Benzodiazepines for anxiety disorders: maximising the benefits and minimising the risks

Providing integrated mental health care as a neurologist

Mental health comorbidities are highly prevalent and problematic in epilepsy, making it important for neurologists to be equipped to manage their patients' mental health concerns. This article explores the paradigm shift toward integrated mental health care approaches, aiming to educate early-career neurologists on their role within epilepsy care. We focus on depression and anxiety, how they present in epilepsy, and the role of integrated mental health care in managing these comorbidities. Key areas include the neurologist's role in identifying mental health issues through patient discussions and screening tools, and the basics of neurologist-led management. This covers the selection and adjustment of antiseizure medications and the use of psychopharmacology. Additionally, we emphasize the importance of providing psychoeducation and promoting healthy lifestyle choices that support mental well-being. Finally, we discuss the neurologist's role in facilitating referrals to mental health specialists, including information about the role of psychological interventions and psychiatry. This article aims to provide foundational knowledge to encourage early-career neurologists to actively engage in integrated mental health care approaches with their patients. This care can be flexible in how it incorporates different modalities and is tailored to local resources. It does not have to be extensive but should be meaningful enough to identify mental health concerns and facilitate patient access to appropriate resources and care.

Prevalence of mental health symptoms and associated risk factors among healthcare workers in specialized COVID-19 hospitals in Anyang, China: A cross-sectional survey

Background

The novel coronavirus disease 2019 (COVID-19) pandemic spread worldwide and brought unprecedented challenges to healthcare systems. Healthcare workers experienced tremendous pressure and psychological issues.

Methods

A cross-sectional online survey was conducted from January 2022 to April 2022 among healthcare workers in Anyang, Henan Province, China. Insomnia, anxiety, depression, post-traumatic stress disorder (PTSD), and problematic internet use (PIU) were evaluated. Logistic regression analyses were used to explore the factors that were associated with mental health problems.

Results

A total of 242 participants (mean [SD] age, 34.7 [6.6] years, 187 female [77.3 %]) were included in the study. The prevalence of symptoms of insomnia, anxiety, depression, PTSD and PIU during the COVID-19 pandemic in China was 53.7 %, 100.0 %, 7.0 %, 20.3 %, and 19.4 %, respectively. Participants who smoked, used sedative-hypnotic drugs and may need psychological assistance were at a higher risk for mental health problems. Respondents who were older than 45 years and were married displayed a lower risk of insomnia and PTSD, respectively.

Conclusions

Mental health symptoms are pervasive among healthcare workers in specialized COVID-19 hospitals during the outbreak. Risk factors include smoking, sedative-hypnotic drug use, and the need for psychological assistance, while protective factors include age and marital status. Developing social media platforms and providing psychological assistance may be effective interventions for healthcare workers.

Synergistic anxiolytic efficacy exploring the combined effects of diazepam and zinc chloride in wistar albino rats

Combinations of medications are frequently employed when their effects are similar. Beyond aiding in the reduction of medication dosages, this approach may yield additional positive outcomes. Studies have shown that zinc can mitigate anxiety-related behavior in laboratory animals. This study aimed to investigate the potential stabilizing effects of zinc chloride and diazepam in Wistar albino rats.Five groups, each comprising six animals. Test groups included two combinations of zinc chloride and diazepam, each with two different doses of diazepam (1 and 2 mg/kg) and 10 mg/kg of zinc chloride. Four established anxiety models-the Elevated Plus Maze (EPM), the hole board, the light and dark box, and the mirror chamber-were employed to assess the anxiolytic effects. The combination of zinc chloride and diazepam proved to be more effective than the individual doses of zinc chloride and diazepam, indicating enhanced anxiolytic effects.

Re-evaluating benzodiazepines for anxiety disorders – déjà-vu all over again?

Benzodiazepines have attracted controversy from shortly after their introduction. They have been subject to periodic calls for their use to be re-evaluated on the basis that their risks have been overstated and their benefits underappreciated. Claims made in recent editorials from the International Task Force on Benzodiazepines in support of their wider use are critiqued in this issue. I examine here whether there is a case to change the conclusions of previous reconsiderations of the question.

Subjective Improvement of Sleep in Insomnia Patients Treated at a Day Rehabilitation Centre After the Use of EEG Neurofeedback Therapy – a Pilot Study

Introduction: Insomnia affects nearly 1/3 of the worldwide population. Electroencephalography neurofeedback (EEG-NFB) is one of the methods used in applied psychophysiology, which can improve nightly sleep scheme. Research objective: The aim of this pilot study was to assess the relative effect of a 20-day neurorehabilitation intervention based on EEG-NFB therapy in insomnia patients treated at a day rehabilitation centre. Materials and methods: Seventy-four patients with insomnia: 28 women (mean age ± SD: 67.9 ± 8.84 years, range: 42–83 years) and 46 men (mean age ± SD: 63.0 ± 9.24 years, range: 42-80 years) were subjected to the EEG-NFB training-neurorehabilitation using the C4 protocol: sensorimotor rhythm (SMR) (12-15 Hz)/theta (4-7 Hz). The individual everyday EEG-NFB training consisted of 20, 30-minute sessions. Before and after the training, the data was collected from 12-electrode quantitative EEG (QEEG) tests. In addition, several standardised psychological questionnaires were performed: Pittsburgh Sleep Quality Index (PSQI), State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI). Results: The EEG-NFB therapy reduced anxiety (7.39 ± 1.0 vs. 6.12 ± 0.88 in STAI, p< 0.001) and improved patients' mood (17.6 ± 3.9 vs. 14.65 ± 3.39 in BDI, p< 0.001). During the PSQI test, the time of falling asleep and number of night awakenings were statistically reduced (both p<0.001). However, there was no significant difference in the -SMR amplitude between pre- to post-treatment (9.15 ± 3.11 and 8.62 ± 2.82, respectively, p=0.095). Conclusions: Due to the subjective improvement of sleep quality, without statistically significant changes in the electrophysiological record (expressed by SMR amplitude), it is advisable to continue research with the use of EEG-NFB therapy.

Are Older People Aware of Potential Risks Related to Benzodiazepines They are Taking and Has Anything Changed in Risk Awareness Over Ten Years?

PURPOSE

The use of benzodiazepines and related drugs (BZD) is common among older adults although there is growing evidence of their harmful effects. This study investigated how well older people are aware of the potential risks related to the BZD they are taking and whether the risk awareness has changed in the years between 2004 and 2015.

PATIENTS AND METHODS

The data were collected by interviewing BZD using home-dwelling patients aged ≥65 years with normal cognitive function (MMSE ≥20) who were admitted to the hospital within a 1 month study period in the years 2004 and 2015. Patients were asked whether they were aware of the ten main potential risks related to BZD use. A risk awareness score (range 0-10) was assessed for each patient, each known potential risk yielding one point.

RESULTS

The study included 37 patients in 2004 and 31 patients in 2015. In 2004, 6/37 patients (16%), while 16/31 patients (52%) in 2015 had risk awareness scores between 6 and 10. Awareness of dependence (p=0.047), interaction with alcohol (p=0.001), dizziness (p=0.002) and developing tolerance (p=0.002) had improved, while awareness of the other potential risks remained unchanged, muscle weakness being the least known (3/37 in 2004 and 4/31 in 2015 were aware of it as a potential risk). Regular BZD use had declined (p=0.043) but pro re nata (PRN; when required) BZD use had increased (p=0.003) between the years 2004 and 2015.

CONCLUSION

Older BZD users' awareness of some potential risks related to BZD use (dependence, interaction with alcohol, dizziness and developing tolerance) had improved between 2004 and 2015, while awareness of other potential risks remained unchanged.

Selective serotonin reuptake inhibitors and benzodiazepines in panic disorder: A meta-analysis of common side effects in acute treatment

BACKGROUND

Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.

AIM

The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.

METHODS

We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.

RESULTS

Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.

CONCLUSION

Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

Benzodiazepine usage and patient preference for alternative therapies: A descriptive study

BACKGROUND AND AIMS

The prevalence of chronic benzodiazepine use in primary care settings remains high despite clear evidence of adverse health outcomes resulting from long-term use and the availability of effective alternative behavioural therapies. Eliciting factors influencing past or current usage experience of benzodiazepine users and their future behavioural intention regarding discontinuation or alternative behavioural therapy adoption could be useful in developing informed strategies facilitating successful benzodiazepine withdrawal in long-term users. The aim of this study was to identify patient factors influencing their current long-term benzodiazepine use, past withdrawal attempt, and future intention to trial safer alternative behavioural therapies. Additionally, the study also aimed to explore patients' preference for information sources on behavioural therapies.

METHODS

Point of purchase surveys were conducted with patients obtaining benzodiazepines from selected pharmacies across New South Wales (NSW), Australia. Survey items included the Beliefs about Medicines Questionnaire (BMQ-specific), questions about patient's sociodemographic characteristics, as well as their views about long-term benzodiazepine use and behavioural therapies.

RESULTS

Seventy-five patients were recruited from 12 pharmacies across New South Wales (NSW). The surveys were conducted from November 2016 to July 2017. The mean (±SD) age of the participants was 54.3 (±16.7) with a range of 23 to 86 years, and 67% of the participants had been using the benzodiazepine for at least 1 year. Lower-education levels, stronger beliefs about the necessity of use, and lower concerns about ongoing benzodiazepine use were significantly associated with prolonged use. Sixty-four percent of the participants were not interested in behavioural therapies, and there was a significant relationship between the participants' future preference for behavioural therapies and their concerns about the potential adverse effects of benzodiazepines. A majority of the participants rated general practitioners (GPs) as their first choice and pharmacists as the second choice for discussing behavioural therapies.

CONCLUSIONS

Specific individual sociodemographic characteristics of benzodiazepine users and their medication-related beliefs influence their current benzodiazepine usage and future intention to trial behavioural therapies as an alternative to their benzodiazepines. Based on the reported preferences of benzodiazepine users in this study, developing and evaluating GP-pharmacist collaborative services to improve the uptake of behavioural therapies as an alternative to benzodiazepines can be recommended.

Benzodiazepine use risk: Understanding patient specific risk perceptions and medication beliefs

BACKGROUND

Benzodiazepines are widely prescribed psychotropic medications. These medications have the potential to cause alertness impairing effects and their prolonged use is associated with serious adverse effects. Despite the listed adverse health outcomes and provision of warnings, many benzodiazepine users tend to ignore the safety information and use them inappropriately.

OBJECTIVE

To elicit the risk perceptions of benzodiazepine users and explore the association of risk perceptions with their socio-demographic factors or medication use profiles (e.g. past withdrawal attempt, length of use and future willingness to try behavioural alternatives).

METHODS

Point of purchase surveys were conducted with patients who were supplied benzodiazepines from selected pharmacies across New South Wales (NSW), Australia. Survey items included questions about patient's demographic characteristics, their past attempt for withdrawing benzodiazepines and their future intention to consider alternative behavioural therapies. The validated Beliefs about Medications Questionnaire (BMQ-specific) and a customised scale assessing risk perception were included in the survey. Data obtained from the surveys were entered into the IBM SPSS package (Version 22.0) and subjected to descriptive, correlational and regression analyses.

RESULTS

Seventy-five patients (67% female, a mean age of 54.3) obtaining benzodiazepines from 12 pharmacies were recruited for the survey. Participant's beliefs regarding potential side effects of benzodiazepines and their level of education were significantly associated with their risk perception scores. While the overall risk perception scores did not influence patient's previous attempts to withdraw benzodiazepines, the risk perception score about immediate effects of benzodiazepines (within 3-4 h of consumption) was a predictor of preference for behavioural therapies. Eighty-three percent (n = 62) of the participants believed that pharmacists can play a key role in improving risk perceptions of consumers around benzodiazepine use.

CONCLUSIONS

Individual patient characteristics and their beliefs about medications significantly influence their perception of risk about benzodiazepine use. The findings of this study suggest that pharmacist support can be utilized in effective risk communication, promoting the safe use of benzodiazepines and in facilitating the uptake of relevant behavioural interventions as alternatives to benzodiazepines.

Why benzodiazepines are not going away

Benzodiazepines are still widely prescribed in psychiatry, mainly for the treatment of anxiety-related disorders. This is not because they are only taken by a hard core component of patients who are addicted and do not need them; it is because they remain the most effective and rapid acting of all drug treatments. Strategies for practitioners to use them more confidently are described.

Self-regulation of breathing as a primary treatment for anxiety

Understanding the autonomic nervous system and homeostatic changes associated with emotions remains a major challenge for neuroscientists and a fundamental prerequisite to treat anxiety, stress, and emotional disorders. Based on recent publications, the inter-relationship between respiration and emotions and the influence of respiration on autonomic changes, and subsequent widespread membrane potential changes resulting from changes in homeostasis are discussed. We hypothesize that reversing homeostatic alterations with meditation and breathing techniques rather than targeting neurotransmitters with medication may be a superior method to address the whole body changes that occur in stress, anxiety, and depression. Detrimental effects of stress, negative emotions, and sympathetic dominance of the autonomic nervous system have been shown to be counteracted by different forms of meditation, relaxation, and breathing techniques. We propose that these breathing techniques could be used as first-line and supplemental treatments for stress, anxiety, depression, and some emotional disorders.

Treatment of depression in cancer and non-cancer patients in German neuropsychiatric practices

AIMS

The aim of this study is to analyze the use of antidepressants in German patients with and without cancer.

METHODS

This study included patients with cancer diagnosed with depression in German neuropsychiatric practices between 2004 and 2013. Each patient was matched for age, gender, health insurance, physician, and index year with a depressed, cancer-free control. The share of patients and controls receiving medical therapy within 1 year after depression diagnosis and the proportion of subjects treated with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, or benzodiazepines were analyzed.

RESULTS

A total of 604 depressed cancer patients and 604 depressed controls were included. There are 27.6% of patients that had breast cancer, 13.3% malignant neoplasms of the lymphoid or hematopoietic tissue, 12.5% brain tumors, 8.3% prostate cancer, and 10.0% cancer of the digestive organs. After 1 year of follow up, 66.5% of patients and 72.8% of controls had received antidepressant drugs (p = 0.017). Tricyclic antidepressants was given less frequently to patients than to controls (31.2% vs 38.2%, p-value = 0.011). By contrast, 7.0% of patients with cancer and 4.2% of controls received benzodiazepines (p-value = 0.033).

CONCLUSIONS

The use of antidepressants in Germany is less common in patients with cancer and depression than in people with depression only. Copyright © 2016 John Wiley & Sons, Ltd.

Long-term use of benzodiazepines: Definitions, prevalence and usage patterns – a systematic review of register-based studies

Background

Numerous treatment guidelines recommend that long-term use of benzodiazepines (BZD) should be avoided primarily due to development of tolerance and a risk for BZD dependence. Despite this, long-term BZD use remains a controversial subject in clinical patient care with “for and against” debates. However, there is no explicit understanding of what is meant by long-term BZD use in real world. The aim of this study was to assess different definitions, usage patterns, prevalence and other characteristics of long-term BZD use based on published register-based studies. Synthesis of these characteristics is essential to derive a meaningful definition of long-term BZD.

Methods

Systematic review of register-based studies on long-term BZD use published in 1994–2014.

Results

Fourty-one studies met our predetermined inclusion criteria. The length of BZD use defined as “long-term” varied in these studies ranging from one month to several years. The most common definition was six months or longer during a year. The prevalence of long-term BZD use in the general population was estimated to be about 3%. The relative proportion of long-term BZD users (all definitions) in adult BZD users ranged from 6% to 76% (mean 24%; 95% CL 13–36%). The estimates were higher in studies only on the elderly (47%; 95% CL 31–64%). Long-term use involved typically steady treatment with low BZD doses. However, in elderly patients long-term BZD use and exceeding recommended doses was relatively common. Several characteristics associated with long-term use were found.

Conclusions

Long-term BZD use is common and a clinical reality. Uniform definitions for “long-term”, which is in line with population-based evidence, is needed to have more comparable results between studies. Our systematic review suggests that duration of BZD treatment over six months, the most common definition for long-term BZD use in the included studies. As also recommended previously, it is a useful starting point for further analyses on disadvantages but also potential advantages associated with long-term BZD use.

The reappraisal of benzodiazepines in the treatment of anxiety and related disorders

Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.