Benzodiazepine research: current findings and practical consequences

Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

BACKGROUND

Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected.

RESULTS

Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53%) articles were original research, predominantly randomized controlled trials (n = 52 [37%]), whereas 58 (42%) were narrative reviews and seven (5%) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57%]). Additional deprescribing strategies included psychological therapies (n = 10 [14%]), mixed interventions (n = 12 [16%]), and others (n = 10 [14%]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76%]), education (n = 36 [47%]), and training (n = 29 [39%]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely.

CONCLUSIONS

Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.

Effects of long-term benzodiazepine medication. A prospective cohort study: methodological and clinical aspects

Benzodiazepine (BDZ) drug impact on mental functions was explored in a cohort study of 30 psychiatric outpatients on long-term BDZ medication. A new questionnaire, the Drug Impact on Mental Processes (DIMP) was used and evaluated. The patients were rated three times: on inclusion in the study, after about 18 months and, finally, only a few days later. Test-retest reliability was evaluated for the two last ratings and was found acceptable for 19/23 items. The DIMP scores indicated negative effects on crisis reaction, intensified defence mechanisms and reduced cognitive, emotional and conative functions. Long-term BDZ treatment intensified passive coping. The drug impact on mental functions ranged between a mild and a moderate degree. The clinical outcomes of the patients' psychiatric disorders were evaluated at a 1-year follow-up after continued or discontinued BDZ treatment. In the subgroup that had discontinued the BDZ treatment at follow-up, significantly more patients reported reduced severity of their psychiatric disorders and significantly more patients had paid jobs. The overall clinical improvement after discontinued BDZ treatment may be explained by recovery from an addiction syndrome. It may also be related to a shift from passive to active coping.

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

The intensity of putative benzodiazepine withdrawal symptoms was evaluated as part of a double blind placebo-controlled study of benzodiazepines and behaviour therapy in the management of agoraphobia. During the first phase of that study, some subjects were switched from low dose diazepam to placebo, and others remained on diazepam. Symptoms were evaluated in long-term benzodiazepine users (n = 30) and non-users n = 32) when they first entered the study and 4 weeks later, after both groups had been randomized to either diazepam or placebo, using eight analog rating scales measuring commonly reported withdrawal symptoms. At baseline, both users and non-users reported a substantial number of symptoms, with higher levels in the more anxious patients, but no differences between groups. After the transition to either diazepam or placebo, the users switched to placebo reported significantly higher levels of symptoms than users switched to diazepam and non-users combined. Multiple regression analysis suggested that the increase in symptoms was associated with the increase in anxiety, which was higher in the withdrawing group than the other three groups. These results raise questions concerning the extent to which withdrawal symptoms uniquely characterize benzodiazepine withdrawal. They confirm the common assumption that an increase in symptoms often accompanies withdrawal from benzodiazepines, but suggest that such symptoms are not so intense as to make withdrawal excessively difficult, at least in low-dose users.

Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia

In a study designed to evaluate the impact of benzodiazepine use on the outcome of behaviour therapy, 91, severe, chronic agoraphobics (46 BDZ users and 45 non-users) were randomly allocated on a double-blind basis to in vivo exposure with low-dose diazepam (ED) or placebo (EP). Drug doses were adjusted on the basis of weekly psychiatric assessments over weeks 1-4. Patients had 8 x 2 hr exposure sessions (weeks 5-12) and were then withdrawn from medication (weeks 13-16). Re-assessments were completed at weeks 4, 12 and 16, and follow-up assessments at approx 20, 46 and 72 weeks. In the analysis of the results, the clinical outcome was evaluated in relation to the therapeutic regime (ED vs EP) and prior BDZ use (users vs non-users). The results showed that the ED group had greater changes in anxiety than the EP group during the drug manipulation phases (anxiety increasing during BDZ withdrawal). There were no group differences in agoraphobic symptoms and no evidence that the outcome of the behavior therapy was significantly affected by concurrent BDZ treatment. There were significant improvements in agoraphobic symptoms over the treatment period, with no evidence for relapse of treatment gains on withdrawal from BDZ, nor for differential responses over the one year follow-up. Initial differences between users and non-users were less marked than expected, although there was a trend for more drop-outs among users across both ED and EP groups.

Psychological treatment of generalised anxiety disorder. A review of the clinical significance of results in outcome studies since 1980

Comparative outcome studies of generalised anxiety disorder suggest that psychological therapy is a potentially valuable alternative to anxiolytic medication. However, on average psychological therapy results in modest improvements in symptoms, with about 50% of patients achieving normal functioning. Limited follow-up data indicate that these changes are maintained over six months. Cognitive therapy appears to be most effective, although comparisons with other therapies are limited and non-specific factors are clearly important. There is also evidence of considerable variability in outcome between studies, with the best results obtained with patients who are free of anxiolytic medication and recruited directly from primary care or other non-psychiatric settings. The effects on outcome of patient characteristics known to be associated with more severe illness and complexity of clinical presentation have yet to be explored. A balanced appraisal of the value of psychological therapy with this common condition requires a fuller description of sample characteristics and more systematic investigation of the clinical significance of treatment effects over the long term.

Adolescent drug use, health and personality

Four factors have confounded the association between drug use and morbidity: (a) known drug users may be less healthy than unknown drug users; (b) drug users are rarely compared to control subjects; (c) the socio-economic status of drug users predisposes them to ill-health; (d) the personality of drug users predisposes them to ill-health. Here, controlling for these confounds, in a study of 210 adolescent drug users it was found that subjective ill-health was more strongly related to drug use than was objective ill-health. Drug use was related to neuroticism and psychopathic deviance. Controlling for personality, drug use accounted for little additional variance in health. It is concluded that drug use and health are not strongly related amongst adolescent drug users, although, because of their personalities, drug users tend not to feel well. Implications are discussed for the self-treatment explanation of drug use and for the design of preventative programmes.

Benzodiazepines, putative anxiolytics and animal models of anxiety

Anxiety is a complex state that includes a broad range of classified symptoms. Anxiolytic treatment has been dominated by the use of benzodiazepine drugs (BZs), which is often prolonged. However, the multiplicity of anxiety states and the lack of BZ specificity preclude the potent targeting of the drugs to different states, and point to the problem of drug dependence. Furthermore, animal models of anxiety give different results when challenged with apparently similar drugs. The search for alternative drugs with a higher specificity has led to 5-HT receptor subtypes. In this review, Simon Green describes how recent research might have dual benefits: in improving drug therapy of anxiety in humans, and in analysing and categorizing more clearly the concept of anxiety itself.

Benzodiazepines, memory and mood: a review

The amnestic effects of benzodiazepines (BZs) have attracted considerable research interest. This reflects not only the clinical implications of memory failure for people prescribed these drugs but also the potential of BZs as tools in modelling organic memory problems. As well as impairing certain aspects of human memory functions, BZs affect mood states by reducing anxiety and inducing sedation. An unresolved issue is the extent to which the amnestic effects of BZs are separable from their sedative and anxiolytic effects. The present review focuses on this issue, first presenting a conceptual framework for evaluating the interrelationship between the various effects of BZs, and then summarising recent volunteer and patient research relevant to dissociating amnestic from other effects. Clinical implications are discussed in terms of the use of BZs alone or as adjuncts to psychotherapy for anxiety disorders, and attention is drawn to the need for more ecological validity in psychopharmacological research. Theoretical implications are explored in terms of BZs as tools in studying both memory failure and the relationship between mood and cognition.

Behaviour therapy and benzodiazepines: allies or antagonists?

Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.