High prevalence of benzodiazepine dependence in out-patient users, based on the DSM-III-R and ICD-10 criteria

Orexin Receptor Antagonists in the Treatment of Depression: A Leading Article Summarising Pre-clinical and Clinical Studies

The orexin (hypocretin) system comprises two neuropeptides (orexin-A and orexin-B) and two G-protein coupled receptors (the orexin type 1 and the orexin type 2 receptor). The system regulates several biological functions including appetite, the sleep-wake cycle, the stress response, and motivation and reward processing. Dysfunction of the orexin system has been implicated in the pathophysiology of depression in human and animal studies, although the exact nature of this dysfunction remains unclear. Orexin receptor antagonists (ORAs) are a class of compounds developed for the treatment of insomnia and have demonstrated efficacy in this area. Three dual orexin receptor antagonists (DORAs) have received licences for treatment of primary insomnia and some ORAs have since been investigated as potential treatments for major depressive disorder (MDD). In this leading article, we summarise the existing literature on use of ORAs in depression, in pre-clinical and clinical studies. In rodent models of depression, investigated ORAs have included the DORA almorexant and TCS1102, the selective orexin 1 receptor antagonists SB334867 and SB674042 and the selective orexin 2 receptor antagonists LSN2424100, MK-1064 and TCS-OX2-29. These pre-clinical studies suggest a possible antidepressant effect of systemic DORA treatment, however the evidence from selective ORAs is conflicting. To date, four published RCTs (one with the DORA filorexant and three with the selective orexin 2 receptor antagonist seltorexant), have compared an ORA with placebo in the treatment of MDD. Only one of these demonstrated a statistically significant difference relative to placebo.

Benzodiazepine high-doses: The need for an accurate definition

OBJECTIVES

A clear definition of what we understand of high-dose misuse or of a 'markedly increased dose' (as stated by the DSM-5) is important and past definitions may be inadequate. The aim of this review is to describe the different definitions used and to test these definitions for their accuracy.

METHODS

A narrative PubMed literature review was conducted based on articles published between 1 January 1990 and 31 December 2020 describing benzodiazepines (in MeSH Terms or MeSH Major Topic) and high-dose (or high-dosage). Specific definitions were applied to a population sample to show how definitions affect high-dose benzodiazepine prevalence.

RESULTS

Multiples of an equivalent-diazepam dose or of the World Health Organization 'defined daily dosage' were used more frequently than the overstep of the recommended maximum therapeutic dosage as a cut-off point.

CONCLUSION

High-dose use is rare but the prevalence in the general population varies among studies, mainly due to different definitions, making both clinical and epidemiological comparisons between studies difficult. Defining a high-dose user as a person who takes at least a higher dose than the maximum usual therapeutic dose over a defined period of time therefore appears to be clinically more consistent.

Assessing the clinical utility of the severity dependence scale for benzodiazepine use disorder

Background

Benzodiazepines are often used as a part of mental health pharmacological management; however, often when prescribed for extended periods, they increase the risk of benzodiazepine use disorder (BUD). Clinical interviews are at the centre of diagnosing this disorder. However, in addition to clinical assessment a simple, validated questionnaire conducted by any healthcare professional may aid in screening for BUD and referral for further management.

Aim

To compare the accuracy of the severity dependence scale (SDS) as a screening tool for BUD against the standard clinical interviews using the Diagnostic and Statistical Manual of Mental Disorders, edition 5, (DSM 5) checklist amongst benzodiazepine users with primary psychiatric disorders.

Setting

Outpatient psychiatric clinic in South Rand Hospital, Johannesburg, South Africa.

Methods

A cross-sectional study was conducted, once informed consent was attained, looking at demographic and clinical profiles of benzodiazepine users. Clinical interviews were conducted in 81 patients who completed the SDS. In comparing the results of the SDS and clinical interview outcomes, chi-square tests were used to determine an association between categorical variables. A receiver-operating characteristic (ROC) curve was generated in determining the cut-off score in the SDS with the highest sensitivity and specificity.

Results

This study indicated that a cutoff score of greater than or equal to six of the SDS showed 86% sensitivity and 90.3% specificity compared to a diagnosis of BUD made with clinical interview. The only categorical variables of marginal significance (p~0.06) in comparison to a BUD diagnosis were with benzodiazepine type (oxazepam) and longer duration of use (greater than 24 months).

Conclusion

This study identified the SDS as a useful screening tool for BUD with a high sensitivity and specificity compared to interview outcomes. Statistically, correlates were identified between duration and type of benzodiazepine prescribed and BUD suggesting emphasis on these factors when prescribing benzodiazepines.

Psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire - Portuguese Version (BENDEP-SRQ-PV)

Objective

To assess psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire – Portuguese Version (BENDEP-SRQ-PV) in a sample of Brazilian chronic hypnotic users.

Methods

One hundred and seventy-nine chronic hypnotic users (benzodiazepines and Z-drugs) were recruited, attended a psychiatric evaluation, and answered the BENDEP-SRQ-PV. Factor structure, reliability, and influence of covariates (dependence diagnosis and type of drug consumed) were assessed in a structural equation modelling environment. Discrimination was assessed with receiver operating characteristic (ROC) plots and stability with the test-retest method.

Results

Participants, mostly women (91.6%), aged 51 to 64 years old, had been using hypnotics for an average of 34.8 months, with a mean defined daily dose of 0.72. Psychometric analysis demonstrated construct and criterion validity, reliability, and response stability. The factor structure was maintained as originally proposed: problematic use (ω = 0.73), preoccupation (ω = 0.74), lack of compliance (ω = 0.74), and withdrawal (ω = 0.93).

Conclusion

The BENDEP-SRQ-PV is an adequate measure of hypnotic dependence in the Brazilian population of chronic users. Our results support using the scale for follow-up in clinical and research applications and in correlational studies.

Denying renal transplantation to an adolescent medical cannabis user: An ethical case study

Medical cannabis is now legal in over half of the United States. As more patients adopt this unconventional therapy, it is inevitable that potential transplant recipients will disclose their cannabis use during transplant evaluation. Transplant teams are tasked with the decision to utilize a pressure resource, often with little guidance from international and national professional organizations. Many healthcare providers remain uniformed or misinformed about the risks of cannabis use and organ transplantation. In order to illustrate the multifaceted and complex evaluation of transplant patients using medical cannabis, this article presents the case of a 20-year-old woman recommended for renal transplant who was originally denied active listing due to her medical cannabis use. A review of the literature explores the perceived and actual risks of cannabis use in the immunocompromised patient. Furthermore, a discussion of the ethics of medical cannabis use and organ transplantation is included with recommendations for multidisciplinary transplant teams.

Prevalence of prescribed benzodiazepine long-term use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort

Background

Data are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population.

Methods

Data came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender.

Results

Weighted prevalence of BLTU were 2.8%(95% CI:2.3–3.4) and 3.8%(95% CI: 3.3–4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02–1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU.

Conclusions

BLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6933-8) contains supplementary material, which is available to authorized users.

Electroacupuncture for tapering off long-term benzodiazepine use: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of using electroacupuncture as an adjunct treatment in enhancing the benzodiazepine cessation rate in long-term benzodiazepine users.

METHODS

This was a randomized, assessor- and subject-blinded, controlled trial. One hundred and forty-four long-term benzodiazepine users were randomly assigned to receive either electroacupuncture or placebo acupuncture (a sham itervention using non-invasive placebo needles) combined with a gradual benzodiazepine tapering schedule for 4 weeks. The primary outcome was the cessation rate of benzodiazepine use. Subjects were assessed on their benzodiazepine usage, benzodiazepine withdrawal symptoms, insomnia severity, and anxiety and depressive symptoms at baseline, week 6 and week 16.

RESULTS

The cessation rates of the electroacupuncture and placebo acupuncture groups at 12 weeks post-treatment were 9.17% and 10.83%, respectively. Both groups showed a reduction in benzodiazepine usage by a self-completed drug record at week 16 (compared to baseline: electroacupuncture group -40.23% versus placebo acupuncture group -48.76%). However, no significant between-group differences were found in the benzodiazepine cessation rate, reduction in benzodiazepine usage, and other secondary measures across all the study time points.

CONCLUSIONS

Electroacupuncture showed a similar cessation rate in benzodiazepine use to that of non-invasive placebo acupuncture in long-term users during a 4-week gradual tapering schedule. The evidence did not support advantages of electroacupuncture over non-invasive placebo acupuncture on reducing insomnia, anxiety, depression, or other withdrawal symptoms during the gradual tapering schedule. Despite a 40% decrease in the benzodiazepine usage in both groups, the effects may be attributed to the non-specific effects of acupuncture.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT02475538.

Electroacupuncture for tapering off long-term benzodiazepine use: study protocol of randomized controlled trial

BACKGROUND

Conventional approaches for benzodiazepine tapering have their limitations. Anecdotal studies have shown that acupuncture is a potential treatment for facilitating successful benzodiazepine tapering. As of today, there was no randomized controlled trial examining its efficacy and safety. The purpose of the study is to evaluate the efficacy of using electroacupuncture as an adjunct treatment to gradual tapering of benzodiazepine doses in complete benzodiazepine cessation in long-term benzodiazepine users.

METHODS/DESIGN

The study protocol of a randomized, assessor- and subject-blinded, controlled trial is presented. One hundred and forty-four patients with histories of using benzodiazepines in ≥50% of days for more than 3 months will be randomly assigned in a 1:1 ratio to receive either electroacupuncture or placebo electroacupuncture combined with gradual benzodiazepine tapering schedule. Both experimental and placebo treatments will be delivered twice per week for 4 weeks. Major assessments will be conducted at baseline, week 6 and week 16 post-randomization. Primary outcome is the cessation rate of benzodiazepine use. Secondary outcomes include the percentage change in the doses of benzodiazepine usage and the severity of withdrawal symptoms experienced based on the Benzodiazepine Withdrawal Symptom Questionnaire, insomnia as measured by the Insomnia Severity Index, and anxiety and depressive symptoms as evaluated by the Hospital Anxiety and Depression Scale. Adverse events will also be measured at each study visit.

DISCUSSION

Results of this study will provide high quality evidence of the efficacy and safety of electroacupuncture as an adjunct treatment for benzodiazepine tapering in long-term users.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02475538 .

[Discontinuation of benzodiazepines in old age : When and if so, how?]

Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.

Withdrawing Benzodiazepines in Patients With Anxiety Disorders

The large class of CNS-depressant medications-the benzodiazepines-have been extensively used for over 50 years, anxiety disorders being one of the main indications. A substantial proportion (perhaps up to 20-30 %) of long-term users becomes physically dependent on them. Problems with their use became manifest, and dependence, withdrawal difficulties and abuse were documented by the 1980s. Many such users experience physical and psychological withdrawal symptoms on attempted cessation and may develop clinically troublesome syndromes even during slow tapering. Few studies have been conducted to establish the optimal withdrawal schedules. The usual management comprises slow withdrawal over weeks or months together with psychotherapy of various modalities. Pharmacological aids include antidepressants such as the SSRIs especially if depressive symptoms supervene. Other pharmacological agents such as the benzodiazepine antagonist, flumazenil, and the hormonal agent, melatonin, remain largely experimental. The purpose of this review is to analyse the evidence for the efficacy of the usual withdrawal regimes and the newer agents. It is concluded that little evidence exists outside the usual principles of drug withdrawal but there are some promising leads.

Dependence on prescription benzodiazepines and Z-drugs among young to middle-aged patients in France

BACKGROUND

Benzodiazepines (BZD) and nonbenzodiazepines hypnotics (z-drugs) are recognized as one of the most widely prescribed medications in the world.

OBJECTIVES

The purpose of the study was to assess the BZD and z-drugs dependence in young to middle-aged outpatients who were taking BZD/z-drugs on a chronic basis, and to characterize their profile.

METHODS

This is a forward-looking cross-sectional epidemiological study. Data were collected through a semi-structured interview within a network of partner pharmacies from the Nantes area, in France. All data were obtained exclusively through patients' declarations. 212 patients (19-64 years old) were included: they were considered dependent when they answered positively to at least three items of the DSM IV. A multivariate logistic regression and a principal component analysis (PCA) were carried out to determine their profile.

RESULTS

Almost half of the patients met criteria for BZD/z-drugs dependence. The risk to develop BZD/z-drugs dependence is significantly associated with psychiatric history and with the quantity of BZD/z-drugs that is taken. A two factor concept of dependence could be identified according to the PCA: one axis with items of "tolerance" and "long term administration or higher doses", and a second axis with "concerned by treatment" and "somatic consequences". Conclusions/Importance: Among this BZD/z-drug dependent population, the two axes identified in the PCA represent two profiles of dependence: being in positive conditioning or suffering from negative consequences. Clinicians need to know them: these two clinical profiles may have an influence in terms of decision-making, especially to manage discontinuation.

Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice

More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review.

Benzodiazepine harm: how can it be reduced?

The benzodiazepines (BZDs) are anxiolytics, hypnotics, anticonvulsants, muscle-relaxants and induce anaesthesia. Adverse effects comprise sedation subjectively and cognitive and psychomotor impairment objectively. Complex skills such as driving can be compromised. Paradoxical excitement can have forensic implications. Long term use beyond the licensed durations is common but both efficacy and adverse effects associated with this have been poorly documented. Withdrawal and dependence have excited particular concern, and even polemic. Perhaps a third of long term (beyond 6  months) users experience symptoms and signs on attempting to withdraw - anxiety, insomnia, muscle spasms and tension and perceptual hypersensitivity. Uncommonly, fits or a psychosis may supervene. The patterns following withdrawal vary widely. The usual method of withdrawal is slow tapering but it may not obviate the problems completely. BZDs are also drugs of abuse either on their own or in conjunction with opioids and stimulants. Claims have been made that the use of BZDs is associated with increased mortality. This is a concern in view of the widespread usage of these drugs, particularly in the elderly. All of these factors impinge on the risk : benefit ratio and the severity of the indications. Harm reduction should focus on choice of alternative treatments both psychological and pharmacological. Guidelines emphasise that BZDs are not drugs of first choice and should only be used short term. Schedules are available to educate about methods of withdrawal in current users, emphasising the slow rate of taper. General principles of harm minimization in the addiction field are appropriate to BZD abuse.

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.

The diagnosis and treatment of generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) is a common and serious disease with a lifetime prevalence of 4.3% to 5.9%. It is underdiagnosed in primary care.

METHODS

Recommendations on the treatment of GAD are given on the basis of all available findings from pertinent randomized trials, retrieved by a selective search of the literature.

RESULTS

Among psychotherapeutic techniques, various kinds of cognitive behavioral therapy (CBT) have been found useful in controlled trials. The drugs of first choice include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephine reuptake inhibitors (SNRIs), and the calcium-channel modulator pregabalin. Tricyclic antidepressants are also effective but have more adverse effects than SSRIs. Although benzodiazepines are effective anxiolytic agents for short-term use, they should not be given over the long term because of the danger of addiction. Buspirone, an azapirone, was found to be effective in a small number of trials, but the findings across trials are inconsistent. The response rate of GAD to CBT in published studies lies between 47% and 75%, while its response rate to drug treatment lies between 44% and 81%.

CONCLUSION

The treatment of GAD with CBT and drugs is evidence-based and has a good chance of improving the manifestations of the disorder.

Benzodiazepineverslaving; een stille verslaving onder ouderen

SAMENVATTING: Benzodiazepinen worden frequent langdurig voorgeschreven voor de behandeling van angst en slaapproblemen, ondanks verschillende richtlijnen hiermee terughoudend te zijn. Deze richtlijnen zijn gebaseerd op de balans tussen de effectiviteit op langere termijn en de bijwerkingen (verslaving, anterograde amnesie en verhoogd risico op (onge)vallen en mortaliteit). De verslavende eigenschappen van benzodiazepinen blijken ook op te treden bij gebruik van laag-therapeutische doseringen. Hoewel aanvankelijk de aandacht uitging naar het optreden van ontwenningsverschijnselen bij staken, is de laatste decennia meer en meer aandacht gekomen voor de psychologische aspecten van deze verslaving. Recentelijk werd in dierexperimenteel onderzoek het effect van benzodiazepinegebruik op het beloningssysteem in de hersenen aangetoond. Wanneer langdurig benzodiazepinegebruik als probleem wordt onderkend door arts en patiënt blijken verschillende behandelmodaliteiten effectief. Eén op de vier langdurig gebruikers kan op eigen kracht stoppen na goede psycho-educatie en aanmoediging. Twee op de drie kunnen stoppen met behulp van systematische dosisreductie onder begeleiding van een arts of psycholoog. In geval van een onderliggende slaap- of angststoornis, verdient het aanbeveling deze laatste behandeling aan te vullen met cognitieve gedragstherapie. In tegenstelling tot wat vaak gedacht wordt, blijken ook de oudste ouderen goed te kunnen profiteren van deze behandelingen.

Benzodiazepine dependence among multidrug users in the club scene

BACKGROUND

Benzodiazepines (BZs) are among the most frequently prescribed drugs with the potential for abuse. Young adults ages 18-29 report the highest rates of BZ misuse in the United States. The majority of club drug users are also in this age group, and BZ misuse is prevalent in the nightclub scene. BZ dependence, however, is not well documented. This paper examines BZ dependence and its correlates among multidrug users in South Florida's nightclub scene.

METHODS

Data were drawn from structured interviews with men and women (N=521) who reported regular attendance at large dance clubs and recent use of both club drugs and BZs.

RESULTS

Prevalences of BZ-related problems were 7.9% for BZ dependence, 22.6% BZ abuse, and 25% BZ abuse and/or dependence. In bivariate logistic regression models, heavy cocaine use (OR 2.27; 95% CI 1.18, 4.38), severe mental distress (OR 2.63; 95% CI 1.33, 5.21), and childhood victimization history (OR 2.43; 95% CI 1.10, 5.38) were associated with BZ dependence. Heavy cocaine use (OR 2.14; 95% CI 1.10, 4.18) and severe mental distress (OR 2.16; 95% CI 1.07, 4.37) survived as predictors in the multivariate model.

DISCUSSION

BZ misuse is widespread among multidrug users in the club scene, who also exhibit high levels of other health and social problems. BZ dependence appears to be more prevalent in this sample than in other populations described in the literature. Recommendations for intervention and additional research are described.

Benzodiazepines revisited--will we ever learn?

AIMS

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

METHODS

A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

RESULTS

Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.

CONCLUSIONS

The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.

The Chinese version of the Severity of Dependence Scale as a screening tool for benzodiazepine dependence in Taiwan

The development of an instrument to estimate the incidence, characteristics, and risk factors of benzodiazepine (BZD) dependence broadly in Taiwan is an important task. This study assessed the validity of the Chinese version of the Severity of Dependence Scale (SDS([Ch])) among regular BZD users in Taiwan (n=228). A positive correlation was shown between SDS([Ch]) and Mini-International Neuropsychiatric Interview diagnosed of BZD dependence. Thirty-six percent of the users received a Mini-International Neuropsychiatric Interview diagnosis of current BZD dependence. The dependent users tended to be divorced/widowed; not schizophrenic; and have higher SDS([Ch]) scores, a longer duration of use, and multiple-BZD use. The SDS([Ch]) for BZD dependence was shown to have high diagnostic utility (area under the receiver operating characteristic curve=0.779), a sensitivity of 80.5%, and a specificity of 85.7%, with a cutoff point of 7. The findings support that the SDS([Ch]) is a valid brief self-reported questionnaire for the assessment of BZD dependence among chronic users in Taiwan.

The Benzodiazepine Dependence Questionnaire (BDEPQ): validity and reliability in Mexican psychiatric patients

BACKGROUND

Benzodiazepine (BZD) dependence is a condition generally circumscribed to a therapeutic framework. Up to 44% of chronic users become dependent. The widespread use of BZD in psychiatry requires the evaluation of psychometric properties of self-reported instruments to characterize this phenomenon.

OBJECTIVE

To examine the reliability, construct and criterion validity of the Benzodiazepine Dependence Questionnaire (BDEPQ) in Mexican psychiatric patients.

METHOD

Patients were included if they met DSM-IV criteria for any Axis I disorder and were BZD users. A total of 150 patients were recruited. Diagnoses were made with the SCID-I and BZD dependence was determined with an adaptation of the substance dependence section of the SCID-I. All patients answered the BDEPQ.

RESULTS

Almost half of the patients met criteria for BZD dependence. The BDEPQ showed adequate factor loadings with strong alpha values for the subscales and total score. A cut-off value of 23 reached the most stable sensitivity and specificity values.

CONCLUSIONS

Psychometric properties of the BDEPQ in Mexican psychiatric patients support its utility as a tool for the clinical work and research as it shows to be a useful instrument for the early recognition of BZD dependence in clinical populations.

Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety (NESDA)

AIM

Results on determinants of benzodiazepine (BZD) use in general and inappropriate use were inconsistent and mostly univariate. The relative importance of sociodemographic, psychological and physical determinants has never been investigated in a comprehensive, multivariate model.

METHODS

We included 429 BZD users and 2423 non-users from the Netherlands Study of Depression and Anxiety (NESDA) in order to investigate sociodemographic, psychological and physical determinants of BZD use and inappropriate use by logistic and linear regression analyses.

RESULTS

BZDs were used by a considerable proportion of the 2852 NESDA participants (15.0%). BZD use was independently associated with older age, singleness, unemployment, treatment in secondary care, higher medical consumption (more severe) anxiety, depression (OR [95% CI]=1.95 [1.29, 2.93]), comorbidity, insomnia, SSRI (OR [95% CI]=2.05 [1.55, 2.70]), TCA and other antidepressant (OR [95% CI]=2.44 [1.64, 3.62]) use. Overall, BZD use was rarely in accordance with all guidelines, mainly because most users (82.5%) exceeded the recommended duration of safe use. Inappropriate use was independently associated with older age (β=0.130) and chronic illnesses (β=0.120). Higher scores on agreeableness were associated with less inappropriate use.

CONCLUSIONS

Mentally or physically vulnerable subjects were most likely to use BZDs. The most vulnerable (i.e. the old and physically ill) BZD users were at highest risk of inappropriate BZD use. Without further evidence of the effectiveness of BZDs in long-term use, caution in initiating BZD prescriptions is recommended, particularly when patients are chronically ill and old, as those are most likely to display inappropriate use.

Management of Hypnotic Discontinuation in Chronic Insomnia

The management of hypnotic discontinuation following regular and prolonged use may be a challenging task for patients and clinicians alike. Current evidence suggests that a stepped-care approach may be a cost-effective approach to assist patients in tapering hypnotics. This approach may involve simple information about the need to discontinue medication, implementation of a supervised and systematic tapering schedule, with or without professional guidance, and cognitive-behavioral therapy. Research evidence shows that this approach appears promising; further research is however necessary to identify treatment and individual characteristics associated with better outcome.

Predictors of the incidence and discontinuation of long-term use of benzodiazepines: a population-based study

Long-term use of benzodiazepines (BZDs) has been linked with an array of negative health consequences and increased medical costs and social burden. In this study, we sought to investigate the factors accounting for differential risks in the process from incident BZD use to long-term use and discontinuation in the general population. On the basis of a random sample of 187,413 people enrolled in Taiwan's National Health Insurance program on January 1, 2000, data of 2000-2002 healthcare and pharmacological services utilization were retrieved. Long-term use (LTU) was defined by having received BZD prescriptions for 180 or more days within any given calendar year. Multivariate logistic regression analyses were carried out to assess the strength of associations while adjusting for the effects of individual sociodemographics, service providers, and pharmacological agents simultaneously. Results indicated that males, elderly, and those with physical or mental disorders were more likely to become long-term users of BZDs. Having received BZD prescriptions in multiple pharmacological agents, short-acting or mixed-type agents, and hypnotic indication were associated with a roughly 2- to 5-fold increased risk of BZD LTU soon after prescription initiation. With respect to discontinuation, the effects of pharmacological characteristics seem more salient as compared to those of individual and service-provider factors. Future strategies targeting individual factors and modifying service-provider prescription behaviors may be considered to reduce possible negative consequences of BZD LTU.

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.

Social-cognitive predictors of intended and actual benzodiazepine cessation among chronic benzodiazepine users

Long-term benzodiazepine use is associated with a variety of negative health consequences. Cessation of long-term use is therefore an important health goal. In a prospective study among chronic benzodiazepine users (N=356) social-cognitive factors of benzodiazepine cessation were examined with a nine-month follow-up. Results showed that outcome expectations, self-efficacy and disengagement beliefs predicted intention, and that intention in turn predicted benzodiazepine cessation. More specifically, benzodiazepine users reported a more positive intention to quit when they perceived more positive consequences and fewer negative consequences of cessation. In addition, a higher self-efficacy to quit and lower disengagement beliefs related to lower higher intention. Intention, in turn was the only significant psychosocial predictor of actual quitting at 9 months. The implications of these results will be discussed in terms of possible intervention strategies.

Long-term effectiveness of computer-generated tailored patient education on benzodiazepines: a randomized controlled trial

AIMS

Chronic benzodiazepine use is highly prevalent and is associated with a variety of negative health consequences. The present study examined the long-term effectiveness of a tailored patient education intervention on benzodiazepine use.

DESIGN

A randomized controlled trial was conducted comprising three arms, comparing (i) a single tailored intervention; (ii) a multiple tailored intervention and (iii) a general practitioner letter. The post-test took place after 12 months.

PARTICIPANTS

Five hundred and eight patients using benzodiazepines were recruited by their general practitioners and assigned randomly to one of the three groups.

INTERVENTION

Two tailored interventions, the single tailored intervention (patients received one tailored letter) and the multiple tailored intervention (patients received three sequential tailored letters at intervals of 1 month), were compared to a short general practitioner letter that modelled usual care. The tailored interventions not only provided different and more information than the general practitioner letter; they were also personalized and adapted to individual baseline characteristics. The information in both tailored interventions was the same, but in the multiple tailored intervention the information was provided to the participants spread over three occasions. In the multiple tailored intervention, the second and the third tailored letters were based on short and standardized telephone interviews.

MEASUREMENTS

Benzodiazepine cessation at post-test was the outcome measure.

FINDINGS

The results showed that participants receiving the tailored interventions were twice as likely to have quit benzodiazepine use compared to the general practitioner letter. Particularly among participants with the intention to discontinue usage at baseline, both tailored interventions led to high percentages of those who actually discontinued usage (single tailored intervention 51.7%; multiple tailored intervention 35.6%; general practitioner letter 14.5%).

CONCLUSIONS

It was concluded that tailored patient education can be an effective tool for reducing benzodiazepine use, and can be implemented easily.

Psychological determinants of the intention to educate patients about benzodiazepines

OBJECTIVE

General practitioners and pharmacists do not properly educate their patients about the disadvantages of benzodiazepines. In order to increase and improve education, this study will investigate which psychological factors (i.e., beliefs, outcome expectation, social norm and self-efficacy) predict the intention to educate.

METHODS

A cross-sectional survey study was conducted in which 339 general practitioners and 149 pharmacists in the Netherlands completed a questionnaire.

RESULTS

The Results show that the above-mentioned factors play an important role in forming intentions to educate. However, differences exist between general practitioners and pharmacists.

CONCLUSION

General practitioners and pharmacists intend to educate in cases where they think that benzodiazepines have well-defined disadvantages, when the education they undertake leads to success, when they feel pressure to educate from their surroundings and when they are capable of educating. Implications for practice These findings contribute to a better understanding of patient education and are of great value in developing new interventions to improve education.

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).

Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program

OBJECTIVE

To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial.

METHOD

We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice.

RESULTS

Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95% CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95% CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95% CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95% CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence.

CONCLUSIONS

Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.

The absence of benzodiazepine craving in a general practice benzodiazepine discontinuation trial

This study aimed to assess benzodiazepine craving longitudinally and to describe its time course by means of the Benzodiazepine Craving Questionnaire (BCQ). Subjects were long-term benzodiazepine users participating in a two-part treatment intervention aimed to reduce long-term benzodiazepine use in general practice in The Netherlands. Four repeated measurements of benzodiazepine craving were taken over a 21-month follow-up period. Results indicated that (1) benzodiazepine craving severity decreased over time, (2) patients still using benzodiazepines experienced significantly more severe craving than patients who had quit their use after one of the two interventions, and (3) the way in which patients had attempted to quit did not influence the experienced craving severity over time, however, (4) patients who had received additional tapering off, on average, reported significantly more severe craving than patients who had only received a letter as an incentive to quit. Although benzodiazepine craving is prevalent among (former) long-term benzodiazepine users during and after discontinuation, craving severity decreases over time to negligible proportions. Self-reported craving can be longitudinally monitored and quantified by means of the BCQ.

Tapering off benzodiazepines in long-term users: an economic evaluation

BACKGROUND

Discontinuation of benzodiazepine usage has never been evaluated in economic terms. This study aimed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy (TO+CBT), tapering off alone (TOA) and usual care.

METHOD

A randomised controlled trial was conducted, incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective. The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients' costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]).

RESULTS

A total of 180 patients were randomised to one of TO+CBT (n = 73), TOA (n = 73) or usual care (n = 34). Intervention treatment costs were an average of 172.99Euro per patient for TO+CBT and 69.50Euro per patient for TOA. Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care. The incremental cost-effectiveness ratios (ICERs) showed that, for each incremental 1% successful benzodiazepine discontinuation, TO+CBT cost 10.30-62.53Euro versus usual care, depending on the study perspective. However, TO+CBT was extendedly dominated or was dominated by TOA. This resulted in ICERs of 0.57Euro, 10.21Euro and 48.92Euro for TOA versus usual care from the limited pharmaceutical, comprehensive pharmaceutical and societal perspective, respectively.

CONCLUSIONS

TO+CBT and TOA both led to a reduction in benzodiazepine costs. However, it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment. Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT, the differences were relatively small. The addition of group CBT to tapering off had no clinical or economic advantages. Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care.

Views of general practitioners and benzodiazepine users on benzodiazepines: a qualitative analysis

Effectively assisting benzodiazepine users to cease use requires a greater understanding of general practitioners' (GPs) and benzodiazepine users' views on using and ceasing benzodiazepines. This paper reports the findings from a qualitative study that examined the views of 28 GPs and 23 benzodiazepine users (BUs) in Cairns, Australia. A semi-structured interview was conducted with all participants and the information gained was analysed using the Consensual Qualitative Research Approach, which allowed comparisons to be made between the views of the two groups of interviewees. There was commonality between GPs and BUs on reasons for commencing benzodiazepines, the role of dependence in continued use, and the importance of lifestyle change in its cessation. However, several differences emerged regarding commencement of use and processes of cessation. In particular, users felt there was greater need for GPs to routinely advise patients about non-pharmacological management of their problems and potential adverse consequences of long-term use before commencing benzodiazepines. Cessation could be discussed with all patients who use benzodiazepines for longer than 3 months, strategies offered to assist in management of withdrawal and anxiety, and referral to other health service providers for additional support. Lifestyle change could receive greater focus at all stages of treatment.

Associations of benzodiazepine craving with other clinical variables in a population of general practice patients

BACKGROUND

The aim of this study was to (1) describe the characteristics of patients reporting craving for benzodiazepines (BZs) and (2) to search for associations between BZ craving and other clinical variables in a population of general practice (GP) patients who have made an attempt to discontinue their long-term BZ use.

METHODS

The Benzodiazepine Craving Questionnaire (BCQ) and other self-report questionnaires were administered once to a population of 113 long-term and 80 former long-term GP BZ users participating in a large BZ reduction trial in GP. Cross-sectional data were gathered on self-reported BZ craving (BCQ), self-reported BZ dependence severity (Bendep-SRQ), psychopathology (General Health Questionnaire 12-item version), mood state (Profile of Mood States), personality (Dutch shortened MMPI), and lifestyle characteristics. Differences between patients who reported craving and patients who did not were analyzed univariately. Multivariate analyses were performed on variables significantly associated with craving, controlling for current use status.

RESULTS

(1) Patients reporting craving differed significantly from patients not reporting craving on aspects of BZ dependence severity, psychopathology, negative mood state, and personality. (2) Negative mood and somatization were positively associated with BZ craving, although only the contribution of negative mood to craving was statistically significant for the total group of (former) BZ users (P = .002).

CONCLUSIONS

Self-reported negative mood and somatization are positively associated with BZ craving. In future BZ craving research, personality factors should be further explored.

The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam

OBJECTIVE

To examine long-term outcome of late-life anxiety disorders and utilization of mental health care services.

METHOD

A cohort of subjects (aged > or = 55 years) with an anxiety disorder (n = 112) was identified in the Longitudinal Aging Study Amsterdam (n = 3107). At 6 year follow-up, the rate of persistence and prognostic factors for persistence of anxiety were established.

RESULTS

Six years after baseline 23% of our sample met the criteria for an anxiety disorder. Another 47% suffered from subclinical anxiety symptoms. Persistence of anxiety was associated with a high score on neuroticism at baseline. Use of benzodiazepines was high (43%), while use of mental health care facilities (14%) and anti-depressants (7%) remained low in those with persistent anxiety.

CONCLUSION

Results indicate that those high in neuroticism are at greater risk for persistence of anxiety. Efforts to enhance appropriate referral of anxious older adults do not seem to have had the desired effect.

Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study

Minimal intervention strategies to decrease long-term benzodiazepine use have not yet been evaluated in large primary care based studies with a blinded control condition and a long follow-up period. The purpose of this study was to assess the effects of a letter with a discontinuation advice sent to long-term benzodiazepine users in family practice followed by an evaluation consultation offer. The experimental group consisted of 2425 long-term benzodiazepine users, 1707 of whom were addressed by a discontinuation letter and an evaluation consultation offer. The control group consisted of 1821 long-term users. Primary endpoints were the number of prescribed daily dosages (PDD) and the percentage of subjects without prescription (quitters). At 21 months a reduction in benzodiazepine prescription of 26% was observed in the experimental group, versus 9% in the control group (PDD difference=12.5; 95%-ci: 8.2-16.8). In the experimental group 13% and in the control group 5% of the study completers were benzodiazepine prescription free through the full follow-up period (RR=2.6; 95%-ci: 2.0-3.4). The percentage of quitters at short-term (6 months) was 24% in the experimental group versus 12% in the control group (RR=2.1; 95%-ci: 1.8-2.4). It is concluded that this intervention strategy steadily reduces long-term benzodiazepine use in family practice.

Psychoactive drug consumption: performance-enhancing behaviour and pharmacodependence in workers

PURPOSE

The aim of this study was to investigate factors associated to psychoactive medication use and dependence in working environment during a 1-year period.

METHODS

We performed a 1-year-follow-up cohort study including workers from Toulouse metropolitan area. During their annual compulsory examination to assess their aptitude to work, subjects were asked to fill in an anonymous questionnaire at 1 year interval, in May 2000 and May-June 2001.

RESULTS

Among a study sample of 1273 subjects (47.4% of men, mean age 39.2 +/- 9.2 years), the prevalence of psychoactive medication use at baseline was 9.1% (4.3% anxiolytic, 1.9% hypnotic, 1.7% antidepressant, 2.1% opiate analgesic and 0.5% antipsychotic drugs, according to ATC classification). Dependence on these drugs was found in 3.5% of workers. This consumption was associated with professional categories (higher in employees versus senior executive, Odds Ratio: 1.80; 95% Confidence Interval [1.04-3.11]), low job satisfaction and outside workplace (1.92; [1.30-2.84] and 3.40; [2.27-5.09] respectively), and patterns of medication use at workplace: for sleeping disorders related to job (18.27; [11.81-28.26]), for enhancing performance at work (28.13; [12.00-65.92]), for relieving unpleasant symptoms at work (22.98; [9.59-55.01]). The risk of psychoactive medication chronic use (psychoactive drug users in 2000 and 2001), and dependence at 1 year were both strongly associated with nicotine dependence (5.99 and 6.23, respectively) and performance-enhancing behaviour with drugs and/or alcohol (8.35 and 3.32 respectively), whereas current use (psychoactive drug users only in 2001) was strongly associated with performance-enhancing behaviour.

CONCLUSIONS

Among workers using psychoactive drugs, one out of three are dependent on psychoactive medications. Performance-enhancing behaviour and coping strategies might be a determinant of psychoactive drug use and could lead to dependence in the workplace.

Usage des benzodiazépines chez les personnes âgées : état des connaissances

Cet article passe en revue la littérature concernant la dépendance aux benzodiazépines (BZD) chez la population des personnes âgées de 65 ans et plus. Alors que les conséquences négatives reliées à l’utilisation prolongée des BZD sont bien connues, le phénomène de la dépendance à ces substances chez cette population l’est beaucoup moins. Il n’existe toujours pas de consensus autour de la définition du problème. L’usage continu des BZD peut être davantage problématique chez les personnes âgées pour qui la tolérance aux agents chimiques diminue avec l’âge. Les facteurs de risque impliqués dans l’usage chronique sont une combinaison interactive entre les caractéristiques des aînés et celles des médecins prescripteurs. Des pistes de recherche étayées sur un changement paradigmatique sont lancées afin de bonifier la recherche dans ce domaine.

Use of benzodiazepine drugs and perceived job stress in a cohort of working men and women in Belgium. Results from the BELSTRESS-study

The aim of the Belstress Study was to see whether use of benzodiazepines is associated with perceived job stress as measured by Karasek's job-strain model. This model has as its central tenet that the most adverse health outcomes are to be expected in high strain jobs characterized by high job demands and low job control. An extension of the model states that the most noxious combination is high job demands, low control and low social support at work. Sample subjects were recruited from 25 Belgian companies between 1994 and 1998, and cover a wide range of occupations. A 5.6% of 16,094 men and 9.3% of 5012 women aged 35-59 years report use of benzodiazepines during the last month. A clear association is displayed between self-reported use of benzodiazepines and a high strain job compared to a low strain job (men: OR=1.93, 99% CI=1.4-2.6; women: OR=1.66, 99% CI=1.0-2.7), after adjustment is made for socio-demographic confounders (age, level of education, occupational group, employment sector, living situation). The independent association with quartile level of job demands is a striking feature (men: OR of highest quartile compared to lowest quartile group=1.91, 99% CI=1.4-2.6; women: OR=1.99, 99% CI=1.3-3.1). In men, an inverse association with quartile level of job control is observed (OR= 0.65, 99% CI=0.5-0.9) whereas in women a clear tendency in that direction is displayed (OR=0.62, 99% CI=0.4-1.1). The association with low social support is less clear; an independent association between use of benzodiazepines and iso-strain was observed particularly in men.

Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach

The aim of this study was to identify risk factors for benzodiazepine (BZD) dependence, such as sociodemographic variables, characteristics of BZD use, and psychiatric parameters, which to date have been found to relate inconsistently to indicators of BZD dependence such as chronic BZD use and BZD withdrawal symptoms. The Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ), Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and Symptom Checklist-90 (SCL-90) were administered to 599 outpatients using BZDs. Regression analyses were conducted using BZD dependence diagnoses and severity scales as dependent variables. BZD dependence diagnoses were only predicted by being a self-help patient and long BZD elimination half-life (for only the DSM-III-R). The main predictors of BZD dependence severity, as measured by the ICD-10, DSM-III-R scales, and Bendep-SRQ Rasch scales, were in decreasing order: (1) being a self-help patient; (2) higher BZD dose, longer duration of BZD use, younger age; and (3) non-native cultural origin, lower level of education, being in outpatient treatment for alcohol and/or drug dependence, and the interaction of BZD dose with duration of BZD use. We conclude that a limited number of recognizable risk factors appear to predict the severity of BZD dependence. Additional administration of a specific BZD dependence instrument is recommended to confirm suspected BZD dependence and guide further clinical decision-making.

Development and psychometric evaluation of the Benzodiazepine Craving Questionnaire

AIM

To assess the scalability, reliability and validity of a newly constructed self-report questionnaire on craving for benzodiazepines (BZs), the Benzodiazepine Craving Questionnaire (BCQ).

SETTING AND PARTICIPANTS

The BCQ was administered once to a sample of 113 long-term and 80 former long-term general practice BZ users participating in a large BZ reduction trial in general practice.

MEASUREMENTS

(1) Unidimensionality of the BCQ was tested by means of the Rasch model. (2) The Rasch-homogeneous BCQ items were assessed for subject and item discriminability. (3) Discriminative and construct validity were assessed.

FINDINGS

The BCQ met the requirements for Rasch homogeneity, i.e. BZ craving as assessed by the scale can be regarded as a unidimensional construct. Subject and item discriminability were good. Construct validity was modest. Highest significant associations were found with POMS depression (Kendall's tau-c = 0.15) and Dutch Shortened MMPI negativism (Kendall's tau-c = 0.14). Discriminative validity was satisfactory. Highest discriminative power was found for a subset of eight items (Mann-Whitney U Z = - 3.6, P = 0.000). The first signs of craving are represented by the acknowledgement of expectations of positive outcome, whereas high craving is characterized by direct intention to use.

CONCLUSIONS

The BCQ proved to be a reliable and psychometrically sound self-report instrument to assess BZ craving in a general practice sample of long-term BZ users.

Plants and the central nervous system

This review article draws the attention to the many species of plants possessing activity on the central nervous system (CNS). In fact, they cover the whole spectrum of central activity such as psychoanaleptic, psycholeptic and psychodysleptic effects, and several of these plants are currently used in therapeutics to treat human ailments. Among the psychoanaleptic (stimulant) plants, those utilized by human beings to reduce body weight [Ephedra spp. (Ma Huang), Paullinia spp. (guaraná), Catha edulis Forssk. (khat)] and plants used to improve general health conditions (plant adaptogens) were scrutinized. Many species of hallucinogenic (psychodysleptic) plants are used by humans throughout the world to achieve states of mind distortions; among those, a few have been used for therapeutic purposes, such as Cannabis sativa L., Tabernanthe iboga Baill. and the mixture of Psychotria viridis Ruiz and Pav. and Banisteriopsis caapi (Spruce ex Griseb.) C.V. Morton. Plants showing central psycholeptic activities, such as analgesic or anxiolytic actions (Passiflora incarnata L., Valeriana spp. and Piper methysticum G. Forst.), were also analysed.Finally, the use of crude or semipurified extracts of such plants instead of the active substances seemingly responsible for their therapeutic effect is discussed.

Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial

BACKGROUND

Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition.

AIMS

To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive-behavioural therapy (CBT).

METHOD

A 3-month randomised, 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care.

RESULTS

Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% nu. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibilityin general practice.

CONCLUSIONS

Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

Benzodiazepines: more "behavioural" addiction than dependence

AIMS

To estimate the prevalence, characteristics and risk factors associated with the development of benzodiazepine dependence in the users of these active ingredients.

DESIGN

A representative sample of patients currently receiving benzodiazepine treatment for 1 month or longer (mean 38.2+/-52 months, range 1-360 months) was studied.

PARTICIPANTS

One thousand and forty eight (1048) consecutive patients attending 20 primary-care health centres of the Canary Islands Health Service participated in this study during 2002.

MEASUREMENTS

The severity of dependence scale (SDS) was used as a screening test of benzodiazepine dependence among patients using benzodiazepines.

FINDINGS

Of patients using benzodiazepines for more than 1 month, 47% developed dependence to these compounds. Benzodiazepine dependence was more prevalent among women who were middle aged, separated, of low educational background, unemployed or housewives. Patients using short half-life benzodiazepines registered higher rates of dependence as well as those using higher doses or the patients with longer use. However, multivariate logistic regression analysis shows that benzodiazepine dependence was closely related only to three of the variables considered: the benzodiazepine dose used, the duration of this use and to the concomitant use of antidepressants.

CONCLUSIONS

The distribution of dose and length of treatment shows no evidence of pharmacological tolerance, neither in the whole sample nor in those patients with addiction (SDS+), reinforcing the idea that psychological dependence (addiction) is more relevant than pharmacological or physiological dependence in benzodiazepine chronic use.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.

The prevalence and clinical course of sedative-hypnotic abuse and dependence in a large cohort

Relatively little is known about the prevalence and clinical characteristics of dependence on sedative-hypnotics, and almost nothing has been published regarding abuse. This report relates information on Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IIIR) sedative-hypnotic use disorders among subjects from the Collaborative Study on the Genetics of Alcoholism (COGA). A standardized interview was used to generate data on 407 men and women in Group 1 with sedative-hypnotic dependence (4.4% of the COGA sample), 34 in Group 2 with abuse (0.4%), and 3,426 comparison subjects in Group 3 with alcohol dependence in the absence of a sedative-hypnotic use disorder (36.7%). The remaining COGA subjects (48.5%) were not included as they had neither alcohol nor sedative-hypnotic dependence or abuse. Those with sedative-hypnotic abuse or dependence were more likely to be Caucasian individuals with abuse or dependence on marijuana, cocaine, amphetamines, or opioids. Subjects in Groups 1 and 2 were also more likely to have histories of independent major depressive and panic disorders, as well as substance-induced mood disorders. Those with dependence, compared to abuse, were likely to be women, reported staying intoxicated for a day or more, but noted less abuse of opioids or amphetamines, although Group 2 members also had high rates of difficulties with sedative-hypnotics. These results highlight notable rates of sedative-hypnotic dependence in the COGA families, and indicate that while sedative-hypnotic abuse does occur, and while the clinical course can involve relatively serious problems, it is less common than dependence.