convincing reports of mania. We report two cases of mania induced by abrupt discontinuation of lorazepam. Both cases were treated by reintroduction of the benzodiazepine followed by gradual dose reduction.

Prevalence of benzodiazepine abuse and dependence in psychiatric in-patients with different nosology. An assessment of hospital-based drug surveillance data

Frequencies of abuse and dependence assessed continuously within a drug surveillance system were analysed as a contribution to risk-benefit evaluations of benzodiazepines (BZDs). In 4.7% of 15,296 patients admitted to psychiatric hospitals between 1980 and 1985, BZDs had been involved in some kind of abuse or dependence. Primary BZD dependence, defined as physical dependence on BZDs in patients who had not been dependent before, was observed in about 1% of admitted patients. Linking these data with psychiatric diagnoses revealed a high risk of primary BZD dependence for in-patients (11.8%) with anxiety neurosis (ICD-9, 300.0), and a lower risk for neurotic (300.4) and for endogenous depressives (296.1) (risk 3.7% and 2.7% respectively). Older age was also related to primary BZD dependence. For depressive in-patients, the risk was twice as high in females as in males. Anecdotal observations advocate more systematic investigation of the emotional effects of long-term therapy with BZDs.

The damnation of benzodiazepines

It is argued that there are two kinds of benzodiazepine dependence: a therapeutic and a morbid kind. The therapeutic dependence is acceptable in that it mitigates the clinical manifestations in patients with long-standing and fluctuating anxious-depressive symptoms. The morbid dependence is an unfortunate complication which can arouse therapeutic concern because it ties patients to an excessive dosage, unless the penalty of a sometimes grim abstinence syndrome is paid on drug reduction. The present, often strident and threatening, damnation of benzodiazepines oversteps the mark and causes avoidable misery to patients whose well-being has become largely and therapeutically dependent on the drug.

Comparative assessment of efficacy and withdrawal symptoms after 6 and 12 weeks' treatment with diazepam or buspirone

Fifty-one out-patients presenting with generalised anxiety disorder were included in a double-blind trial, and treated with either buspirone (a new non-benzodiazepine antianxiety drug) or diazepam over 6 or 12 weeks, after which they were abruptly withdrawn and continued on placebo to 14 weeks. Ratings of anxiety and other symptoms were administered fortnightly and additional withdrawal symptoms noted. Forty patients completed the study; 8 of the 11 drop-outs were taking buspirone. Both drugs reduced anxiety, diazepam more rapidly, but with greater withdrawal symptoms, particularly after 6 weeks. Regular treatment with diazepam for 6 weeks leads to a significant risk of pharmacological dependence that is not present with buspirone.