The reappraisal of benzodiazepines in the treatment of anxiety and related disorders

Prevalence and clinical correlates of benzodiazepine use in the patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a serious and disabling condition characterized by abnormal mood changes. Clinical guidelines for depression treatment recommend antidepressant medications, with benzodiazepines acting as short-term synergists. However, little is currently known about the prevalence and associated clinical risk factors of benzodiazepine use among Chinese patients with MDD. This study aimed to explore the prevalence and clinical risk factors associated with benzodiazepine use in this population.

METHODS

A total of 2742 patients with MDD (males/females = 816/1926, aged 14-60 years) participated in this cross-sectional observational study. General information and psychosis assessments were collected online. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7), and sleep problems and suicidal tendencies using the third and ninth items of the PHQ-9. Multivariable logistic regression analysis models were employed to identify factors associated with benzodiazepine use.

RESULTS

The prevalence of benzodiazepine use among patients with MDD was 42.9 %. Among these patients, 99.6 % used a single benzodiazepine, with oxazepam being the most frequently prescribed. Age, severity of sleep problems, depressive symptoms, and anxiety symptoms were significantly correlated with benzodiazepine use (all P < 0.001).

LIMITATIONS

The cross-sectional design of this study precludes establishing causal relationships.

CONCLUSION

Our findings indicate a high prevalence of benzodiazepine use among Chinese patients with MDD. Factors such as severe depressive symptoms, anxiety symptoms, age, and sleep problems appear to be associated with benzodiazepine use. These results underscore the importance of vigilance regarding benzodiazepine use in patients with MDD.

cAMP-PKA signaling pathway and anxiety: Where do we go next?

Cyclic adenosine monophosphate (cAMP) is an intracellular second messenger that is derived from the conversion of adenosine triphosphate catalysed by adenylyl cyclase (AC). Protein kinase A (PKA), the main effector of cAMP, is a dimeric protein kinase consisting of two catalytic subunits and two regulatory subunits. When cAMP binds to the regulatory subunits of PKA, it leads to the dissociation and activation of PKA, which allows the catalytic subunit of PKA to phosphorylate target proteins, thereby regulating various physiological functions and metabolic processes in cellular function. Recent researches also implicate the involvement of cAMP-PKA signaling in the pathologenesis of anxiety disorder. However, there are still debates on the prevention and treatment of anxiety disorders from this signaling pathway. To review the function of cAMP-PKA signaling in anxiety disorder, we searched the publications with the keywords including "cAMP", "PKA" and "Anxiety" from Pubmed, Embase, Web of Science and CNKI databases. The results showed that the number of publications on cAMP-PKA pathway in anxiety disorder tended to increase. Bioinformatics results displayed a close association between the cAMP-PKA pathway and the occurrence of anxiety. Mechanistically, cAMP-PKA signaling could influence brain-derived neurotrophic factor and neuropeptide Y and participate in the regulation of anxiety. cAMP-PKA signaling could also oppose the dysfunctions of gamma-aminobutyric acid (GABA), intestinal flora, hypothalamic-pituitary-adrenal axis, neuroinflammation, and signaling proteins (MAPK and AMPK) in anxiety. In addition, chemical agents with the ability to activate cAMP-PKA signaling demonstrated therapy potential against anxiety disorders. This review emphasizes the central roles of cAMP-PKA signaling in anxiety and the targets of the cAMP-PKA pathway would be potential candidates for treatment of anxiety. Nevertheless, more laboratory investigations to improve the therapeutic effect and reduce the adverse effect, and continuous clinical research will warrant the drug development.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Simple Coumarins from Peucedanum luxurians Fruits: Evaluation of Anxiolytic Activity and Influence on Gene Expression Related to Anxiety in Zebrafish Model

Anxiety is one of the most common central nervous system disorders, affecting at least one-quarter of the worldwide population. The medications routinely used for the treatment of anxiety (mainly benzodiazepines) are a cause of addiction and are characterized by many undesirable side effects. Thus, there is an important and urgent need for screening and finding novel drug candidates that can be used in the prevention or treatment of anxiety. Simple coumarins usually do not show side effects, or these effects are much lower than in the case of synthetic drugs acting on the central nervous system (CNS). This study aimed to evaluate the anxiolytic activity of three simple coumarins from Peucedanum luxurians Tamamsch, namely officinalin, stenocarpin isobutyrate, and officinalin isobutyrate, in a 5 dpf larval zebrafish model. Moreover, the influence of the tested coumarins on the expression of genes involved in the neural activity (c-fos, bdnf) or dopaminergic (th1), serotoninergic (htr1Aa, htr1b, htr2b), GABA-ergic (gabarapa, gabarapb), enkephalinergic (penka, penkb), and galaninergic (galn) neurotransmission was assessed by quantitative PCR. All tested coumarins showed significant anxiolytic activity, with officinalin as the most potent compound. The presence of a free hydroxyl group at position C-7 and the lack of methoxy moiety at position C-8 might be key structural features responsible for the observed effects. In addition, officinalin and its isobutyrate upregulated the expression of genes involved in neurotransmission and decreased the expression of genes connected with neural activity. Therefore, the coumarins from P. luxurians might be considered as promising drug candidates for the therapy of anxiety and related disorders.

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

Anxiolytic effect of Anthemis nobilis L. (roman chamomile) and Citrus reticulata Blanco (tangerine) essential oils using the light-dark test in zebrafish (Danio rerio)

ETHNOPHARMACOLOGICAL RELEVANCE

The anxiety disorders are the most prevalent mental health condition, and anxiety is considered the sixth cause of disability surpassing diabetes mellitus, chronic obstructive pulmonary disease, and osteoarthritis. Besides, the COVID-19 pandemic provided an increase in the number of psychiatric diseases diagnosis in all social layers around the world. About 55%-94% of patients diagnosed with anxiety disorders are treated with benzodiazepines, meanwhile benzodiazepines can promote several adverse effects. In this way, alternative therapies, such as essential oils may offer significant benefits in the treatment of patients with anxiety disorders. However, the anxiolytic effect of these essential oils must be proper evaluated appropriate as well as the suitable dosage and side effect need further research.

AIM OF THE STUDY

The aim was to evaluate the anxiolytic effect of Roman chamomile (Anthemis nobilis L.) and tangerine (Citrus reticulata Blanco) essential oils using the light-dark test in adult zebrafish (Danio rerio).

MATERIAL AND METHODS

Both essential oils were analyzed by GC-MS and the major compounds were identified. The anxiolytic effect was evaluated by light-dark test in adult zebrafish.

RESULTS

The results showed that roman chamomile essential oil has anxiolytic effect in adult zebrafish, whereas tangerine essential oil tends to reduce anxiety The major compounds of tangerine essential oil were limonene and γ-terpinene, and the major compounds of roman chamomile were pentadecyl-3-methyl-2-butenoate, hexadecyl-3-methyl-2-butenoate, 1-piperidinol and trans-1-ethyl-3-methyl-cyclopentane.

CONCLUSIONS

The present study demonstrated that this anxiolytic effect may be attributed to the synergistic effect of the compounds present in roman chamomile essential oil, particularly the major compounds. The roman chamomile essential oil at the highest concentration showed anxiolytic effect. The tangerine essential oil showed a tendency to reduce anxiety, but it was not statistically significative. In addition, roman chamomile and tangerine essential oils did not cause cause alteration in locomotion activity and exploratory ability of the fish.

Escitalopram and lorazepam differentially affect nesting and open field behaviour in deer mice exposed to an anxiogenic environment

Large nest building behaviour (LNB), as expressed by a subpopulation of laboratory housed deer mice (Peromyscus maniculatus bairdii), is persistent and repetitive. However, the response of LNB to an anxiogenic environment has not yet been investigated. Here, we employed LNB and normal nesting (NNB) expressing mice, subdivided into three drug-exposed groups per cohort, i.e. water (28 days), escitalopram (50 mg/kg/day, 28 days) and lorazepam (2 mg/kg/day; 4 days) to investigate this theme. During the last 4 days of drug exposure, mice were placed inside anxiogenic open field arenas which contained a separate enclosed and dark area for 4 consecutive nights during which open field and/or nest building assessments were performed. We show that LNB behaviour in deer mice is stable, irrespective of the anxiety-related context in which it is assessed, and that LNB mice find an open field arena to be less aversive compared to NNB mice. Escitalopram and lorazepam differentially affected the nesting and open field behaviour of LNB expressing mice, confirming deer mouse LNB as a repetitive behavioural phenotype that is related to a compulsive-like process which is regulated by the serotonergic system.

Immediate retrograde amnesia induced by midazolam: A prospective, non-randomised cohort study

BACKGROUND

Midazolam, a short-acting benzodiazepine, has sedative, anxiolytic, amnestic and anticonvulsant effects. Given its advantages of rapid onset, short duration and low toxicity, midazolam is optimal for any procedural sedation. Midazolam is known to cause anterograde amnesia; however, the possibility of retrograde amnesia has also been raised. This prospective cohort, non-randomised study evaluated the presence and extent of retrograde amnesia induced by midazolam during caesarean delivery.

METHODS

One hundred parturients scheduled for elective caesarean delivery under spinal anaesthesia were enrolled. As soon as giving birth, six picture cards were shown to the patients in 1-min intervals, and then midazolam (0.1 mg/kg) was given or not according to the patients' preference. This overall retrograde recall rate of six cards was the primary outcome of our study, which was asked by a blinded investigator.

RESULTS

The overall retrograde card recall rate was lower in the midazolam group compared with the control group (77.0 ± 13.4 vs. 87.7 ± 3.9%, P < .001), especially at 1 minute before midazolam administration (58% vs. 88%, P < .001). Decreased memory trend was observed as time progressed towards midazolam administration in the midazolam group (P = .035). More patients answered 'yes' to the factitious event in the midazolam group than in the control group (26% vs. 4%, P = .004).

CONCLUSION

Intravenous midazolam could cause a brief-period retrograde amnesia in visual and event memory. Moreover, there were more spurious reports of intraoperative factitious events in the midazolam group, implying that episodic memories were also affected by midazolam.

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

Comparative efficacy and acceptability of antidepressants and benzodiazepines for the treatment of panic disorder: A systematic review and network meta-analysis

OBJECTIVE

This systematic review aims to assess the efficacy and acceptability of the different types of antidepressants and benzodiazepines for the treatment of panic disorder (PD) in adult patients.

METHODS

PubMed, Web of Science, EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) published between 1995 and 2020 on the use of antidepressants and benzodiazepines for the treatment of PD. A systematic review and network meta-analysis were performed.

RESULTS

42 RCTs were included in the network meta-analysis, with a comparison of 11 interventions.Escitalopram (odds ratios OR 1.52, 95 % credible interval CI 1.09-2.10), venlafaxine (OR 1.33, 95 % CI 1.16-1.51) and benzodiazepines (OR 1.50, 95 % CI 1.29-1.75) had greater efficacy and acceptability than the placebo. Imipramine(OR 1.43, 95 % CI 1.15-1.79) was also demonstrated to be efficacious and tolerated but the results were restricted to small sample size. Moreover, paroxetine, sertraline, fluoxetine, citalopram and clomipramine (OR 1.37, 1.36, 1.45, 1.33 and 1.36, respectively) were more efficacious, although the acceptability of paroxetine and sertraline were significantly less tolerated than benzodiazepines. Notably, the efficacy of reboxetine and fluvoxamine were merely as equal as that of the placebo.

OUTCOMES

This is the first systematic review of antidepressants and benzodiazepines for the treatment of PD to use a network analysis. Escitalopram and venlafaxine as well as benzodiazepines may be effective choices as treatments for PD with relatively good acceptability, which still needs to be confirmed byhigh-quality RCTs.

Relationship between benzodiazepine prescription, aggressive behavior, and behavioral disinhibition: a retrospective study in a Swiss prison

Background

Benzodiazepines are commonly prescribed in prisons amidst the controversies surrounding their potential role in causing behavioral disinhibition and aggressive behavior and their association with use and trafficking of illicit and addictive substances. The present study aimed to (1) ascertain the relationship between benzodiazepine prescription (including their dosage and duration of use) and aggressive behavior and behavioral disinhibition in prison and (2) investigate whether there was an association between benzodiazepine prescription, (including their dosage and duration of use) and using and trafficking illicit and addictive substances during imprisonment.

Methods

Data were extracted from the electronic database of an open Swiss prison (n=1206, 1379 measures) over a 5-year period (20102015). Measures included benzodiazepine prescription, duration of benzodiazepine use and mean dosage, and punishable behaviors (physical and verbal aggression, disinhibited but not directly aggressive behaviors, property damage or theft, substance-related offenses, and rule transgression). We assessed the relationship between benzodiazepine prescription and punishable behaviors after propensity score matching. Logistic regressions were also used to test the relationship of benzodiazepine use duration and dosage with punishable behaviors among participants who received benzodiazepines.

Results

After propensity score matching, benzodiazepine prescription was not significantly associated with any punishable behavior. Among detained persons who took benzodiazepines, there was no significant association of dosage and duration of use with offenses involving illicit or addictive substance use or trafficking.

Conclusions

Our study did not empirically support the occurrence of increased aggressive or disinhibited behaviors or increased risk of substance abuse in detained persons who received benzodiazepines in prison. This suggests a need to reconsider restrictions in prescribing benzodiazepines in the prison setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00504-5.

Absence of definitive scientific evidence that benzodiazepines could hinder the efficacy of exposure-based interventions in adults with anxiety or posttraumatic stress disorders: A systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES

Exposure-based interventions (EBIs) are the first-line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders.

METHODS

We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies.

RESULTS

We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow-up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases.

CONCLUSIONS

Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.

Zebrafish and mouse models for anxiety evaluation - A comparative study with xanthotoxin as a model compound

The ever-present trend for introducing new drugs of natural origin with anxiolytic properties meets healthcare needs of the population, whose almost 34 % struggles with anxiety-related disorders. At the same time, animal assays that could serve as fast and reliable models of anxiety-like behaviors are of great interest to scientists. Thus, the aim of the present study was to evaluate the utility of the zebrafish model for assessing the influence of natural compounds on anxiety in comparison with the well-known mouse model. Secondly, this study is also the first attempt to investigate the influence of a naturally occurring metabolite, i.e. xanthotoxin, on anxiety-related behaviors. The anxiety level in zebrafish was assessed by measuring thigmotaxis, a specific animal behavior to move closer to the boundaries of an open area and to avoid its center. In mice, the elevated plus maze test was chosen to study anxiety-related behaviors. Our results show that xanthotoxin exerted reversed U-shape effect on anxiety behaviors in both models. The similar pattern of xanthotoxin-induced anxiety-related behaviors in both animal models not only confirms the pharmacological properties of xanthotoxin but also proves the predictive power of the zebrafish model for behavioral research of natural compounds.

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

IMPORTANCE

The proportion of patients who develop long-term benzodiazepine use remains controversial, as do the length of time before long-term use develops and the factors associated with long-term use.

OBJECTIVE

To investigate the incidence of long-term benzodiazepine and related drug (BZDR) use and factors associated with the development of long-term use implementing a follow-up design with new BZDR users.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used a nationwide cohort of 129 732 new BZDR users in Finland. New users of BZDRs aged 18 years or older were identified from the prescription register maintained by the Social Insurance Institution of Finland as individuals who initiated BZDR use during 2006 and had not used BZDRs from 2004 to 2005. The follow-up continued until death, long-term hospitalization, a gap of 2 years in BZDR use, or December 31, 2015. The population was analyzed according to age at treatment initiation, categorized into younger (<65 years) and older (≥65 years) subcohorts. Analyses were conducted from May 2019 to February 2020.

EXPOSURES

Use of BZDRs, modeled from register-based data using the PRE2DUP (from prescriptions to drug use periods) method.

MAIN OUTCOMES AND MEASURES

Long-term BZDR use, defined as continuous use of 180 days or longer, and factors associated with long-term vs short-term use, compared using Cox proportional hazards models.

RESULTS

Among the 129 732 incident BZDR users, the mean (SD) age was 52.6 (17.7) years, and 78 017 (60.1%) individuals were women. During the follow-up period, 51 099 BZDR users (39.4%) became long-term users. Long-term treatment was more common in the older subcohort (19 103 individuals [54.5%]) than the younger subcohort (31 996 individuals [33.8%]). At 6 months, 28 586 individuals (22.0%) had become long-term users: 11 805 (33.7%) in the older subcohort and 16 781 (17.7%) in the younger subcohort. The largest proportions of initiators who became long-term users were those persons who initiated treatment with nitrazepam (76.4%; 95% CI, 73.6%-79.1%), temazepam (63.9%; 95% CI, 62.9%-65.0%), lorazepam (62.4%; 95% CI, 59.7%-65.1%), or clonazepam (57.5%; 95% CI, 55.9%-59.2%). Factors associated with the development of long-term use included male sex, older age, receipt of social benefits, psychiatric comorbidities, and substance abuse.

CONCLUSIONS AND RELEVANCE

The findings of this population-based cohort study conducted in Finland suggest that the incidence of subsequent long-term BZDR use in individuals who initiate use of BZDRs is high, especially among older persons, and that the specific BZDR used initially is associated with the development of long-term BZDR use and should be carefully considered when prescribing BZDRs. The observed factors that appear to be associated with development of long-term BZDR use also should be considered in clinical decision-making when starting and monitoring BZDR treatment.

Perceptions, clinical characteristics, and other factors associated with prolonged and high daily dose of benzodiazepine use among patients with anxiety or depressive disorders

BACKGROUND

Benzodiazepines (BZDs) have been widely used to treat anxiety; however, the risk of adverse health effects caused by their long-term use is high. This study examined the factors associated with the duration and higher daily dose of BZDs use among a population with anxiety or depressive disorders.

METHODS

A cross-sectional study design was used. Patients from a psychiatric outpatient department who had been prescribed BZDs were recruited. Data were collected from 250 patients.

RESULTS

Nearly 94% of patients were long-term BZDs users. The mean duration of BZDs use was 5.5 years; and mean defined daily dose (DDD) of BZDs use, converted to diazepam milligram equivalent (DDD), was 1.53 DME-DDD. Patients who knew more about alternative treatments were less prone to use BZD longer. Patients aged 65 years or older and those with difficulty falling asleep were more prone to use BZDs longer. Patients who were currently taking BZDs at higher daily dose were those who felt more depressed, prescribed second generation antipsychotics, suffered from disrupted sleep, less aware of alternative treatments, had comorbid chronic physical illness, and were current smokers.

LIMITATIONS

The cross-sectional study design limited its ability to confirm causal relationships.

CONCLUSIONS

Long-term and excessive daily dose of BZDs use in patients with depressive or anxiety disorders needs to be noted. Providing information or program of non-pharmacological treatment in reducing anxiety and improving specific sleep disturbance is suggested. Elderly, suffering from depressive mood, had comorbid chronic physical illness need to be targeted for further intervention.

Threat-sensitivity in affective disorders: A case-control study

BACKGROUND

Anxiety disorders are highly comorbid with major depression but differ in their symptom profiles and pharmacological responses. Threat-sensitivity may explain such differences, yet research on its relationship to specific disorders is lacking.

METHODS

One-hundred patients (71 women) and 35 healthy controls (23 women) were recruited. Thirty-five had Panic Disorder (PD), 32 had Generalized Anxiety Disorder (GAD) and 33 Major Depressive Disorder (MDD). Threat-sensitivity was measured via behaviour (Joystick Operated Runway Task; JORT) and self-report (Fear Survey Schedule; FSS).

RESULTS

Behavioural sensitivity to simple threat was higher in females compared to males (p = .03). Self-reported sensitivity to simple threat (FSS Tissue Damage Fear) was higher in PD patients compared to other groups (p ≤ .007) and in GAD patients compared to controls (p = .02). Behavioural sensitivity to complex threat was higher in females than males (p = .03) and a group by sex interaction (p = .01) indicated that this difference was largest in PD patients. Self-reported sensitivity to complex threat (FSS Social Fear) was higher in all patients compared to controls (p ≤ .001). Females scored higher than males on FSS Tissue Damage Fear and FSS Social Fear).

CONCLUSIONS

Our findings oppose the simple/complex threat dichotomy, instead suggesting elevated sensitivity to physical threat differentiates anxiety disorders from MDD, whereas elevated sensitivity to social threat is associated with both anxiety disorders and MDD.

Current and Novel Psychopharmacological Drugs for Anxiety Disorders

Anxiety disorders, including panic disorder/agoraphobia (PDA), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and others, are the most prevalent mental disorders. In this paper, recommendations are given for the psychopharmacological treatment of these disorders which are based on comprehensive treatment guidelines, meta-analyses, and systematic reviews of available randomized controlled studies. Anxiety disorders can effectively be treated with psychotherapy, pharmacotherapy, or a combination of both. First-line drugs are the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Benzodiazepines are not recommended for routine use due to their possible addiction potential. Other treatment options include the calcium modulator pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. Drug treatment can be combined with psychological treatments. Novel treatment strategies include medications that act on GABA, glutamate, and other neurotransmitter systems. After remission, medications should be continued for 6 to 12 months.

Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms

The current report provides an updated review of sleep disturbance in posttraumatic stress disorder and anxiety-related disorders. First, this review provides a summary description of the unique and overlapping clinical characteristics and physiological features of sleep disturbance in specific DSM anxiety-related disorders. Second, this review presents evidence of a bidirectional relationship between sleep disturbance and anxiety-related disorders, and provides a model to explain this relationship by integrating research on psychological and neurocognitive processes with a current understanding of neurobiological pathways. A heuristic neurobiological framework for understanding the bidirectional relationship between abnormalities in sleep and anxiety-related brain pathways is presented. Directions for future research are suggested.

Selective serotonin reuptake inhibitors and benzodiazepines in panic disorder: A meta-analysis of common side effects in acute treatment

BACKGROUND

Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.

AIM

The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.

METHODS

We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.

RESULTS

Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.

CONCLUSION

Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

Photopotentiation of the GABAA receptor with caged diazepam

As the inhibitory γ-aminobutyric acid-ergic (GABAergic) transmission has a pivotal role in the central nervous system (CNS) and defective forms of its synapses are associated with serious neurological disorders, numerous versions of caged GABA and, more recently, photoswitchable ligands have been developed to investigate such transmission. While the complementary nature of these probes is evident, the mechanisms by which the GABA receptors can be photocontrolled have not been fully exploited. In fact, the ultimate need for specificity is critical for the proper synaptic exploration. No caged allosteric modulators of the GABA_A receptor have been reported so far; to introduce such an investigational approach, we exploited the structural motifs of the benzodiazepinic scaffold to develop a photocaged version of diazepam (CD) that was tested on basolateral amygdala (BLa) pyramidal cells in mouse brain slices. CD is devoid of any intrinsic activity toward the GABA_A receptor before irradiation. Importantly, CD is a photoreleasable GABA_A receptor-positive allosteric modulator that offers a different probing mechanism compared to caged GABA and photoswitchable ligands. CD potentiates the inhibitory signaling by prolonging the decay time of postsynaptic GABAergic currents upon photoactivation. Additionally, no effect on presynaptic GABA release was recorded. We developed a photochemical technology to individually study the GABA_A receptor, which specifically expands the toolbox available to study GABAergic synapses.

Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety

Importance: Benzodiazepines (BZs) are still widely prescribed for the treatment of anxiety disorders despite many publications in the literature which favour antidepressants (ADs) instead. What is the evidence?Observations: Treatment guidelines favour ADs over BZs for treatment of anxiety disorders without any head-to-head comparison of both drug groups with placebo. BZs are claimed to cause less efficacy and more safety issues than ADs, yet ADs also cause disturbing adverse events and, similar to BZs, discontinuation symptoms. Until evidence-based data become available, a look at two 6-month generalized anxiety disorder trials conducted by the same research group, one with a BZ and the other with an AD, might provide some guidance for the clinician. Most improvement with a BZ was obtained by 4 weeks, suggesting that BZ treatment longer than 4 weeks should only be offered to patients maximally improved at 4 weeks. In contrast, ADs may have to be prescribed for 3-6 months to obtain maximal benefits.Conclusion: Results of a controlled trial as proposed will go a long way in providing clinicians missing information to guide them in the appropriate use of both BZs and ADs in anxiety disorders.

Exploring characteristics associated with first benzodiazepine prescription in patients with affective disorders and related diagnoses

OBJECTIVE

In patients with affective disorders, benzodiazepines (BZDs) are frequently administered at the onset, sometimes inappropriately. We sought to identify clinical variables associated with first BZD prescription in a large sample of patients with affective disorders.

METHODS

Four hundred sixty patients with mood or anxiety disorders attending different psychiatric services were assessed comparing those who received BZD as first treatment (BZD w/) and those who did not (BZD w/o).

RESULTS

More than one third (35.7%) of the total sample had received BZDs as first prescription. In relation to mood disorders, BZD w/ subjects more frequently (a) had not a psychiatrist as first therapist, (b) had anxious symptoms at onset, (c) had adjustment disorder as first diagnosis, (d) were treated as outpatients. In relation to specific diagnoses, (a) personal decision of treatment for major depressive disorder, (b) outpatient status for bipolar disorder and (c) longer duration of untreated illness for adjustment disorder were more frequently associated with first BZD prescription. For anxiety disorders, the presence of stressful life events and the diagnoses of panic disorder or specific phobias were more frequently observed in BZD w/ patients.

CONCLUSION

Patients with affective disorders frequently received BZDs as first prescription with significant differences between and within mood and anxiety disorders.

Effect of Salvia Officinalis L. and Rosmarinus Officinalis L. leaves extracts on anxiety and neural activity

Anxiety, the illness of our time, is one of the most prevalent and co-morbid psychiatric disorder that represents a significant socioeconomic burden. Conventional treatment is associated with a number of side effects and there is a need to develop new therapeutic strategies. Therefore, it is of interest to investigate the modulating effects of Salvia Officinalis L. and Rosmarinus Officinalis L. leaves extracts on anxiety using different behavioral tests, and on neural activity using the Multi-electrode array technique. Data shows the decrease of the time of the immobility associated with a significant increase in the time spent in the center of the open field arena in the treated animals compared to the controls. The number of buried marbles has also decreased in the treated animals in the marble-burying test. On the other hand results also show a decrease of the neural activity explained by a decrease of the number of spikes after 24,48 and 72 h following the addition of 12,5 µg/ml of the plant leaf extracts to the neural culture. However, there were no spikes after the administration of 25µg/ml of the plants extracts.

Benzodiazepine ingestion as a way to die by suicide and related safety: the case of an elderly patient

Benzodiazepines (BDZs) are widespread psychotropic compounds, often prescribed as first-line symptomatic option by general practitioners in patients with different psychiatric disorders. Sometimes, however, they contribute to delay the administration of the first appropriate psychopharmacological treatment, thus leading to a longer duration of untreated illness in patients with depressive and anxiety disorders. The well-established pros of BDZs use in clinical practice include efficacy, rapidity of action, versatility, and safety. Among the cons, BDZs can provoke cognitive side-effects, asthenia, and misuse/abuse. Although their overall safety has been traditionally viewed as one of their greatest strengths, BDZs massive ingestion for suicidal purposes may pose, in some cases, serious life-threatening conditions, as described in the present case report. Hence, particular attention needs to be paid in prescribing these compounds to special populations, such as elderly patients. Among these, their prescription should be limited to the short-term and particularly monitored in case of risk factors, as they may be unsafe in case of overdose.

Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle

Objective:

This study aimed to determine the prevalence of benzodiazepine (BZD) use in Brazil and to investigate the direct and indirect effects of alcohol consumption, sedentary lifestyle (SL), depressive symptoms (DS), and sleep dissatisfaction (SD) on BZD use.

Methods:

The Second Brazilian Alcohol and Drugs Survey (II BNADS) used stratified cluster probabilistic sampling to select 4,607 individuals aged 14 years and older from the Brazilian household population.

Results:

The lifetime and 12-month prevalence of BZD use was 9.8 and 6.1%, respectively. Older participants (age 40 and older) and women had higher rates. Alcohol use disorder, DS, and SD were significantly more prevalent in BZD users. The parallel multiple mediator model showed a positive direct effect of alcohol consumption on BZD use, with significant positive indirect effects of SL, SD, and DS as simultaneous mediators leading to higher BZD intake. Other statistically significant indirect pathways were DS alone, SD alone, and all of the above except SL.

Conclusion:

The prevalence of BZD use in Brazil is high compared to that of other countries. Knowledge of the main risk factors and pathways to consumption can guide prevention initiatives and underlie the development of better tailored and effective treatment strategies.

Does initial use of benzodiazepines delay an adequate pharmacological treatment? A multicentre analysis in patients with psychotic and affective disorders

It is established that delayed effective pharmacotherapy plays a significant role in the overall burden of psychiatric disorders, which are often treated with symptomatic drugs, that is benzodiazepines (BZDs), in relation to their rapid onset of action and safety, despite long-term side effects. We aimed to assess the influence of initial treatment with BZDs on the duration of untreated illness (DUI) and whether specific sociodemographic and clinical factors could influence the choice of BZDs as first treatment in 545 patients affected by schizophrenia, mood and anxiety spectrum disorders. Statistical analyses (one-way analysis of variance and χ) were carried out to compare patients who used BZDs as first treatment (BZD w/) and those who did not (BZD w/o). The overall DUI, irrespective of diagnosis, resulted in significantly longer in BZD w/ versus w/o patients, who also experienced more frequently anxious/depressive symptoms at onset. Furthermore, BZD w/ patients more frequently autonomously decided to look for treatment (mainly refering to psychologists or general practitioners) and experimented more frequently phobias, than BZD w/o ones. The present findings suggest that initial BZDs treatment may prolong the overall DUI, although their prescription seems to be influenced by specific sociodemographic and clinical factors. Further studies are needed to confirm the present findings.

Predictors of benzodiazepine use in a transdiagnostic sample of panic disorder, social anxiety disorder, and obsessive-compulsive disorder patients

We investigated the rates of current and past benzodiazepine (BZD) use in a sample of 102 subjects attending specialized anxiety disorder clinics, including panic disorder (PD; N = 36), social anxiety disorder (SAD; N = 28) and obsessive-compulsive disorder (OCD; N = 38) patients. Almost 56% of the entire sample was using BZDs at the moment of the assessment, and 74.5% described having used them at some point during their lifetimes. The duration of psychiatric treatment and a lifetime history of PD, but not any other "transdiagnostic" measure of severity (such as the Panic and Agoraphobia Scale, the Social Phobia Inventory, the Dimensional Obsessive-Compulsive Scale, the Anxiety Sensitivity Index-36, and the Beck Inventories) were independent risk factors for current prescription of BZDs. Patients who continued to use BZDs differed from patients who stopped them by being older (both currently and when firstly seen in the clinic), by having a later age at onset of their most significant anxiety disorder, by being more agoraphobic/avoidant, and by believing to be less capable of stopping their BZDs for the fear of not being able to sleep.

Treatment of anxiety disorders

Anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, social anxiety disorder, and others) are the most prevalent psychiatric disorders, and are associated with a high burden of illness. Anxiety disorders are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the disorder. The treatment recommendations given in this article are based on guidelines, meta-analyses, and systematic reviews of randomized controlled studies. Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for routine use. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. After remission, medications should be continued for 6 to 12 months. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.

Psychiatrists' treatment preferences for generalized anxiety disorder

OBJECTIVE

The objective of this study is to ascertain psychiatrists' treatment preferences for generalized anxiety disorder (GAD) and compare them to the same psychiatrists' treatment preferences in the hypothetical scenario that treatment is to be administered to themselves as patients.

METHODS

A questionnaire was completed by 221 psychiatrists from 3 Balkan countries. They were asked to indicate their treatment preferences for patients with GAD and for themselves as patients.

RESULTS

A large majority of psychiatrists chose selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors as preferred treatment option for GAD patients. Fewer psychiatrists selected benzodiazepines and pregabalin and about one third chose psychotherapy. The majority of psychiatrists chose the same treatments for their patients and for themselves, with main differences being in terms of pharmacotherapy (especially benzodiazepines) being less frequently recommended and psychotherapy being more frequently recommended as preferred treatment option for psychiatrists as patients.

CONCLUSIONS

Treatment preferences for GAD by psychiatrists in the 3 West Balkan countries were mostly in accordance with treatment guidelines and treatment preferences for patients and for psychiatrists as patients were mostly concordant. However, some psychiatrists were more likely to choose pharmacotherapy for patients and psychotherapy for themselves as patients. These findings have implications for education of psychiatrists and for efforts to improve treatment guidelines and mental health services.

Insomnia in hospitalized psychiatric patients: prevalence and associated factors

OBJECTIVES

To quantify and describe the prevalence of insomnia in hospitalized psychiatric patients and to investigate the associations between insomnia and demographic and clinical factors in hospitalized psychiatric patients.

METHODS

The participants included 203 individuals hospitalized for psychiatric treatment at an academic medical center. Demographic information, psychiatric diagnoses, current psychotropic medication use, and history of substance use were collected. Insomnia screening was performed using the Insomnia Severity Index. Depressive and anxiety symptoms were also evaluated using the Generalized Anxiety Disorder questionnaire and the Patient Health Questionnaire. Restless legs syndrome (RLS) symptoms were evaluated using the Restless Legs Syndrome Rating Scale (RLSRS). Statistical analysis was conducted to detect the prevalence of insomnia among the participants and to examine possible associations among psychiatric disorders, psychotropic medications, and RLS.

RESULTS

Out of the 203 participants that completed the survey, 67.4% were found to have insomnia and 14.3% were found to have RLS. The severity of insomnia was found to be associated with the presence of RLS, depressive and anxious symptomatology, suicidal ideation, use of selective serotonin reuptake inhibitors, and use of benzodiazepines.

Morbid Anxiety: Identification and Treatment

Due to their prevalence, chronicity, and poorly understood pathophysiology, anxiety disorders remain an important public health problem. Despite clear diagnostic guidelines and the availability of excellent evidence-based treatments, most anxiety patients remain underrecognized and inadequately treated. This clinical synthesis highlights changes to anxiety disorder diagnosis that became effective with DSM-5. The article also provides some clinical perspective on clarifying differential diagnostic problems and building an alliance with the anxious patient. The quality and strength of the evidence base for current anxiolytic medications options (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, and other agents), antianxiety psychotherapies (cognitive-behavioral therapy and brief dynamic therapies), and combination treatments are discussed. A brief update on newer treatment strategies, such as cognitive enhancement, complementary therapies, and neuromodulation, is included. Future directions for anxiety nosology and treatment are summarized, including the National Institute of Mental Health Research Domain Criteria initiative and the promising role of personalized medicine.

Which factors influence onset and latency to treatment in generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder?

Anxiety disorders are common, comorbid, and disabling conditions, often underdiagnosed and under-treated, typically with an early onset, chronic course, and prolonged duration of untreated illness. The present study aimed to explore the influence of sociodemographic and clinical factors in relation to onset and latency to treatment in patients with generalized anxiety disorder (GAD), panic disorder (PD), and obsessive-compulsive disorder (OCD). A total of 157 patients with a Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR) diagnosis of PD (n=49), GAD (n=68), and OCD (n=40) were recruited, and epidemiological and clinical variables were collected through a specific questionnaire. Statistical analyses were carried out to compare variables across diagnostic groups. PD, GAD, and OCD patients showed a duration of untreated illness of 53.9±81.5, 77.47±95.76, and 90.6±112.1 months, respectively. Significant differences between groups were found with respect to age, age of first diagnosis, age of first treatment, family history of psychiatric illness, onset-related stressful events, benzodiazepine prescription as first treatment, antidepressant prescription as first treatment, and help-seeking (self-initiated vs. initiated by others). Patients with GAD, PD, and OCD showed significant differences in factors influencing onset and latency to treatment, which may, in turn, affect condition-related outcome and overall prognosis. Further studies with larger samples are warranted in the field.

Benzodiazepine Use During Hospitalization: Automated Identification of Potential Medication Errors and Systematic Assessment of Preventable Adverse Events

Objective

Benzodiazepines and “Z-drug” GABA-receptor modulators (BDZ) are among the most frequently used drugs in hospitals. Adverse drug events (ADE) associated with BDZ can be the result of preventable medication errors (ME) related to dosing, drug interactions and comorbidities. The present study evaluated inpatient use of BDZ and related ME and ADE.

Methods

We conducted an observational study within a pharmacoepidemiological database derived from the clinical information system of a tertiary care hospital. We developed algorithms that identified dosing errors and interacting comedication for all administered BDZ. Associated ADE and risk factors were validated in medical records.

Results

Among 53,081 patients contributing 495,813 patient-days BDZ were administered to 25,626 patients (48.3%) on 115,150 patient-days (23.2%). We identified 3,372 patient-days (2.9%) with comedication that inhibits BDZ metabolism, and 1,197 (1.0%) with lorazepam administration in severe renal impairment. After validation we classified 134, 56, 12, and 3 cases involving lorazepam, zolpidem, midazolam and triazolam, respectively, as clinically relevant ME. Among those there were 23 cases with associated adverse drug events, including severe CNS-depression, falls with subsequent injuries and severe dyspnea. Causality for BDZ was formally assessed as ‘possible’ or ‘probable’ in 20 of those cases. Four cases with ME and associated severe ADE required administration of the BDZ antagonist flumazenil.

Conclusions

BDZ use was remarkably high in the studied setting, frequently involved potential ME related to dosing, co-medication and comorbidities, and rarely cases with associated ADE. We propose the implementation of automated ME screening and validation for the prevention of BDZ-related ADE.

Antidepressants and benzodiazepines for panic disorder in adults

BACKGROUND

A panic attack is a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. Panic disorder is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, antidepressants and benzodiazepines are the mainstay of treatment for panic disorder. Different classes of antidepressants have been compared; and the British Association for Psychopharmacology, and National Institute for Health and Care Excellence (NICE) consider antidepressants (mainly selective serotonin reuptake inhibitors (SSRIs)) as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). In addition to antidepressants, benzodiazepines are widely prescribed for the treatment of panic disorder.

OBJECTIVES

To assess the evidence for the effects of antidepressants and benzodiazepines for panic disorder in adults.

SEARCH METHODS

The Specialised Register of the Cochrane Common Mental Disorders Group (CCMDCTR) to 11 September 2015. This register includes relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950-), Embase (1974-) and PsycINFO (1967-). Reference lists of relevant papers and previous systematic reviews were handsearched. We contacted experts in this field for supplemental data.

SELECTION CRITERIA

All double-blind randomised controlled trials allocating adult patients with panic disorder to antidepressants or benzodiazepines versus any other active treatment with antidepressants or benzodiazepines.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a standard form. Data were entered in RevMan 5.3 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details, settings and outcome measures in terms of efficacy, acceptability and tolerability.

MAIN RESULTS

Thirty-five studies, including 6785 participants overall (of which 5365 in the arms of interest (antidepressant and benzodiazepines as monotherapy)) were included in this review; however, since studies addressed many different comparisons, only a few trials provided data for primary outcomes. We found low-quality evidence suggesting no difference between antidepressants and benzodiazepines in terms of response rate (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.67 to 1.47; participants = 215; studies = 2). Very low-quality evidence suggested a benefit for benzodiazepines compared to antidepressants in terms of dropouts due to any cause, even if confidence interval (CI) ranges from almost no difference to benefit with benzodiazepines (RR 1.64, 95% CI 1.03 to 2.63; participants = 1449; studies = 7). We found some evidence suggesting that serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs (when looking at the number of patients experiencing adverse effects). We failed to find clinically significant differences between individual benzodiazepines. The majority of studies did not report details on random sequence generation and allocation concealment; similarly, no details were provided about strategies to ensure blinding. The study protocol was not available for almost all studies so it is difficult to make a judgment on the possibility of outcome reporting bias. Information on adverse effects was very limited.

AUTHORS' CONCLUSIONS

The identified studies are not sufficient to comprehensively address the objectives of the present review. The majority of studies enrolled a small number of participants and did not provide data for all the outcomes specified in the protocol. For these reasons most of the analyses were underpowered and this limits the overall completeness of evidence. In general, based on the results of the current review, the possible role of antidepressants and benzodiazepines should be assessed by the clinician on an individual basis. The choice of which antidepressant and/or benzodiazepine is prescribed can not be made on the basis of this review only, and should be based on evidence of antidepressants and benzodiazepines efficacy and tolerability, including data from placebo-controlled studies, as a whole. Data on long-term tolerability issues associated with antidepressants and benzodiazepines exposure should also be carefully considered.The present review highlights the need for further higher-quality studies comparing antidepressants with benzodiazepines, which should be conducted with high-methodological standards and including pragmatic outcome measures to provide clinicians with useful and practical data. Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.

Attitudes towards a maintenance (-agonist) treatment approach in high-dose benzodiazepine-dependent patients: a qualitative study

BACKGROUND

High-dose benzodiazepine dependence constitutes a major clinical concern. Although withdrawal treatment is recommended, it is unsuccessful for a significant proportion of affected patients. More recently, a benzodiazepine maintenance approach has been suggested as an alternative for patients' failing discontinuation treatment. While there is some data supporting its effectiveness, patients' perceptions of such an intervention have not been investigated.

METHODS

An exploratory qualitative study was conducted among a sample of 41 high-dose benzodiazepine (BZD)-dependent patients, with long-term use defined as doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use, such as mixing substances, dose escalation, recreational use, or obtainment by illegal means. A qualitative content analysis approach was used to evaluate findings.

RESULTS

Participants generally favored a treatment discontinuation approach with abstinence from BZD as its ultimate aim, despite repeated failed attempts at withdrawal. A maintenance treatment approach with continued prescription of a slow-onset, long-acting agonist was viewed ambivalently, with responses ranging from positive and welcoming to rejection. Three overlapping themes of maintenance treatment were identified: "Only if I can try to discontinue…and please don't call it that," "More stability and less criminal activity…and that is why I would try it," and "No cure, no brain and no flash…and thus, just for everybody else!"

CONCLUSIONS

Some patients experienced slow-onset, long-acting BZDs as having stabilized their symptoms and viewed these BZDs as having helped avoid uncontrolled withdrawal and abstain from criminal activity. We therefore encourage clinicians to consider treatment alternatives if discontinuation strategies fail.

Use of benzodiazepines in obsessive-compulsive disorder

This study aimed to determine the frequency of benzodiazepine (BDZ) use in a large sample of patients with obsessive-compulsive disorder (OCD) and ascertain the type of BDZ used and the correlates and predictors of BDZ use in OCD. The sample consisted of 955 patients with OCD from a comprehensive, cross-sectional, multicentre study conducted by the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders between 2003 and 2009. The rate of BDZ use over time in this OCD sample was 38.4%. Of individuals taking BDZs, 96.7% used them in combination with other medications, usually serotonin reuptake inhibitors. The most commonly used BDZ was clonazepam. Current age, current level of anxiety and number of additional medications for OCD taken over time significantly predicted BDZ use. This is the first study to comprehensively examine BDZ use in OCD patients, demonstrating that it is relatively common, despite recommendations from treatment guidelines. Use of BDZs in combination with several other medications over time and in patients with marked anxiety suggests that OCD patients taking BDZs may be more complex and more difficult to manage. This calls for further research and clarification of the role of BDZs in the treatment of OCD.

Pharmacological treatment for generalized anxiety disorder in adults: an update

INTRODUCTION

Modest response and remission rates for the selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitors, coupled with mounting evidence that the tolerability of the antidepressants (ADs) may have been overstated in the literature, has contributed to changes in prescribing patterns for generalized anxiety disorder (GAD). New interest in the absence of evidence that supports these standard therapies as superior to benzodiazepines stimulated a review of the literature.

AREAS COVERED

A literature search was conducted in the MedLine database with search terms 'generalized anxiety disorder' and 'treatment' for purposes of including relevant literature related to pharmacologic treatment of GAD. Aside from a review of pivotal literature, the authors also included newer studies that evaluated novel drug treatments. Last, the database was searched for benzodiazepine comparisons to standard therapy secondary to concerns that such literature is sparse. The review of newer modalities and the decision to include related literature was also based on the strength of the evidence and the status of their approval for the treatment of GAD.

EXPERT OPINION

Although ADs remain the most frequently prescribed medications for GAD, alternative and off-label therapies such as pregabalin, the atypical antipsychotics and vortioxetine are garnering interest. Based on the evidence available to us, it is our recommendation that along with the ADs, benzodiazepines be considered a possible first-line therapy in eligible patients based on the discretion and clinical judgment of the treating physician.

TSPO, a Mitochondrial Outer Membrane Protein, Controls Ethanol-Related Behaviors in Drosophila

The heavy consumption of ethanol can lead to alcohol use disorders (AUDs) which impact patients, their families, and societies. Yet the genetic and physiological factors that predispose humans to AUDs remain unclear. One hypothesis is that alterations in mitochondrial function modulate neuronal sensitivity to ethanol exposure. Using Drosophila genetics we report that inactivation of the mitochondrial outer membrane translocator protein 18kDa (TSPO), also known as the peripheral benzodiazepine receptor, affects ethanol sedation and tolerance in male flies. Knockdown of dTSPO in adult male neurons results in increased sensitivity to ethanol sedation, and this effect requires the dTSPO depletion-mediated increase in reactive oxygen species (ROS) production and inhibition of caspase activity in fly heads. Systemic loss of dTSPO in male flies blocks the development of tolerance to repeated ethanol exposures, an effect that is not seen when dTSPO is only inactivated in neurons. Female flies are naturally more sensitive to ethanol than males, and female fly heads have strikingly lower levels of dTSPO mRNA than males. Hence, mitochondrial TSPO function plays an important role in ethanol sensitivity and tolerance. Since a large array of benzodiazepine analogues have been developed that interact with the peripheral benzodiazepine receptor, the mitochondrial TSPO might provide an important new target for treating AUDs.

Alcohol use disorders (AUDs) affect millions of patients worldwide and result in high social and economic burdens. Although environmental factors are involved, there are clear genetic components to AUDs. Both the acute sedating effect of alcohol exposure and alcohol tolerance contribute to long term risk for alcohol dependence and addiction. Yet the genetic etiology of AUDs remains to be determined. The mitochondria play a central role in ethanol metabolism and are important in many aspects of cellular physiology such as REDOX and ROS regulation, and apoptosis. The mitochondrial outer membrane translocator protein 18 kDa (TSPO) binds the benzodiazepines and perhaps other addictive drugs, and thus may play a role in AUDs. Since Drosophila is a well-established model for ethanol-related behaviors, we have developed systems for manipulating the Drosophila tspo gene and protein. With these systems, we have discovered that neuronal TSPO controls sensitivity to ethanol sedation via ROS and caspase-mediated signaling and that systemic TSPO levels are important in the development of tolerance to repeated ethanol exposure. Given the variety of known TSPO ligands, and the common mechanisms of various abusive substances, our studies suggest that TSPO might be a promising target to combat alcoholism as well as addiction to other drugs.