Changes in "withdrawal symptoms" following discontinuation of low-dose diazepam

WITHDRAWN: Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings

This review was withdrawn from publication in June 2013 because it is substantially out‐of‐date.

The editorial group responsible for this previously published document have withdrawn it from publication.

Withdrawing benzodiazepines in primary care

The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addiction have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescribers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discontinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescribers.This review sets out the stratagems that have been evaluated, concentrating on those of a pharmacological nature. Simple interventions include basic monitoring of repeat prescriptions and assessment by the doctor. Even a letter from the primary-care practitioner pointing out the continuing usage of benzodiazepines and questioning their need can result in reduction or cessation of use. Pharmacists also have a role to play in monitoring the use of benzodiazepines, although mobilizing their assistance is not yet routine. Such stratagems can avoid the use of specialist back-up services such as psychiatrists, home care, and addiction and alcohol misuse treatment facilities.Pharmacological interventions for benzodiazepine dependence have been reviewed in detail in a recent Cochrane review, but only eight studies proved adequate for analysis. Carbamazepine was the only drug that appeared to have any useful adjunctive properties for assisting in the discontinuation of benzodiazepines but the available data are insufficient for recommendations to be made regarding its use. Antidepressants can help if the patient is depressed before withdrawal or develops a depressive syndrome during withdrawal. The clearest strategy was to taper the medication; abrupt cessation can only be justified if a very serious adverse effect supervenes during treatment. No clear evidence suggests the optimum rate of tapering, and schedules vary from 4 weeks to several years. Our recommendation is to aim for withdrawal in <6 months, otherwise the withdrawal process can become the morbid focus of the patient's existence. Substitution of diazepam for another benzodiazepine can be helpful, at least logistically, as diazepam is available in a liquid formulation.Psychological interventions range from simple support through counselling to expert cognitive-behavioural therapy (CBT). Group therapy may be helpful as it at least provides support from other patients. The value of counselling is not established and it can be quite time consuming. CBT needs to be administered by fully trained and experienced personnel but seems effective, particularly in obviating relapse.The outcome of successful withdrawal is gratifying, both in terms of improved functioning and abstinence from the benzodiazepine usage. Economic benefits also ensue.Some of the principles of withdrawing benzodiazepines are listed. Antidepressants may be helpful, as may some symptomatic remedies. Care must be taken not to substitute one drug dependence problem for the original one.

Combined psychotherapy plus benzodiazepines for panic disorder

BACKGROUND

The efficacy of combining psychotherapy and benzodiazepines for panic disorder is unclear, despite widespread use.

OBJECTIVES

To examine the efficacy of the combination compared with either treatment alone.

SEARCH STRATEGY

Randomised trials comparing the combination of psychotherapy and benzodiazepine with either therapy alone for panic disorder were identified. The Cochrane Depression, Anxiety and Neurosis Group Studies and References Registers were searched. References of relevant trials and other reviews were checked. Experts in the field were contacted. Additional unpublished data were sought from authors of the original trials.

SELECTION CRITERIA

Two authors independently checked the records retrieved by the searches to identify randomised trials comparing the combined therapy versus either of the monotherapies, among adults with panic disorder.

DATA COLLECTION AND ANALYSIS

Two authors independently checked eligibility, assessed quality and extracted data from the eligible trials using a standardised data extraction form. The primary outcome was "response" based on global judgement. Random-effects meta-analyses were conducted, combining data from included trials.

MAIN RESULTS

Three trials met eligibility criteria. A 16-week behaviour therapy intervention was used in two trials, and a 12-week cognitive-behaviour therapy intervention in the third. Duration of follow-up varied, ranging from 0 to 12 months. Two trials (total 166 participants) provided data comparing combination with psychotherapy alone (both using behaviour therapy). No statistically significant differences were observed in response during the intervention (relative risk (RR) for combination 1.25, 95% CI 0.78 to 2.03, P = 0.35), at the end of the intervention (RR 0.78, 0.45 to 1.35, P = 0.37), or at the last follow-up time point, although the follow-up data suggested that the combination might be inferior to behaviour therapy alone (RR 0.62, 0.36 to 1.07, P = 0.08). One trial (77 participants) compared combination with a benzodiazepine alone. No differences were found in response during the intervention (RR 1.57, 0.83 to 2.98, P = 0.17). Although the combination appeared to be superior to the benzodiazepine alone at the end of treatment (RR 3.39, 1.03 to 11.21, P = 0.05) the finding was only borderline statistically significant, and no significant differences were observed at the 7-month follow-up (RR 2.31, 0.79 to 6.74, P = 0.12).

AUTHORS' CONCLUSIONS

The review established the paucity of high quality evidence investigating the efficacy of psychotherapy combined with benzodiazepines for panic disorder. Currently, there is inadequate evidence to assess the clinical effects of psychotherapy combined with benzodiazepines for patients who are diagnosed with panic disorder.

Combination of psychotherapy and benzodiazepines versus either therapy alone for panic disorder: a systematic review

BACKGROUND

The efficacy of combined psychotherapy and benzodiazepine treatment for panic disorder is still unclear despite its widespread use. The present systematic review aims to examine its efficacy compared with either monotherapy alone.

METHODS

All randomised trials comparing combined psychotherapy and benzodiazepine for panic disorder with either therapy alone were identified by comprehensive electronic search on the Cochrane Registers, by checking references of relevant studies and of other reviews, and by contacting experts in the field. Two reviewers independently checked eligibility of trials, assessed quality of trials and extracted data from eligible trials using a standardized data extraction form. Our primary outcome was "response" defined by global judgement. Authors of the original trials were contacted for further unpublished data. Meta-analyses were undertaken synthesizing data from all relevant trials.

RESULTS

Only two studies, which compared the combination with behaviour (exposure) therapy, met our eligibility criteria. Both studies had a 16-week intervention. Unpublished data were retrieved for one study. The relative risk for response for the combination was 1.25 (95%CI: 0.78 to 2.03) during acute phase treatment, 0.78 (0.45 to 1.35) at the end of treatment, and 0.62 (0.36 to 1.07) at 6-12 months follow-up. Some secondary outcomes hinted at superiority of the combination during acute phase treatment. One study was identified comparing the combination to benzodiazepine. The relative risk for response was 1.57 (0.83 to 2.98), 3.39 (1.03 to 11.21, statistically significant) and 2.31 (0.79 to 6.74) respectively. The superiority of the combination was observed on secondary outcomes at all the time points. No sub-group analyses were conducted due to the limited number of included trials.

CONCLUSION

Unlike some narrative reviews in the literature, our systematic search established the paucity of high quality evidence for or against the combined psychotherapy plus benzodiazepine therapy for panic disorder. Based on limited available published and unpublished data, however, the combined therapy is probably to be recommended over benzodiazepine alone for panic disorder with agoraphobia. The combination might be superior to behaviour therapy alone during the acute phase, but afterwards this trend may be reversed. We know little from these trials about their adverse effects.

Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings

BACKGROUND

The improved safety profile of benzodiazepines compared to barbiturates has contributed to a high rate of prescription since the seventies. Although benzodiazepines are highly effective for some disorders, they are potentially addictive drugs and they can provide reinforcement in some individuals.

OBJECTIVES

To evaluate the effectiveness of pharmacological interventions for benzodiazepine mono-dependence.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group' Register of Trials (October 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (January 1966 to October 2004), EMBASE (January 1988 to October 2004), PsycInfo (1985 to October 2004), CINAHL (1982 to October 2004), Pascal, Toxibase, reference lists of articles.

SELECTION CRITERIA

Randomized trials of benzodiazepines dependence management regardless of type, dose (daily and total) and duration of benzodiazepine treatment.

DATA COLLECTION AND ANALYSIS

Reviewers independently assessed trials for inclusion, rated their methodological quality and extracted data.

MAIN RESULTS

Eight trials involving 458 participants were included. The studies included could not be analysed cumulatively because of heterogeneity of inteventions and participants' characteristics. Results support the policy of gradual rather than abrupt withdrawal of benzodiazepine. Progressive withdrawal (over 10 weeks) appeared preferable if compared to abrupt since the number of drop-outs was less important and the procedure judged more favourable by the participants. Short half-life benzodiazepine, associated with higher drop-out rates, did not have higher withdrawal symptoms scores. Switching from short half-life benzodiazepine to long half-life benzodiazepine before gradual taper withdrawal did not receive much support from this review. The role of propanolol in benzodiazepine withdrawal was unclear; adding tricyclic antidepressant (dothiepin) decreased the intensity of withdrawal symptoms but did not increase the rate of benzodiazepine abstinence at the end of the trial. Buspirone and Progesterone failed to suppress any benzodiazepine symptoms. Carbamazepine might have promise as an adjunctive medication for benzodiazepine withdrawal, particularly in patients receiving benzodiazepines in daily dosages of 20 mg/d or more of diazepam (or equivalents).

AUTHORS' CONCLUSIONS

The results of this systematic review point to the potential value of carbamazepine as an effective intervention for benzodiazepine gradual taper discontinuation. Carbamazepine has shown rather modest benefit in reducing withdrawal severity, although it did significantly improve drug-free outcome. Larger controlled studies are needed to confirm these benefits, to assess adverse effects and to identify when its clinical use might be most indicated. Other suggested treatment approaches to benzodiazepine discontinuation management should be explored (antidepressants, benzodiazepine receptors modulator).

Effect of diazepam treatment and its withdrawal on pro/antioxidative processes in rat brain

Exploratory studies were undertaken to ascertain the role of pro/antioxidative processes during a 3 weeks administration of low sub-toxic dose of diazepam and its withdrawal. Rats were administered 3 mg/kg diazepam for 21 consecutive days and the changes observed in different regions of rat brain at the sub-cellular level. Mitochondria from cerebrum showed a 27% lowering of TBARS whereas those from cerebellum and brain stem showed 48 and 24% enhanced MDA levels respectively. No significant alteration in the SOD isozymes was observed after the dose schedule. The mitochondrial glutathione reductase (GR) activity showed a decrease in all the regions with maximum decrease (36%) recorded in brain stem while post mitochondrial fraction showed significant lowering in cerebrum (37%). Total -SH content increased in all the three regions with maximum enhancement recorded in cerebellum while the free thiol content also showed significant changes (p < 0.001) in cerebellum and brain stem. One week after the withdrawal of the drug MDA levels decreased by 38% in cerebrum and 53% each in mitochondrial fractions of cerebellum and brain stem. Regional heterogeneity in response was also observed in the post mitochondrial fractions. Mn-SOD showed lowered activity in cerebellum (22%) and in brain stem (15%). The mitochondrial GR activity decreased in all the regions being highest in cerebrum with no significant change in post mitochondrial fractions. The total and free -SH content in the withdrawn animals increased by 46% in cerebellum with no change in the other two regions. The results indicate towards lower oxidative phenomenon during 3 weeks treatment with diazepam while abrupt withdrawal causes lowering of antioxidant defenses which showed regional heterogeneity. A decrease in peroxidative decomposition of polyunsaturated fatty acids of membranes was observed on withdrawal, which could be due to stabilisation of membranes after long-term binding of diazepam.

Pro and antioxidant responses to repeated administration of diazepam in rat brain

The role of pro/antioxidative processes during a low, subtoxic dose schedule of diazepam (3 mg/kg/day i.p.) for 7 days and its withdrawal in subcellular preparations of rat brain regions was studied in detail. The results indicated heterogeneity in the regional responses as well as in subcellular compartments. After 7 days of exposure to the drug, a decrease in the Mn-SOD activity was observed in the 3 regions studied while a significant increase in Cu/Zn-SOD activity was seen in cerebellum (CBL) and brain stem (BS) along with that of mitochondrial glutathione reductase. The post-mitochondrial fraction (PMF) showed a significant increase in GR activity in cerebrum. Enhancement of total and free thiol levels was observed in cerebrum and cerebellum whereas in BS free thiols were not enhanced. It was interesting to note that in the animals withdrawn from the drug and sacrificed after an interval of 7 days, the level of TBARS showed a highly significant increase in mitochondria of CB and CBL and 89% increase in BS. Similar trend was observed in the post-mitochondrial fractions of all the 3 regions whereas the activity of isozymes of SOD decreased (p < 0.001) in CBL and BS and to a lesser extent in CB. The GR activity was significantly decreased only in the mitochondria of cerebrum with a 34% rise in cerebellum and no change in BS. The PMFs showed a decrease in CB and CBL but a 20% rise in BS. Thus, the data show modulation of antioxidant responses during short-term administration of diazepam, and a lowering of peroxidative decomposition of polyunsaturated fatty acids of membranes. However, after withdrawal of the drug, PUFAs were found to be more vulnerable to peroxidative decomposition and changes in the antioxidant defenses were also observed, which did not come back to normal level during the study.