A three-year follow-up of psychiatric morbidity in urban and rural primary care

Relationships between treatments received in the Nottingham Study of Neurotic Disorder over 30 years and personality status

We compared the drug treatments and health service contacts of anxious and depressed patients separated by personality disturbance in 200 patients over 30 years. Contact details with health professionals at 5, 12 and 30 years were recorded and analysed by multilevel models at all time points. Over 30 years, patients with dependent and anankastic personality disturbance and cothymia (the general neurotic syndrome) were 2.27 times more likely to receive selective serotonin reuptake inhibitors (SSRIs) and new antidepressants (95% confidence interval [CI]: 1.22-4.24), particularly paroxetine, and were 1.6 weeks (95% CI: 1.2-2.3) longer on the drug than those without the syndrome. Similar results with SSRIs and new antidepressants in patients with personality disorder fell short of significance after adjusting for age, sex and DSM status. Most patients had a DSM diagnosis at follow-up points, and these had increased psychological treatment, psychiatric admissions, multiple drugs, SSRIs and new antidepressants. At later follow-up, most drug treatments decreased apart from psychological treatment, SSRIs and new antidepressants, and baseline personality disorder had little impact on treatment histories compared with others. We conclude that the (Galenic) general neurotic syndrome is associated with greater use of treatments in the long term, showing that combined personality and symptomatic pathology overcomes that of personality disorder alone.

Drug treatment for personality disorders

There is some evidence that antidepressants, particularly the selective serotonin reuptake inhibitors and the monoamine oxidase inhibitors, have some benefits in the management of borderline personality disorder, and lesser evidence (partly because of limited trial data) for the benefits of antipsychotic drugs and mood stabilisers. There is not sufficient distinction between the different personality disorders to recommend that any one disorder should be treated by any one drug, and successful treatment is dependent on careful management, sensitive to the patient's expectations.

Measuring perceived rehabilitation needs of Caregivers of People with Schizophrenia in mainland China

This paper reports the development and validation of the Wuxi version of the Rehabilitation Needs Questionnaire for Caregivers of People with Schizophrenia (PRNQ-C-WX) based on the original Hong Kong version (PRNQ-C-HK). PRNQ-C-WX was validated by exploratory factor analysis (EFA) using a convenience sample consisting of 200 caregivers of people with schizophrenia. EFA yielded an eight-factor solution accounting for 63.8 % of the total variance which resulted in a 50-item PRNQ-C-WX. The questionnaire has excellent internal consistencies. Its factor structure is similar to the Hong Kong version. Some suggestions for policy, service and research development in mental health in mainland China are made.

Urban-rural differences in the nature and prevalence of mental ill-health in adults with intellectual disabilities

BACKGROUND

In the general population there are statistically significant urban-rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue.

AIMS

To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas.

METHODS

Cross-sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi-squared test for the difference in two independent proportions.

RESULTS

No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas.

CONCLUSIONS

We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas.

Psychiatric disorders in primary care: why so many differences?

Scopo - (I) Operare una revisione critica degli studi che hanno indagato la frequenza dei disturbi psichici tra i pazienti della medicina generale, utilizzando come criterio un'intervista psichiatrica standardizzata; (II) discutere i possibili fattori all'origine delle diverse frequenze riscontrate; (III) mettere in luce il ruolo di primaria importanza che possono assolvere in questo campo gli studi multicentrici condotti grazie a programmi di collaborazione internazionale. Metodo - sono stati selezionati i lavori pubblicati nella letteratura internazionale tra il 1970 ed il 1993. La selezione è stata effettuata grazie ad una ricerca computerizzata, nel corso della quale sono stati incrociati i databases MEDLINE e Psychological Abstracts; questa è stata a sua volta integrata da una ricerca manuale, consistente neU'esame delle bibliografie contenute nei lavori cosi individuati e nella consultazione degli indici analitici delle principal! riviste psichiatriche internazionali. Infine, è stata consultata la bibliografia commentata, curata da Wilkinson (1985), relativa a lavori di interesse e pertinenza psichiatrici condotti nella medicina generale e pubblicati tra il 1977 ed il 1985. Risultati - Sono stati individuati 30 lavori, ma 9 sono stati esclusi, dal momento che replicavano dati già riportati in letteratura o presentavano limiti metodologici. È emerso cosi che indagini sulla frequenza complessiva dei disturbi psichici tra i soggetti che si rivolgevano ai servizi di medicina generale sono state finora condotte secondo procedure standardizzate solo in 13 Paesi. La frequenza dei disturbi psichici variava tra il 10% ed il 50% circa. Le possibili ragioni all'origine dellem diverse frequenze riscontrate sono state discusse alia luce di tre fattori: I) le caratteristiche dell'indagine; II) l'affidabilità e la confrontabilità delle categorie diagnostiche e dei sistemi nosografici utilizzati; e III) la diversa organizzazione dei servizi sanitari nei vari Paesi. Conclusioni - alia luce delle difficoltà che si incontrano quando si tenta di confrontare i risultati forniti da studi indipendenti condotti in Paesi diversi o perfino nello stesso Paese viene suggerito il ruolo di primaria importanza che possono assolvere in questo campo gli studi multicentrici condotti grazie a programmi di collaborazione internazionale.

The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams

BACKGROUND

Personality status is seldom assessed in community mental health teams except at a rudimentary level. This study challenges the assumption that this policy is either prudent or wise.

AIMS

To measure the prevalence of personality disorder within community mental health teams and to investigate its relationship to mental state disorders and overall pathology.

METHOD

A cross-sectional survey of 2,528 of 2,567 psychiatric patients (98.5%) managed by community mental health teams in four urban settings in the UK in which diagnoses of personality and mental state pathology were assessed separately. Of these, a sample of 400 was interviewed, with a 70.5% completion rate for more in depth information.

RESULTS

In total, 40% of all patients in secondary care suffered from at least one personality disorder. Regression modelling showed personality pathology accounted for a greater degree of global psychopathology than psychosis, alcohol or drug dependence, but was associated with anxiety disorders.

CONCLUSION

Comorbid personality pathology contributes greatly to overall psychopathology in secondary psychiatric care. It should be both recognised and managed.

Generalised anxiety disorder

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

Mental illness in a rural area: a Norwegian psychiatric epidemiological study

OBJECTIVES

Few epidemiological studies have compared less well-integrated urban areas with well-integrated rural areas with the same methods. The aim of this study was to explore the prevalence of mental disorder in a socially stable demographic western region of Norway and make comparison with previously observed prevalence figures of mental illness in Oslo, the capital of Norway.

METHOD

A random sample of the 107,738 residents of Sogn and Fjordane, a western rural region of Norway, age 18-65 years, was drawn from the Norwegian Population Register. A total of 1,080 subjects, 63% of the original sample, were interviewed with the Composite International Diagnostic Interview.

RESULTS

The mean age of the subjects was 39.2 years. The 12-month prevalence of mental illness was 16.5% and the lifetime prevalence was 30.9%. Simple phobia and social phobia had the highest 12-month prevalence whereas alcohol abuse and major depression had the highest lifetime prevalence. All mental disorders were more prevalent in women than in men, with the exception of alcohol and drug abuse. Severe psychopathology was found in 2.2% (12 month prevalence) and 5.1% (lifetime prevalence). These observations show that the 12-month and the lifetime prevalence of mental illness in this western area is approximately half the rate of figures observed for Oslo.

CONCLUSION

Epidemiological figures for a western rural region of Norway showing 12-month and the lifetime prevalence of mental disorder are considerably lower than figures obtained in studies from the capital of Norway. However, the same basic pattern of mental illness can be observed in the rural as in the urban area of Oslo, with alcohol abuse/dependence and major depression being the most common disorders at both sites. The sex pattern is also the same with higher figures for women both in rural and urban areas with the exception of alcohol and drug abuse being higher in men.

A European approach to rural-urban differences in mental health: the ESEMeD 2000 comparative study

OBJECTIVE

The study aimed to answer the following questions: Are there any rural-urban differences in mental health, once sociodemographic variables are controlled for, and are any of these differences observed in EU countries? Did the individuals suffering from mental health disorders have the same characteristics in rural and urban areas, particularly concerning self-reported impairment?

METHOD

The European Study of the Epidemiology of Mental Disorders (ESEMeD 2000 study) is a cross-sectional, in-person, household interview survey based on probability samples representative of the adult population of 6 European countries: Belgium, France, Germany, Italy, the Netherlands, and Spain. The rural population is defined as those living in towns with fewer than 10,000 inhabitants, and the urban population is defined as those living in towns or cities with 10,000 or more inhabitants. A stratified, multistage, random sample without replacement was drawn in each country. The overall response rate of the study was about 61.2% (weighted response rate).

RESULTS

The study results confirmed previous findings on the variation in mood disorders between rural and urban areas. Overall, urbanicity seemed to be linked to a higher risk of mental health disorders, particularly depressive disorders, whereas the link to anxiety disorders was only moderate and there was no link at all to alcohol disorders. Country differences concerned male respondents and not female respondents, with the exception of Belgium, where the differences concerned women only (and showed fewer disorders in rural areas).

CONCLUSIONS

This study will, hopefully, stimulate further intra-European studies using comparable methods and instruments to look at the experience across the European continent and introduce steps to harmonize rural-urban population limits across diverse countries.

Pharmacotherapy for personality disorders

Although there are many methodological uncertainties in the treatment of personality disorders, which make it difficult to be confident about efficacy, there is growing evidence that at least in some personality disorders, drug treatment may be of value. Borderline personality disorder is a condition in which treatment evidence is the most promising, but it is also one of the most difficult disorders to disentangle the mental state from personality components. In summary, there is reasonable evidence that antidepressants, particularly serotonin re-uptake inhibitors and monoamine oxidase inhibitors, have beneficial effects independent of their antidepressive ones and albeit, less favourable, evidence that antipsychotic drugs and mood stabilisers may also be of value. None of this evidence is yet sufficient to point to any specific drug treatment indications.

Prevalence of personality disorder in alcohol and drug services and associated comorbidity

AIMS

To compare the prevalence of personality disorder in alcohol and drug populations with special attention to its impact on psychopathology and service characteristics.

DESIGN

Cross-sectional survey.

SETTING

Three alcohol and four drug services in four urban UK centres.

PARTICIPANTS

Two hundred and sixteen drug and 64 alcohol service patients randomly sampled from current treatment populations.

MEASUREMENTS

A treatment population census recorded demographic and diagnostic data. Patient interviews assessed the presence, cluster type and severity of personality disorder using the Quick Personality Assessment Schedule (PAS-Q). Other psychopathology was measured using the Comprehensive Psychopathological Rating Scale (CPRS). A case-note audit recorded psychotic psychopathology using the OPCRIT schedule and data regarding social morbidity.

FINDINGS

The overall prevalence of personality disorder was 37% in the drug service sample and 53% in the alcohol service sample. The distribution of severity and clusters differed markedly between the two samples. There was a significant association between the severity of personality disorder and psychopathology in both samples. Levels of morbidity associated with clusters B and C were similar. Clinical diagnosis of personality disorder showed high specificity but low sensitivity when compared to PAS-Q.

CONCLUSIONS

In both alcohol and drug service populations, personality disorder is associated with significantly increased rates of psychopathology and social morbidity that worsens with increasing severity of the disorder. Despite this, personality disorder is poorly identified by clinical staff. The PAS-Q may be useful as a clinical assessment tool in the substance misuse population for the early identification and management of patients with personality disorder.

Mental illness in a general hospital's family medicine clinic in Taiwan

There has been a paucity of evidence-based information regarding mental illness in general medical settings among the Chinese population. Aims of the present study are to investigate the patterns and distribution of mental disorders among family medicine clinic attenders, illness behavior of attenders with such disorders, and the recognition and management given by family physicians for them. A random sample (n = 200) of patients attending a family medicine clinic in a medical center in Taiwan, received a standardized psychiatric assessment using the semistructured Clinical Interview Schedule (CIS) after they had seen the family physician. A total of 12 family physicians, who were blind to the psychiatric status of their patients, were then asked to assess the physical and psychological condition of the subjects. Of all study subjects, 51% had at least one psychiatric diagnosis based on the CIS assessment, and the corresponding figure was 21.5% from family physicians. While the specificity of psychiatric case identification among family physician was high (91%), the sensitivity was very low (30%), especially for depressive disorders and alcohol-related disorders. Because the same magnitude of psychiatric morbidity and similarly low detection rates by general medical physicians were found in other developing countries, the improvement in psychiatric education for medical students and family physicians is highly implicated there.

The Dependent Personality Questionnaire (DPQ): a screening instrument for dependent personality

BACKGROUND

There are no specific instruments for rating dependent personality, although this may be an important subject in clinical practice, where knowledge of dependent personality features may influence treatment.

AIMS

To develop a simple self-rating questionnaire for dependent personality features and compare the findings in two groups, one with and one without established dependent personality disorder.

METHOD

An 8-item Dependent Personality Questionnaire (DPQ) was developed and its acceptability and validity tested by administration to 30 psychiatric patients, half of whom had dependent personality disorder using clinical and research data, and the other 15 (pair-matched for age and sex) having other psychiatric diagnoses (including other personality disorders) but no dependent personality features.

RESULTS

The mean score on the dependent personality questionnaire (DPQ) was 13.7 in those with dependent personality disorder and 7.5 in those without such a disorder (p < .005). The DPQ was also a good predictor of the diagnosis of dependent personality disorder, with sensitivity, specificity, predicted positive, and predicted negative accuracies of 87%.

CONCLUSIONS

The results suggest that the DPQ may be a suitable screening instrument for dependent personality characteristics.

Factors influencing prescription of CNS medications in different elderly populations

Factors influencing the use of neuroleptic and other CNS-acting medications ('antidepressants' and 'hypnotics/anxiolytics') were examined in different elderly populations (> 65 years): long-stay care hospital subjects (n = 381), nursing home subjects (n = 1247), private residential home subjects (n = 321), statutory residential home subjects (n = 525), old age psychiatry facility subjects (n = 48), community dwellers (n = 97), in different geographical areas (urban n = 1223 and rural n = 1396). Neuroleptics were prescribed in 28% of the individuals, hypnotics/anxiolytics in 33% and antidepressants in 12%. Prescription of neuroleptics was significantly predicted by institutional placement (other than long-stay care hospital facility), lower cognitive function and rural geographical area. Age greater than 75 years and lower functional score (lower dependency) significantly decreased the likelihood of receipt of neuroleptics. Antidepressant use was significantly less likely in male subjects, patients with cognitive impairment and patients greater than 85 years. Institutional placement (other than long-stay care hospital facility and old age psychiatry facility) and rural locality predicted increased likelihood of antidepressant prescription. Institutional placement (other than long-stay care hospital facility) and geographical (rural) location were significant independent predictors of hypnotic/anxiolytic use. Prescription of hypnotic/anxiolytic drug class was significantly less likely in those individuals with lower cognitive status. In this representative elderly cohort, patient characteristics: age, sex, cognitive score, functional score, place of residence and geographical location markedly influenced drug utilisation.

Metropolitan-nonmetropolitan differences in amount and type of mental health treatment

This article examines the extent to which, conditional on receiving treatment, the type of care differs across metropolitan and nonmetropolitan areas. Using data from the Medical Expenditure Panel Survey (MEPS), the findings indicate that nonmetro residents who obtained mental health care (n = 2,381) have fewer mental health visits in a calendar year than their metro counterparts after adjusting for individual-level characteristics. Although observed rates of hospitalization and contact with physicians are higher in nonmetro areas than metro areas, this difference is attributable primarily to compositional differences between metro and nonmetro residents.

Personality traits and socio-epidemiological status of hospitalised elderly benzodiazepine users

OBJECTIVE

to define personality traits and socio-epidemiological status of hospitalised elderly chronic benzodiazepine (BZD) users.

METHODS

this case controlled study assessed psychological characteristics (using the Millon Clinical Multiaxial Inventory-MCMI-I) and socio-epidemiological status (sex, age, education, marital status and housing) in 40 hospitalised geriatric patients taking BZDs for at least 3 months and 40 non-users, excluding dementia.

RESULTS

comparisons between groups: Compulsive personality pattern was more pronounced in the control group (p = 0.008). Severe personality pathology: a predisposition to borderline disorder was stronger among the BZD-users (p = 0.001). Clinical syndromes: anxiety, dysthymic disorder (p < 0.001) and tendency to alcohol dependence (p = 0.020) prevailed in the BZD-users. No severe syndromes were found. Widowed persons were more prevalent between the BZD-users (p = 0.03). All significant differences resulted from disparities between females. Predictors of BZD-use and clustering of traits: Dysthymic disorder was predictive of BZD-use (odds ratio (OR) 6.3 [95% confidence intervals (CI) 2.2-18.2]). It was strongly correlated with anxiety (r(s) = 0.93) and somatoform disorder (r(s) = 0.71). Dysthymic disorder and alcohol dependence predicted BZD-use in women (OR 15.3 [CI: 2.4-95.7] and OR 9.1 [CI: 1.2-64.9], respectively). There were no specific predictors in men.

CONCLUSIONS

chronic elderly BZD-users are typically widowed females with dysthymic disorder, anxiety, predisposition to alcohol dependence and borderline disorder. Before prescribing BZDs, it is important to recognize the nature of the elderly population at risk for BZD-use and to consider a broader-ranging therapeutic management of the predisposing personality traits.

Economic impact of personality disorders in UK primary care attenders

BACKGROUND

The economic impact of personality disorders on UK health services is unknown.

AIMS

To test the hypothesis that people with personality disorders have higher mean health and non-health costs compared with those without personality disorders.

METHOD

Prospective cohort study design. A total of 303 general practice attenders were followed-up I year after they had been assessed for the presence of personality disorders. Costs were estimated in pound sterling at 1999 price levels.

RESULTS

The mean total cost for patients with personality disorders was pound sterling 3094 (s.d.=5324) compared with pound sterling 1633 (s.d.=3779) for those without personality disorders. Personality disorders were not independently associated with increased costs. Multivariate analyses identified the presence of a significant interaction between personality disorders and common mental disorders and increased total costs (coefficient=499, 95% CI 180.1-626.2, P=0.002).

CONCLUSIONS

Personality disorders are not independently associated with increased costs. An interaction between personality disorders and common mental disorders significantly predicts increased total costs.

Depressive disorders in Europe: prevalence figures from the ODIN study

BACKGROUND

This is the first report on the epidemiology of depressive disorders from the European Outcome of Depression International Network (ODIN) study.

AIMS

To assess the prevalence of depressive disorders in randomly selected samples of the general population in five European countries.

METHOD

The study was designed as a cross-sectional two-phase community study using the Beck Depression inventory during Phase 1, and the Schedule for Clinical Assessment in Neuropsychiatry during Phase 2.

RESULTS

An analysis of the combined sample (n=8.764) gave an overall prevalence of depressive disorders of 8.56% (95% CI 7.05-10.37). The figures were 10.05% (95% CI 7.80-12.85) for women and 6.61% (95% CI 4.92-8.83) for men. The centres fall into three categories: high prevalence (urban Ireland and urban UK), low prevalence (urban Spain) and medium prevalence (the remaining sites).

CONCLUSIONS

Depressive disorder is a highly prevalent condition in Europe. The major finding is the wide difference in the prevalence of depressive disorders found across the study sites.

Chronic benzodiazepine use in general practice patients with depression: an evaluation of controlled treatment and taper-off: report on behalf of the Dutch Chronic Benzodiazepine Working Group

BACKGROUND

Many patients with depression take benzodiazepine drugs long term despite the absence of continuing therapeutic value.

AIMS

To evaluate a treatment programme involving gradual discontinuation with or without simultaneous selective serotonin reuptake inhibitor (SSRI) prescribing and to determine the long-term outcome after benzodiazepine withdrawal.

METHOD

Patients went through three phases - change to an equivalent dose of diazepam; subsequent randomisation to either 20 mg of paroxetine or placebo; and gradual reduction of diazepam in depression-free patients - with a follow-up after 2 or 3 years.

RESULTS

A total of 230 patients were recruited and 75% in the paroxetine group and 61% in the placebo group were successfully treated after 6 weeks (P:=0.067). After 2 or 3 years 13% of patients were still benzodiazepine free: 26% of those who had successfully tapered off benzodiazepine and 6% of the total group.

CONCLUSIONS

Transfer to diazepam followed by gradual withdrawal is an effective way of discontinuing chronic benzodiazepine use. The addition of SSRI treatment is of limited value.

Outcomes of Depression International Network (ODIN). Background, methods and field trials. ODIN Group

BACKGROUND

ODIN aims (a) to provide data on the prevalence, risk factors and outcome of depressive disorders in rural and urban settings within the European Union (EU) based on an epidemiological sampling frame; and (b) to assess the impact of two psychological interventions on the outcome of depression and on service utilisation and costs.

METHOD

Five centres across the EU are participating in ODIN. The centres are linked electronically and members meet regularly for training and strategic reviews. Urban and rural areas have been identified in each centre. The sampling frame is of adults aged 18-64, identified via primary care databases or electoral registers. Potential cases of depressive disorders are identified using the Beck Depression Inventory SCAN II and other validated measures are used to assign caseness against DSM-IV and ICD-10 criteria; assess comorbidity, disability, genetic/familial susceptibility, psychosocial stressors, personality traits and cognitive factors; and utilisation of local health care services. A randomised controlled trial of individual problem-solving treatment and a group educational programme is undertaken for respondents identified as cases of depressive disorder individuals are followed-up at six and 12 months.

RESULTS AND CONCLUSIONS

ODIN has already stimulated the development of an effective international research partnership.

Mental health in primary care. An epidemiological study of morbidity and use of health resources

BACKGROUND

The main objectives of the survey were: (a) to analyse the sociological, clinical and illness-related correlates of mental illness in primary care; (b) to study, during one-year follow-up, outcome and use of health resources.

METHOD

The survey comprised a two-phase cross-sectional study. In the first phase patients were classified using the GHQ-28 or by the general practitioner (GP). In the second phase they were assessed by the SCAN system.

RESULTS

The prevalence rate of mental illness (in attenders) using the GHQ was 33.2%. The corresponding rate for the GP was 14.1%, and for the SCAN 31.5%. Mental illness mainly comprised depression, anxiety and alcohol-related diagnoses. The presence of mental illness and the use of health resources during follow-up were dependent on demographic characteristics and on their original psychiatric status.

CONCLUSIONS

In primary care, mental illness constitutes a major health problem. Despite this fact, GPs do not recognise a substantial proportion of these health problems.

Factors predicting long-term outcome after chronic benzodiazepine therapy

41 patients who took part in a withdrawal programme from long-term treatment with diazepam in a controlled clinical trial were followed up five years later. Assessments were made of outcome derived from clinical symptomatology, formal psychiatric diagnosis, psychotropic drug use and frequency of contact with both primary care and psychiatric services. Using discriminant function analysis it was found that better outcome was associated with younger patients, fewer symptoms at time of withdrawal and, more particularly, six months later, less personality disturbance, and longer duration of diazepam use before withdrawal. The implications are discussed with particular reference to policies for withdrawing benzodiazepines.