Benzodiazepines as a Monotherapy in Depressive Disorders: A Systematic Review

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Revisiting benzodiazepines (GABA Enhancers):A transdiagnostic and precision medicine approach

Since the mid 1980's, there has been an increased focus on the side effects of benzodiazepines (GABA enhancers), and as a result there has been a decrease in their use. We have systematically reviewed recent studies of GABA enhancers in psychiatry, and highlight evidence of their utility which may impact their negative conceptualization in clinical practice. We propose a new perspective on the appropriate use of these medications and describeclinical reasoning underpinning the use of benzodiazepine (GABA enhancers) based on their effect on specific receptors. A translational approach, involving a more comprehensive characterization of GABA receptors and their neuroscience-based mechanisms allows for a more precise use of this medication class. By adopting a precision person-centered approach, instead of a categorical approach, supports the prescribing of GABA enhancers when a cross-cutting transdiagnostic assessment shows anxiety symptoms associated with clinical impairment.

Depression pathophysiology, risk prediction of recurrence and comorbid psychiatric disorders using genome-wide analyses

Depression is a common psychiatric disorder and a leading cause of disability worldwide. Here we conducted a genome-wide association study meta-analysis of six datasets, including >1.3 million individuals (371,184 with depression) and identified 243 risk loci. Overall, 64 loci were new, including genes encoding glutamate and GABA receptors, which are targets for antidepressant drugs. Intersection with functional genomics data prioritized likely causal genes and revealed new enrichment of prenatal GABAergic neurons, astrocytes and oligodendrocyte lineages. We found depression to be highly polygenic, with ~11,700 variants explaining 90% of the single-nucleotide polymorphism heritability, estimating that >95% of risk variants for other psychiatric disorders (anxiety, schizophrenia, bipolar disorder and attention deficit hyperactivity disorder) were influencing depression risk when both concordant and discordant variants were considered, and nearly all depression risk variants influenced educational attainment. Additionally, depression genetic risk was associated with impaired complex cognition domains. We dissected the genetic and clinical heterogeneity, revealing distinct polygenic architectures across subgroups of depression and demonstrating significantly increased absolute risks for recurrence and psychiatric comorbidity among cases of depression with the highest polygenic burden, with considerable sex differences. The risks were up to 5- and 32-fold higher than cases with the lowest polygenic burden and the background population, respectively. These results deepen the understanding of the biology underlying depression, its disease progression and inform precision medicine approaches to treatment.

Benzodiazepines Remain Important Therapeutic Options in Psychiatric Practice

Benzodiazepines and medications acting on benzodiazepine receptors that do not have a benzodiazepine structure (z-drugs) have been viewed by some experts and regulatory bodies as having limited benefit and significant risks. Data presented in this article support the use of these medications as treatments of choice for acute situational anxiety, chronic anxiety disorders, insomnia, alcohol withdrawal syndromes, and catatonia. They may also be useful adjuncts in the treatment of anxious depression and mania, and for medically ill patients. Tolerance develops to sedation and possibly psychomotor impairment, but not to the anxiolytic effect of benzodiazepines. Sedation can impair cognitive function in some patients, but assertions that benzodiazepines increase the risk of dementia are not supported by recent data. Contrary to popular opinion, benzodiazepines are not frequently misused or conduits to misuse of other substances in patients without substance use disorders who are prescribed these medications for appropriate indications; most benzodiazepine misuse involves medications that are obtained from other people. Benzodiazepines are usually not lethal in overdose except when ingested with other substances, especially alcohol and opioids. Benzodiazepines comprise one of the few classes of psychotropic medication the mechanisms of action of which are clearly delineated, allowing for greater precision in their clinical use. These medications, therefore, belong in the therapeutic armamentarium of the knowledgeable clinician.

Peptide LCGA-17 Attenuates Behavioral and Neurochemical Deficits in Rodent Models of PTSD and Depression

We have previously described the LCGA-17 peptide as a novel anxiolytic and antidepressant candidate that acts through the α2δ VGCC (voltage-gated calcium channel) subunit with putative synergism with GABA-A receptors. The current study tested the potential efficacy of acute and chronic intranasal (i.n.) LCGA-17 (0.05 mg/kg and 0.5 mg/kg) in rats on predator odor-induced conditioned place aversion (POCPA), a model of post-traumatic stress disorder (PTSD), and chronic unpredictable stress (CUS) that produce a range of behavioral and physiological changes that parallel symptoms of depression in humans. CUS and LCGA-17 treatment effects were tested in the sucrose preference (SPT) social interaction (SI), female urine sniffing (FUST), novelty-suppressed feeding (NSFT), and forced swim (FST) tests. Analysis of the catecholamines content in brain structures after CUS was carried out using HPLC. The efficacy of i.n. LCGA-17 was also assessed using the Elevated plus-maze (EPM) and FST. Acute LCGA-17 administration showed anxiolytic and antidepressant effects in EPM and FST, similar to diazepam and ketamine, respectively. In the POCPA study, LCGA-17 significantly reduced place aversion, with efficacy greater than doxazosin. After CUS, chronic LCGA-17 administration reversed stress-induced alterations in numerous behavioral tests (SI, FUST, SPT, and FST), producing significant anxiolytic and antidepressant effects. Finally, LCGA-17 restored the norepinephrine levels in the hippocampus following stress. Together, these results support the further development of the LCGA-17 peptide as a rapid-acting anxiolytic and antidepressant.

An age-period-cohort study of completed suicides in Greece: Patterns and implications for suicide prevention

Suicide is a dynamic phenomenon. Psychiatric medication intake, illicit drug and alcohol use or the preference for particular suicide methods shift continuously over time. To capture such variations -and their potential implications for suicide prevention-, we researched the forensic records of suicide cases for the period 1992-2016 at a large department of forensic medicine and conducted age-period-cohort (APC) analyses of our sample (1162 suicides, 77.45% males, 22.25% females). We primarily investigated socio-demographic and toxicological parameters. Benzodiazepine, alcohol and illicit drug use increased considerably towards the younger cohorts. The segment of individuals of foreign nationality raised significantly too; likewise, the proportion of prison suicides. Hanging appears increasingly preferred by the younger APCs (the opposite is true for jumping). Hanging seems more popular among males, prisoners, and those under the influence of illicit drugs; jumping by females and those less likely to have consumed alcohol or illicit drugs. Given that the method of a prior attempt, if a highly lethal one, usually gets repeated in the completed suicide, a history of an attempt by hanging should never be underestimated. The mental health needs of immigrants and prisoners look inadequately addressed. Young-middle aged immigrant prisoners appear a group at high suicide risk.

GABA System in Depression: Impact on Pathophysiology and Psychopharmacology

BACKGROUND

The pathophysiology of major depressive disorder (MDD), one of the major causes of worldwide disability, is still largely unclear, despite the increasing data reporting evidence of multiple alterations of different systems. Recently, there was a renewed interest in the signalling of gamma aminobutyric acid (GABA) - the main inhibitory neurotransmitter.

OBJECTIVE

The aim of this study was to review and comment on the available literature about the involvement of GABA in MDD, as well as on novel GABAergic compounds possibly useful as antidepressants.

METHODS

We carried out a narrative review through Pubmed, Google Scholar and Scopus, by using specific keywords.

RESULTS

The results, derived from various research tools, strongly support the presence of a deficiency of the GABA system in MDD, which appears to be restored by common antidepressant treatments. More recent publications would indicate the complex interactions between GABA and all the other processes involved in MDD, such as monoamine neurotransmission, hypothalamus-pituitary adrenal axis functioning, neurotrophism, and immune response. Taken together, all these findings seem to further support the complexity of the pathophysiology of MDD, possibly reflecting the heterogeneity of the clinical pictures.

CONCLUSION

Although further data are necessary to support the specificity of GABA deficiency in MDD, the available findings would suggest that novel GABAergic compounds might constitute innovative therapeutic strategies in MDD.

When Anxiety and Depression Coexist: The Role of Differential Diagnosis Using Clinimetric Criteria

Depressive and anxiety disorders are frequently associated. Depression may be a complication of anxiety and anxiety can complicate depression. The nature of their relationship has been a source of controversy. Reviews generally base their conclusions on randomized controlled trials and meta-analyses that refer to the average patient and often clash with the variety of clinical presentations that may occur when anxiety and depression coexist. The aim of this review was to examine the literature according to profiling of subgroups of patients based on clinimetric criteria, in line with the recently developed concept of medicine-based evidence. We critically reviewed the literature pertaining to the specific presentations of anxiety and depression, outlining the advantages and disadvantages of each treatment approach. The following prototypic cases were presented: depression secondary to an active anxiety disorder, depression in patients with anxiety disorders under treatment, anxious depression, anxiety as a residual component of depression, and demoralization secondary to anxiety disorder. We argue that the selection of treatment when anxiety and depression coexist should take into account the modalities of presentation and be filtered by clinical judgment. Very different indications may ensue when the literature is examined according to this perspective.

Prior benzodiazepine use and mortality among adult patients with sepsis: A retrospective population-based cohort study in South Korea

OBJECTIVES

This study investigated whether long-term benzodiazepine use is associated with increased 90-day mortality among patients with sepsis.

METHODS

A retrospective population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea was conducted. All adult patients (≥18 years) admitted to the hospital with a primary diagnosis of sepsis or septic shock during 2010-2018 were included in the study. Sepsis and septic shock were diagnosed based on the International Classification of Diseases (10th revision: A40, A41 and R65.2). Benzodiazepine users were defined as individuals who were prescribed regular benzodiazepine continuously for over 6 months before admission.

RESULTS

A total of 251 837 patients with sepsis were included in this study, 16 686 of which (6.6%) were benzodiazepine users, and 235 151 (93.4%) were non-users. After propensity score (PS) matching, 33 370 patients (16 685 in both groups) were ultimately included. Moreover, following PS matching, the 90-day mortality among benzodiazepine users and non-users was 60.9% (10 167) and 41.4% (6916), respectively. Cox regression analysis further revealed the hazard ratio (HR) for 90-day mortality in benzodiazepine users to be 1.75, compared with non-users [95% confidence interval (CI): 1.70-1.81; P < .001]. Sensitivity analyses showed that, compared with non-users, HRs for 90-day mortality in benzodiazepine users without and with other psychiatric illnesses were 1.43 (95% CI: 1.38-1.49; P < .001) and 1.89 (95% CI: 1.84-1.94; P < .001), respectively.

CONCLUSION

Long-term benzodiazepine use is associated with increased 90-day mortality among adult patients with sepsis compared with non-users. This association was more evident in benzodiazepine users with other psychiatric diseases, such as depression or anxiety disorder.

In silico Screening and Behavioral Validation of a Novel Peptide, LCGA-17, With Anxiolytic-Like Properties

The aim of the study was to develop better anxiolytics and antidepressants. We focused on GABA_A receptors and the α2δ auxiliary subunit of V-gated Ca²⁺ channels as putative targets because they are established as mediators of efficacious anxiolytics, antidepressants, and anticonvulsants. We further focused on short peptides as candidate ligands because of their high safety and tolerability profiles. We employed a structural bioinformatics approach to develop novel tetrapeptides with predicted affinity to GABA_A receptors and α2δ. In silico docking studies of one of these peptides, LCGA-17, showed a high binding score for both GABA_A receptors and α2δ, combined with anxiolytic-like properties in a Danio rerio behavioral screen. LCGA-17 showed anxiolytic-like effects in the novel tank test, the light–dark box, and the social preference test, with efficacy comparable to fluvoxamine and diazepam. In binding assays using rat brain membranes, [³H]-LCGA-17 was competed more effectively by gabapentinoid ligands of α2δ than ligands of GABA_A receptors, suggesting that α2δ represents a likely target for LCGA-17. [³H]-LCGA-17 binding to brain lysates was unaffected by competition with ligands for GABA_B, glutamate, dopamine, serotonin, and other receptors, suggesting specific interaction with α2δ. Dose-finding studies in mice using acute administration of LCGA-17 (i.p.) demonstrated anxiolytic-like effects in the open field test, elevated plus maze, and marble burying tests, as well as antidepressant-like properties in the forced swim test. The anxiolytic effects were effectively blocked by bicuculline. Therefore, LCGA-17 is a novel candidate anxiolytic and antidepressant that may act through α2δ, with possible synergism by GABA_A receptors.

[Evaluation of the Lippstädter Benzo-Check as a Screening Tool for Side Effects of Long-term Use of Benzodiazepines and Z-drugs]

OBJECTIVE

The Lippstädter Benzo-Check is intended to motivate those affected by unwanted effects of Benzodiazepines and Z-drugs. This study serves as the first check whether the Lippstädter Benzo-Check adequately recorded the symptoms of longterm-use before the withdrawal and, on the other hand, a depressive control group without taking the corresponding drugs unremarkable values ​​achieved.

METHODS

101 inpatient withdrawal patients with dependency on Benzodiazepines or Z-drugs and 154 day clinic patients without benzodiazepines or Z-drugs completed the Lippstädter Benzo-Check at the beginning of treatment. The total score and a subscore "dependency" were compared between the two groups.

RESULTS

The total score ​​of the Lippstädter Benzo-check in the two collectives differ highly significantly, nevertheless around half oft he depressed patients are in the lowest of three warning areas - "the symptoms you have specified probably come from the long-term use oft he medication".The items "sleep disorder", "stealth", "loss of effectiveness", "fixation on medication" and "extension oft he indication" can be combined into a subscore ("dependency score"). This achieves a high selectivity for a cut-off value of<5 points, since 100% of the day clinic patients and only 10% of the withdrawal patients are below it.

CONCLUSIONS

The results of this first study using the Lippstädter Benzo-Check as a screening tool for undesirable consequences on benzodiazepines or Z-drugs are encouraging, despite methodological limitations and the need for further investigations.

The use of biofeedback intervention in the improvement of depression levels: a randomised trial

OBJECTIVE

To evaluate the use of biofeedback intervention in the levels of depression. The main hypothesis tested if the use of biofeedback improves depression levels compared to the control group.

METHODS

A randomised clinical trial. The final sample was composed of 36 participants (18 in the experimental group, receiving 6 training, once a week, with biofeedback; and 18 in the control group, who received conventional treatment in the service).Outcome measures were assessed in two stages: pre-test and post-test. The research used the following instruments: demographic survey data, Mini International Neuropsychiatric Interview 5.0.0 and Beck Depression Inventory (BDI). The factors and variables were presented in terms of descriptive and inferential statistics. Fisher's exact test (p < 0.05) was used to verify the existence of an association between the counting variables. The multinomial logistic regression model was adopted, and the Logit link function was used, as the software RStudio version 3.6.2.

RESULTS

The factors that remained in the final model were group, sex, partner, atypical antidepressant, benzodiazepines, mood stabiliser, antiepileptic and antihistamine, according to the levels of depression based on the BDI. The group that did not receive biofeedback intervention had 16 times more chances of increasing the depression levels compared to participants in the experimental group.

CONCLUSION

The use of biofeedback reduces depression, thus, representing a complementary alternative for the treatment of moderate and severe depression, and dysthymia.

Doxepin Exacerbates Renal Damage, Glucose Intolerance, Nonalcoholic Fatty Liver Disease, and Urinary Chromium Loss in Obese Mice

Doxepin is commonly prescribed for depression and anxiety treatment. Doxepin-related disruptions to metabolism and renal/hepatic adverse effects remain unclear; thus, the underlying mechanism of action warrants further research. Here, we investigated how doxepin affects lipid change, glucose homeostasis, chromium (Cr) distribution, renal impairment, liver damage, and fatty liver scores in C57BL6/J mice subjected to a high-fat diet and 5 mg/kg/day doxepin treatment for eight weeks. We noted that the treated mice had higher body, kidney, liver, retroperitoneal, and epididymal white adipose tissue weights; serum and liver triglyceride, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, and creatinine levels; daily food efficiency; and liver lipid regulation marker expression. They also demonstrated exacerbated insulin resistance and glucose intolerance with lower Akt phosphorylation, GLUT4 expression, and renal damage as well as higher reactive oxygen species and interleukin 1 and lower catalase, superoxide dismutase, and glutathione peroxidase levels. The treated mice had a net-negative Cr balance due to increased urinary excretion, leading to Cr mobilization, delaying hyperglycemia recovery. Furthermore, they had considerably increased fatty liver scores, paralleling increases in adiponectin, FASN, PNPLA3, FABP4 mRNA, and SREBP1 mRNA levels. In conclusion, doxepin administration potentially worsens renal injury, nonalcoholic fatty liver disease, and diabetes.

Behavioral Deficits Induced by Somatostatin-Positive GABA Neuron Silencing Are Rescued by Alpha 5 GABA-A Receptor Potentiation

INTRODUCTION

Deficits in somatostatin-positive gamma-aminobutyric acid interneurons (SST+ GABA cells) are commonly reported in human studies of mood and anxiety disorder patients. A causal link between SST+ cell dysfunction and symptom-related behaviors has been proposed based on rodent studies showing that chronic stress, a major risk factor for mood and anxiety disorders, induces a low SST+ GABA cellular phenotype across corticolimbic brain regions; that lowering Sst, SST+ cell, or GABA functions induces depressive-/anxiety-like behaviors (a rodent behavioral construct collectively defined as "behavioral emotionality"); and that disinhibiting SST+ cells has antidepressant-like effects. Recent studies found that compounds preferentially potentiating receptors mediating SST+ cell functions, α5-GABAA receptor positive allosteric modulators (α5-PAMs), achieved antidepressant-like effects. Together, the evidence suggests that SST+ cells regulate mood and cognitive functions that are disrupted in mood disorders and that rescuing SST+ cell function via α5-PAM may represent a targeted therapeutic strategy.

METHODS

We developed a mouse model allowing chemogenetic manipulation of brain-wide SST+ cells and employed behavioral characterization 30 minutes after repeated acute silencing to identify contributions to symptom-related behaviors. We then assessed whether an α5-PAM, GL-II-73, could rescue behavioral deficits.

RESULTS

Brain-wide SST+ cell silencing induced features of stress-related illnesses, including elevated neuronal activity and plasma corticosterone levels, increased anxiety- and anhedonia-like behaviors, and impaired short-term memory. GL-II-73 led to antidepressant- and anxiolytic-like improvements among behavioral deficits induced by brain-wide SST+ cell silencing.

CONCLUSION

Our data validate SST+ cells as regulators of mood and cognitive functions and demonstrate that bypassing low SST+ cell function via α5-PAM represents a targeted therapeutic strategy.

Altered GABA-mediated information processing and cognitive dysfunctions in depression and other brain disorders

Cognitive dysfunctions, including impaired attention, learning, memory, planning and problem solving, occur in depressive episodes, often persist during remission, predict relapse, worsen with recurrent episodes, and are not treated by current antidepressants or other medications. Cognitive symptoms are also present in other psychiatric disorders, are a hallmark of aging, and define several late-life disorders, including Alzheimer's disease. This pervasive occurrence suggests either a non-specific outcome of a diseased brain, or a shared underlying pathology contributing to this symptom dimension. Recent findings suggest a role for altered GABAergic inhibition in cognitive symptoms. Cellular, molecular and biochemical studies in human subjects report changes affecting the gamma-amino butyric acid (GABA) system, specifically somatostatin-expressing (SST+) GABAergic interneurons, across brain disorders and during aging. SST+ neurons gate excitatory input onto pyramidal neurons within cortical microcircuits. Experimentally reducing the function of these neurons affects excitatory signal-to-noise ratio, reduces synchronized cellular and neural activity, and leads to cognitive dysfunctions. Conversely, augmenting SST+ cell post-synaptic α5-GABA-A receptor activity has pro-cognitive efficacy in stress and aging models. Together, this suggests that reduced signaling of the SST+ neuron/α5-GABA-A receptor pathway contributes to cognitive dysfunctions, and that it represents a novel therapeutic target for remediating mood and cognitive symptoms in depression, other psychiatric disorders and during aging.

Understanding the effects of chronic benzodiazepine use in depression: a focus on neuropharmacology

Benzodiazepines are frequently prescribed on an ongoing basis to individuals with depression, mainly to alleviate anxiety or insomnia, despite current guideline recommendations that continuous use should not exceed 4 weeks. Currently, there are no efficacy trials published beyond 8 weeks. Several antidepressant trials demonstrate that the concomitant use of a benzodiazepine is associated with poorer depressive outcomes and functional status; however, it is unclear why this is the case. Patients with depression receiving a benzodiazepine may reflect a more ill or high anxiety group, although even within anxiety disorders, the use of a benzodiazepine is associated with poorer outcomes. The neuroadaptive consequences of long-term benzodiazepine use may be a factor underlying these findings. Chronic benzodiazepine use results in decreased gamma-aminobutyric acid and monoaminergic function, as well as interference with neurogenesis, which are all purported to play a role in antidepressant efficacy. This review will discuss the oppositional neuropharmacological interactions between chronic benzodiazepine use and antidepressant mechanism of action, which could result in reduced antidepressant efficacy and function in depression.

Mental Pain as a Transdiagnostic Patient-Reported Outcome Measure

Patient-reported outcomes (PROs) refer to any report coming directly from patients about how they function or feel in relation to a health condition or its therapy. PROs have been applied in medicine for the assessment of the impact of clinical phenomena. Self-report scales and procedures for assessing physical pain in adults have been developed and used in clinical trials. However, insufficient attention has been dedicated to the assessment of mental pain. The aim of this paper is to outline the implications that assessment of mental pain may entail in psychiatry and medicine, with particular reference to a clinimetric index. A simple 10-item self-rating questionnaire, the Mental Pain Questionnaire (MPQ), encompasses the specific clinical features of mental pain and shows good clinimetric properties (i.e., sensitivity, discriminant and incremental validity). The preliminary data suggest that the MPQ may qualify as a PRO measure to be included in clinical trials. Assessment of mental pain may have important clinical implications in intervention research, both in psychopharmacology and psychotherapy. The transdiagnostic features of mental pain are supported by its association with a number of psychiatric disorders, such as depression, anxiety, eating disorders, as well as borderline personality disorder. Further, addressing mental pain may be an important pathway to prevent and diminish the opioid epidemic. The data summarized here indicate that mental pain can be incorporated into current psychiatric assessment and included as a PRO measure in treatment outcome studies.

Benzodiazepines Reduce Relapse and Recurrence Rates in Patients with Psychotic Depression

The long-term use of benzodiazepines is not recommended for the treatment of major depressive disorder (MDD) due to the risk of adverse effects, including dependence, falls, dementia, mortality and the lack of evidence of effectiveness for symptoms other than anxiety. However, there are many patients with MDD for whom antidepressants are co-administrated with benzodiazepines. This study aimed to identify whether the use of benzodiazepines is associated with a lower risk of relapse or recurrence of MDD in some patients, and the characteristics of these patients. Kaplan–Meier survival analysis was used to quantify the relapse and recurrence of MDD in 108 patients with MDD who achieved remission during hospitalization. Among them, 26 patients had been diagnosed with severe MDD with psychotic features. There was no significant difference in the rate of relapse/recurrence between patients with and without benzodiazepines when all patients were analyzed together. However, among the 26 patients with psychotic depression, 21.2% in the benzodiazepine group and 75.0% in the non-benzodiazepine group experienced relapse (log rank p = 0.0040). Kaplan–Meier survival analysis revealed that this effect was dose-dependent. The adjunctive use of benzodiazepines may reduce relapse/recurrence rates in patients with severe MDD with psychotic features.

Benzodiazepines related sexual dysfunctions: A critical review on pharmacology and mechanism of action

INTRODUCTION

Normal sexual functioning of both men and women, being a very complex process, is affected by numerous issues besides aging. Many factors affect the sexual function and lifestyle of the young population. In this article, we tried to review the literature to update the knowledge on benzodiazepine-related (BZD) sexual dysfunction (SD) and involved mechanisms of actions based on animal and human studies.

METHODS

Different standard websites such as PubMed were used to review the literature and keywords including benzodiazepines, sexual dysfunction, gammaaminobutyric acid A (GABAA) receptor and erectile dysfunction were used.

RESULTS

SD is one of the most common disorders in males and females which has recently been demonstrated to be associated with psychotropic medications such as antihypertensive agents, tranquilizers, antihistamines, appetite suppressants, antidepressants and anxiolytics. BZDs are among the most common psychotropic agents worldwide. SD including decreased libido, erectile dysfunction (ED) and other undesired sexual urges were observed in the patients receiving BZDs.

DISCUSSION

The mechanisms of action of BZDs to induce SD mainly relate to enhanced GABAA receptor function which reduces penile erection.

Allopregnanolone in postpartum depression: Role in pathophysiology and treatment

Postpartum depression (PPD) is a unique subtype of major depressive disorder and a substantial contributor to maternal morbidity and mortality. In addition to affecting the mother, PPD can have short- and long-term consequences for the infant and partner. The precise etiology of PPD is unknown, but proposed mechanisms include altered regulation of stress response pathways, such as the hypothalamic-pituitary-adrenal axis, and dysfunctional gamma-aminobutyric acid (GABA) signaling, and functional linkages exist between these pathways. Current PPD pharmacotherapies are not directly related to these proposed pathophysiologies. In this review, we focus on the potential role of GABAergic signaling and the GABA_A receptor positive allosteric modulator allopregnanolone in PPD. Data implicating GABAergic signaling and allopregnanolone in PPD are discussed in the context of the development of brexanolone injection, an intravenous formulation of allopregnanolone recently approved by the United States Food and Drug Administration for the treatment of adult women with PPD.

May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance

In recent years there has been a considerable debate on antidepressant drugs. Continued drug treatment with antidepressant medications may stimulate processes that run counter to the initial acute effects of a drug. The oppositional model of tolerance may explain loss of treatment efficacy during maintenance treatment and the fact that some side effects tend to occur only after a certain time. These processes may also direct the illness into a treatment-unresponsive course, including manifestations of bipolar disorder or paradoxical reactions. When drug treatment ends, oppositional processes no longer encounter resistance, resulting in potential onset of new withdrawal symptoms, persistent post-withdrawal disorders, hypomania, and resistance to treatment if it is reinstituted. In all these cases, antidepressant medications may constitute a form of iatrogenic comorbidity, which increases chronicity and vulnerability to depressive episodes. Antidepressant medications are essential drugs for the treatment of major depressive episodes. They are less likely, however, to provide protection for relapse prevention. Current prescription practices need to be reformulated in light of consideration of vulnerabilities and adverse effects of treatment. The oppositional model of tolerance provides a conceptual framework for weighing all these elements in the individual case. The model does not appear to apply to all patients who undergo treatment with AD, but only to a part of them. Studying the variables that are associated with such occurrence in certain patients and not in others would be one of the most important tasks of current therapeutic research. Current diagnostic systems in psychiatry do not consider the iatrogenic components of psychopathology, and can be applied to only patients who are drug free. They are suited for a patient who no longer exists: most of the cases that are seen in psychiatric clinical practice receive psychotropic drugs and such treatment is likely to affect prognosis and treatment choices.

Benzodiazepine and unhealthy alcohol use among adult outpatients

OBJECTIVES

Concomitant excessive alcohol consumption and benzodiazepine use is associated with adverse health outcomes. We examined associations of unhealthy alcohol use and other patient characteristics with benzodiazepine use.

STUDY DESIGN

A cross-sectional analysis of 2,089,525 Kaiser Permanente of Northern California outpatients screened for unhealthy alcohol use in primary care between November 1, 2014, and December 31, 2016.

METHODS

We fit multivariable generalized linear models to estimate the associations between unhealthy alcohol use and benzodiazepine dispensation and, among patients who were dispensed a benzodiazepine, mean doses (in mean lorazepam-equivalent daily doses [LEDDs]) and prescription durations. We controlled for patient sex, age, race/ethnicity, estimated household income, Charlson Comorbidity Index (CCI) score, anxiety disorder, alcohol use disorder, insomnia, musculoskeletal pain, and epilepsy.

RESULTS

In the 12 months centered around (6 months before and 6 months after) the first alcohol-screening visit, 7.5% of patients used benzodiazepines. The following characteristics were independently associated with higher rates of benzodiazepine use, higher LEDD, and longer prescription duration: older age, white race/ethnicity, lower estimated household income, higher CCI score, and the presence of an anxiety disorder, insomnia, musculoskeletal pain, or epilepsy. Women and patients with an alcohol use disorder or unhealthy alcohol use, compared with men and patients with low-risk drinking or abstinence, were more likely to use a benzodiazepine; however, their LEDDs were lower and their prescription durations were shorter.

CONCLUSIONS

Benzodiazepine use in primary care was associated with older age, female sex, white race/ethnicity, lower socioeconomic status, and unhealthy alcohol use. These findings may be applied to develop policies and interventions to promote judicious benzodiazepine use.

Clinical characterization of allostatic overload

Allostatic load reflects the cumulative effects of stressful experiences in daily life and may lead to disease over time. When the cost of chronic exposure to fluctuating or heightened neural and systemic physiologic responses exceeds the coping resources of an individual, this is referred to as "toxic stress" and allostatic overload ensues. Its determination has initially relied on measurements of an interacting network of biomarkers. More recently, clinical criteria for the determination of allostatic overload, that provide information on the underlying individual experiential causes, have been developed and used in a number of investigations. These clinimetric tools can increase the number of people screened, while putting the use of biomarkers in a psychosocial context. The criteria allow the personalization of interventions to prevent or decrease the negative impact of toxic stress on health, with particular reference to lifestyle modifications and cognitive behavioral therapy.

Can psychomotor disturbance predict ect outcome in depression?

Psychomotor symptoms are core features of melancholic depression. This study investigates whether psychomotor disturbance predicts the outcome of electroconvulsive therapy (ECT) and how the treatment modulates psychomotor disturbance. In 73 adults suffering from major depressive disorder psychomotor functioning was evaluated before, during and after ECT using the observer-rated CORE measure and objective measures including accelerometry and a drawing task. Regression models were fitted to assess the predictive value of melancholic depression (CORE ≥ 8) and the psychomotor variables on ECT outcome, while effects on psychomotor functioning were evaluated through linear mixed models. Patients with CORE-defined melancholic depression (n = 41) had a 4.9 times greater chance of reaching response than those (n = 24) with non-melancholic depression (Chi-Square = 7.5, P = 0.006). At baseline, both higher total CORE scores (AUC = 0.76; P = 0.001) and needing more cognitive (AUC = 0.78; P = 0.001) and motor time (AUC = 0.76; P = 0.003) on the drawing task corresponded to superior ECT outcomes, as did lower daytime activity levels (AUC = 0.76) although not significantly so after Bonferroni correction for multiple testing. A greater CORE-score reduction in the first week of ECT was associated with higher ECT effectiveness. ECT reduced CORE-assessed psychomotor symptoms and improved activity levels only in those patients showing the severer baseline retardation. Although the sample was relatively small, psychomotor symptoms were clearly associated with beneficial outcome of ECT in patients with major depression, indicating that monitoring psychomotor deficits can help personalise treatment.

The effect of short-term use of benzodiazepines on cognitive function of major depressive disorder patients being treated with antidepressants

BACKGROUND

This study aimed to evaluate the effect of short-term use of benzodiazepines (BZDs) on cognitive function of major depressive disorder (MDD) patients being treated with antidepressants (ADs).

METHODS

This was a part of a multi-center, multi-stage and prospective study of "Objective Diagnostic Indicators and Individualized Drug Intervention of Major Depressive Disorder (OIMDD)". Three hundred and fifty-three patients treated with the selective serotonin reuptake inhibitors (SSRIs) alone (Group 1) and 49 patients treated with SSRIs combined with short-term use of BZDs (Group 2) during the acute treatment period were included in the analysis. Cognitive function and depressive and anxiety symptoms were assessed at baseline, weekend 8 and 48. A cognitive test battery included 5 domains: information processing speed assessed by the Animal Verbal Fluency Scale (AVFS), Digit Symbol Coding Test (DSCT) and Color Trial Test (CTT), verbal learning assessed by the Hopkins Verbal Learning Test-Revised (HVLT-R), visual learning assessed by the Brief Visual Memory Test-Revised (BVMT-R), executive function assessed by the Stroop Color Word Test (SCWT), and attention or vigilance assessed by the Continuous Performance Test (CPT).

RESULTS

Significant differences were found in education level (χ² = 5.442, p = 0.020), the severity of depressive (t = -1.982, p = 0.048) and anxiety symptoms (t = -2.629, p = 0.009) between Group 1 and 2 at baseline. There were no significant differences between G1 and G2 in cognitive functions at baseline. After Multiple correction, DSCT was better in patients treated with BZDs combined with ADs than in patients with ADs alone at weekend 8 without controlling education level, depressive and anxiety symptoms at baseline (F = -2.747, p = 0.042). After controlling these factors at baseline, the DSCT was still slightly high in patients treated with ADs combined with BZDs than in patients with ADs alone at weekend 8 (OR = 1.052, 95%CI:1.000-1.105). The repeated measurement analysis of variance showed that the DSCT could be improved by the treatment of BZDs combined with ADs at 1-year follow-up compared to baseline (F = 7.569, p = 0.006).

CONCLUSIONS

The findings suggest that short-term use of BZDs does not impair cognitive function of MDD patients; conversely, it could improve the information processing speed after acute treatment and at 1 year follow up.

Keeping up with the clinical advances: depression

Major depressive disorder (MDD) is a prevalent and heterogeneous disorder. Although there are many treatment options for MDD, patients with treatment-resistant depression (TRD) remain prevalent, wherein delayed time to response results in inferior chances of achieving remission. Recently, therapeutics have been developed that depart from the traditional monoamine hypothesis of depression and focus instead on the glutamatergic, GABAergic, opioidergic, and inflammatory systems. The literature suggests that the foregoing systems are implicated in the pathophysiology of MDD and preclinical trials have informed the development of pharmaceuticals using these systems as therapeutic targets. Pharmaceuticals that target the glutamatergic system include ketamine, esketamine, and rapastinel; brexanolone and SAGE-217 target the GABAergic system; minocycline targets the inflammatory system; and the combinatory agent buprenorphine + samidorphan targets the opioidergic system. The aforementioned agents have shown efficacy in treating MDD in clinical trials. Of particular clinical relevance are those agents targeting the glutamatergic and GABAergic systems as they exhibit rapid response relative to conventional antidepressants. Rapid response pharmaceuticals have the potential to transform the treatment of MDD, demonstrating reduction in depressive symptoms within 24 hours, as opposed to weeks noted with conventional antidepressants. Novel therapeutics have the potential to improve both patient mood symptomatology and economical productivity, reducing the debased human capital costs associated with MDD. Furthermore, a selection of therapeutic targets provides diverse treatment options which may be beneficial to the patient considering the heterogeneity of MDD.

Brexanolone, a neurosteroid antidepressant, vindicates the GABAergic deficit hypothesis of depression and may foster resilience

The GABAergic deficit hypothesis of depression states that a deficit of GABAergic transmission in defined neural circuits is causal for depression. Conversely, an enhancement of GABA transmission, including that triggered by selective serotonin reuptake inhibitors or ketamine, has antidepressant effects. Brexanolone, an intravenous formulation of the endogenous neurosteroid allopregnanolone, showed clinically significant antidepressant activity in postpartum depression. By allosterically enhancing GABA _A receptor function, the antidepressant activity of allopregnanolone is attributed to an increase in GABAergic inhibition. In addition, allopregnanolone may stabilize normal mood by decreasing the activity of stress-responsive dentate granule cells and thereby sustain resilience behavior. Therefore, allopregnanolone may augment and extend its antidepressant activity by fostering resilience. The recent structural resolution of the neurosteroid binding domain of GABA _A receptors will expedite the development of more selective ligands as a potential new class of central nervous system drugs.

Exploring characteristics associated with first benzodiazepine prescription in patients with affective disorders and related diagnoses

OBJECTIVE

In patients with affective disorders, benzodiazepines (BZDs) are frequently administered at the onset, sometimes inappropriately. We sought to identify clinical variables associated with first BZD prescription in a large sample of patients with affective disorders.

METHODS

Four hundred sixty patients with mood or anxiety disorders attending different psychiatric services were assessed comparing those who received BZD as first treatment (BZD w/) and those who did not (BZD w/o).

RESULTS

More than one third (35.7%) of the total sample had received BZDs as first prescription. In relation to mood disorders, BZD w/ subjects more frequently (a) had not a psychiatrist as first therapist, (b) had anxious symptoms at onset, (c) had adjustment disorder as first diagnosis, (d) were treated as outpatients. In relation to specific diagnoses, (a) personal decision of treatment for major depressive disorder, (b) outpatient status for bipolar disorder and (c) longer duration of untreated illness for adjustment disorder were more frequently associated with first BZD prescription. For anxiety disorders, the presence of stressful life events and the diagnoses of panic disorder or specific phobias were more frequently observed in BZD w/ patients.

CONCLUSION

Patients with affective disorders frequently received BZDs as first prescription with significant differences between and within mood and anxiety disorders.

Benzodiazepines or related drugs and risk of pneumonia: A systematic review and meta-analysis

OBJECTIVE

Benzodiazepines and benzodiazepine-related drugs (BZRDs) are used to treat various psychiatric diseases. However, there are concerns that BZRDs increase the risk of pneumonia.

METHODS

We performed a systematic review and meta-analysis of observational studies to determine whether BZRD use affects the risk of pneumonia. Our analysis included all observational studies that compared pneumonia development among patients receiving BZRD vs those with no treatment.

RESULTS

In total, 12 citations of 10 studies involving more than 120,000 pneumonia cases were included in our meta-analysis. After pooling the estimates, the odds for developing pneumonia were 1.25-fold higher (odd ratio, OR = 1.25; 95% confidence interval (CI), 1.09-1.44) in BZRD users compared with individuals who had not taken BZRD. On the basis of exposure window, we found an increased risk of pneumonia among current (OR = 1.4; 95%CI, 1.22-1.6) and recent (OR = 1.38; 95%CI, 1.06-1.8) users, but not with the past users (OR = 1.11; 95%CI, 0.96-1.27).

CONCLUSION

Current or recent exposure to BZRD is associated with an increased pneumonia risk. Clinicians need to weight the benefit-risk balance of BZRD use, especially those with other risk factors for pneumonia.