Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified?

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Abstract

The benzodiazepines are still extensively used in psychiatry, neurology and medicine in general. Anxiety disorder and severe insomnia are important syndromal indications, but these drugs are widely prescribed at the symptomatic level, resulting in potential overuse. The official data sheets recommend short durations of usage and conservative dosage. Although short-term efficacy is established, long-term efficacy remains controversial, as relevant data are scanty and relapse, rebound and dependence on withdrawal not clearly distinguished. The risks of the benzodiazepines are well-documented and comprise psychological and physical effects. Among the former are subjective sedation, paradoxical release of anxiety and/or hostility, psychomotor impairment, memory disruption, and risks of accidents. Physical effects include vertigo, dysarthria, ataxia with falls, especially in the elderly. Dependence can supervene on long-term use, occasionally with dose escalation. The benzodiazepines are now recognised as major drugs of abuse and addiction. Other drug and non-drug therapies are available and have a superior risk benefit ratio in long-term use. It is concluded that benzodiazepines should be reserved for short-term use — up to 4 weeks — and in conservative dosage.

Introduction

The benzodiazepines comprise a large group of drugs which are used extensively in psychiatry, neurology and other branches of medicine. They were first introduced over 30 years ago, and have been extensively prescribed to treat anxiety, insomnia, muscle spasm, and epilepsy. They have also been used to induce anaesthesia. Although generally regarded as safe and effective drugs, their risk/benefit profile is becoming increasingly questioned (Rosenbaum, 1982, Maczaj, 1993, Lader, 1994).

The benzodiazepines were originally marketed as improvements on the barbiturates and on meprobamate. They seemed much safer in overdose, had fewer drug interactions and probably a low liability for both dependence in licit medical use and illicit abuse ‘on the street’. Over the years the unwanted effects of the benzodiazepines have become more obvious: psychomotor/cognitive impairment is common and more serious neuropsychiatric reactions such as amnesic and aggressive episodes may occur. With long-term use dependence is now a recognised risk, and abuse, orally, intravenously and by ‘snorting’ (Sheehan et al., 1991) is a burgeoning worldwide concern. Despite these misgivings, the benzodiazepines are still regarded in many European countries as useful drugs providing they are prescribed appropriately. I will concentrate on two indications, anxiety and insomnia. Both tend to be chronic conditions.

Section snippets

Indications, dosage and duration of treatment

Fig. 1, Fig. 2 show the recommendations in the UK data sheets for diazepam and temazepam, respectively. Both refer to ‘short-term management’ when the disorder is “severe, disabling or subjecting the individual to extreme distress”. There are also similar definitions of ‘short-term’: 2–4 weeks which includes a tapering-off period in the case of temazepam. Extension beyond this time is acknowledged to be necessary sometimes but only with re-evaluation of the patient’s status.

Dosage

Short-term

Anxiety disorders are found commonly in the general population. Estimates range from 5 to 20% depending on the severity criteria for ‘caseness’ and the mode of detection. Generalised anxiety disorder is probably the commonest of these conditions, followed by panic disorder (with or without agoraphobia), and social phobia. Acute stress reactions and anxiety symptoms as part of other psychiatric disorders or physical disorders are very commonly encountered. Despite the frequency of these

Risks

These will be reviewed under several headings.

Other therapies

A range of other treatments are available, some being appropriate for long-term treatment. For GAD and PD, these alternatives include tricyclic antidepressants (TCAs) such as imipramine and clomipramine, selective serotonin reuptake inhibitors (SSRIs) like citalopram, fluoxetine, sertraline and paroxetine, and monoamine oxidase inhibitors (MAOIs) both non-selective and irreversible, like phenelzine, and selective and reversible (moclobemide). Such use of antidepressants is formally approved by

Conclusions

A wide spectrum of opinions is expressed concerning the benzodiazepines. As this symposium shows this ranges from protestations that they are valuable drugs grossly underused and therefore depriving suffering patients of effective symptomatic relief to judgements that their risk benefit ratios as anxiolytics and hypnotics is adverse under all circumstances. The middle ground, held by most prescribers is that short-term use is acceptable but that questions hang over long-term use.

Thus:

“even if

Summary

Benzodiazepines, despite their vicissitudes, are seen as effective treatments, at least in the short-term. The risk/benefit ratio of these drugs becomes less favourable or even adverse as treatment becomes prolonged: efficacy wanes and risks accumulate. Patients with severe anxiety, panic and insomnia disorders can be greatly helped by short-term intervention with a benzodiazepine but the benefits long-term remain debatable (Ashton, 1994, Lader, 1994). A comprehensive treatment strategy is

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