Bdzs In Clinical Practice
BDZs are nowadays among the most widely prescribed drugs in current psychiatric practice and have relatively favourable pharmacokinetics and pharmacodynamic profile. Pharmacological profile of BDZ includes sedation, anxiolysis, hypnotic effect, anterograde amnesia, muscle relaxation and anticonvulsant properties. Different BDZs are available in practice, and basic indication of each BDZ preparation is declared by its most manifested effect. According to the guidelines and recommendations, systematic reviews and metaanalyses, there is a spectrum of use of BDZ in psychiatric clinical practice: anxiety and affective disorders, alcohol withdrawal, sleep disorders, delirium, aggressive behaviour in psychoses and neurolepticinduced disorders .
The main advantage of BDZs is their quick action, which can be seen soon after the first taking of the drug. BDZs are usually taken orally or may be administered intravenously. Due to well absorbance, they usually reach their maximum of concentration in plasma for about 1 h. They bind strongly to plasma proteins, and their high liposolubility causes many of them to accumulate gradually in the fatty tissue. BDZs are generally metabolized and excreted as glucuronides in urine . According to their pharmacokinetics properties, BDZs are divided into three groups: shortacting , intermediateacting and longacting .
Figure 3.
Who Should Avoid Benzodiazepines
However, there are some patients who should never take this type of medication. These include those with kidney or liver disease or any kind of chronic liver condition. Also, patients who have a history of allergies to benzodiazepines should avoid them. In addition, people taking medications to lower their blood pressure must avoid taking these pills, as high blood pressure can increase feelings of anxiety.
Who Needs Medication For Anxiety
Feeling anxious now and then is part of life. It is a component of the bodyâs natural self-defense system and linked closely with the fight or flight response. But there is a difference between feeling anxious prior to performing in front of a crowd, and being afraid to leave your house because you might encounter people outside. Just as there is a difference between jiggling the doorknob once as you leave your home to make sure it is locked, and checking the doorknob two dozen times.
Essentially, anyone who suffers from an anxiety disorder is a potential candidate for anxiety medication. But, just because someone might benefit from anxiety medication, it does not mean they necessarily should take one. They may be served just as effectively by a combination of psychotherapy and exercise. The most important thing is that the decision to use an anxiety medication is arrived at only after careful consultation with your doctor.
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Are Benzos Safe Long Term
No, benzos are not safe for long term use. Diazepam and clorazepate, also belong to the class of benzodiazepines. They are the least addictive benzodiazepines. They can be taken for long term use, but with certain limitations.
Some common side effects may occur, as mentioned in the first section. But, you should rush to your doctor if the situation will worsen.
Alcohol consumption should be avoided along with Benzos. Pregnant, trying to get pregnant, and breastfeeding women should avoid benzos.
Recommended Treatment Options For Panic Disorder
Current treatment guidelines for the treatment of panic disorder, with or without agoraphobia, single out 4 drug classes with proven and roughly comparable efficacy: tricyclic antidepressants , selective serotonin reup-take inhibitors , monoamine oxidase inhibitors, and benzodiazepines. The guidelines recommend that the decision about which medication to choose for panic disorder should involve considerations of adverse side effects and cost. A similar approach is advocated for primary care patients.
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Evaluation For Other Psychiatric Disorders
The evaluation for other psychiatric disorders is probably the most challenging aspect of patient evaluation because the symptoms of GAD overlap with those of other psychiatric disorders and because these disorders often occur concomitantly with GAD. Generally, GAD should be considered a diagnosis of exclusion after other psychiatric disorders have been ruled out. Because of the overlap and comorbidity associated with other psychiatric disorders, some authors have questioned whether GAD is a distinct entity and have posited that it is a variant of panic disorder or major depression.18,19
Symptoms of GAD can occur before, during or after the onset of the symptoms of major depression or panic disorder.12 Some patients have symptoms of anxiety and depression but do not meet the full criteria as delineated in DSM-IV,10 for GAD, panic disorder or major depression. In these cases, the term mixed anxiety-depressive disorder can be applied, although it is not yet part of the official nosology. Despite the confusion, anxious patients should be asked about the symptoms of panic attacks and the neurovegetative symptoms that are associated with major depression. When more than one psychiatric condition exists, an attempt should be made to determine which disorder occurred first. Some distinguishing characteristics of GAD, panic disorder and major depression are listed in Table 3.10,19
|
Neurovegetative symptoms |
Symptoms remit but may recur |
Major depression, alcohol abuse |
History And Current Use Of Benzodiazepines
Benzodiazepines the prototypical anxiolytics were introduced in the early 1960s. They quickly became very popular for a variety of reasons. The most succinct explanation for their rise was the societal need for substances with calming effects. Over the centuries this need has been met mainly with alcohol. In the decade prior to the introduction of benzodiazepines, barbiturates and meprobamate were often used to alleviate anxiety and distress. However, these medications were associated with dependence, and barbiturates were lethal in overdose. Being much safer than barbiturates and meprobamate, benzodiazepines were described as one of the twentieth centurys greatest inventions . Small wonder, then, that in the mid-1970s they became the most widely prescribed group of psychotropic medications in the world .
What caused the subsequent fall in enthusiasm for benzodiazepines? It is undoubtedly the fact that they are associated with pharmacological dependence and that difficulties in ceasing the drugs after long-term use are common. One inquiry into this matter concluded that addiction should be differentiated from non-addictive or therapeutic dependence, and that benzodiazepines were more associated with the latter, not the former . Unfortunately, this nuanced approach to benzodiazepine-induced dependence was quickly lost in the noise produced by the more vocal and influential benzodiazepine opponents.
BOX 1 Reasons for benzodiazepine use in anxiety disorders
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Pharmacokinetic And Pharmacodynamic Modifications
Pharmacokinetic modifications represent favourable approach since the substances with similar pharmacological activity are adapted to different therapeutic indications. The application of different BDZ as anxiolytics, hypnotics or myorelaxants, is primarily determined by their pharmacokinetic properties, such as dosage form, administration route and the presence of active metabolites. By reducing time of their action, great success has been achieved in the treatment of insomnia, thereby avoiding the morning drowsiness, and enabling the motor vehicle operation . However, this type of modifications could not solve problems such as cognitive impairments and loss of coordination, especially in elderly. Since pharmacokinetic modifications did not lead to separation of desired and unwanted effects of BDZ, new approaches applied to the synthesis of a number of substances with different pharmacological profiles.
Characteristics Of Included Studies
The initial search identified 222 reports involving BDZ and AD in the treatment of anxiety disorders for potential inclusion in the systematic review . Of these, we excluded 111 studies, which focused on the treatment of patients with primary diagnoses other than anxiety disorders or were laboratory trials or studies conducted in nonclinical populations. We excluded a further 89 studies because they did not compare directly the treatment of anxiety disorders with BDZ versus AD, represented reanalyses of data published elsewhere, or reported outcomes other than treatment efficacy or adverse effects during treatment.
Therefore, a total of 22 papers met the criteria for inclusion in the study. There were 18 studies concerned with tricyclic antidepressants , 1 with phenelzine and 3 studies with newer AD 9 studies compared TCA with BDZ in mixed anxiety, GAD and specific or complex phobias. These studies and those involving newer AD will be summarized and critically reviewed according to the characteristics of each sample.
Only in panic disorder was there a sufficient number of trials to warrant quantitative methods of analysis. We thus submitted to meta-analysis data from 10 reports on treatment of panic disorder with or without agoraphobia with BDZ versus TCA.
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Are There Any Side Effects
Not everyone who takes benzodiazepines will get side effects. Talk to your doctor if you are worried about side effects.
Addiction
You should only be prescribed benzodiazepines for the shortest amount of time possible. Taking benzodiazepines regularly for a few weeks or more can lead to addiction. Doctors recommend that you only take them for 2-4 weeks.
Intermittent use may help to avoid addiction. Intermittent means that you dont take it regularly. For example, you dont take it every day.
The risk of addiction is higher if you have a history of drug or alcohol abuse. Or if you have a personality disorder.
Common side effects
- Hallucinations. This is when you see, her, smell or feel things that are not there.
- Delusions. This is where you have beliefs that dont match reality
When will withdrawal side effects stop?
Your withdrawal side effects will usually stop after a few weeks. But they can last longer for a small amount of people. You may not get withdrawal side effects when you stop your benzodiazepine medication.
You should talk to your doctor or local pharmacist if you are worried about the withdrawal effects of benzodiazepines.
Is there anything that can help with my symptoms through withdrawal?
Antidepressant and mood stabilizing drugs may help with the withdrawal effects of benzodiazepines.
If you have insomnia you may benefit from treatment with melatonin.
What Conditions Are Benzodiazepines Used For
Benzodiazepines have a calming, relaxing effect, and are used to treat a number of conditions, such as:
- severe anxiety, agitation or panic attacks if other treatments are not working
- severe insomnia if other treatments are not working
- to relax and/or sedate you during certain medical procedures or operations
- to reduce the symptoms of alcohol withdrawal if you have stopped drinking
- muscle spasms, to help relax your muscles
- epileptic fits if a quick effect is needed.
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A Typical Clinical Case Vignette
A 56-year-old woman started taking diazepam 3 years ago because of panic attacks and anxiety. This was at about the time she was going through a difficult divorce. Her mood has fluctuated over the years and she has had at least two episodes of depression. Treatment with several antidepressants failed because of intolerable side-effects: she was sick in the stomach, zonked out or felt like she was going to explode. At the time of referral, she was on a stable regimen of diazepam 15 mg/day, and occasionally 20 mg/day. She felt that diazepam helped her to deal with her financial worries and cope better with her adult children. She also believed that diazepam made it possible for her to sleep and relax. She denied experiencing any side-effects and was able to find a new job. At the assessment, she exhibited no significant symptoms of anxiety and she did not feel depressed. There was no history of substance misuse problems. She believed that ceasing diazepam would be premature, but was willing to reconsider it in the future.
Tolerance Dependence And Withdrawal
Benzodiazepines have the potential for physical dependence when used for long periods of time, especially at high doses. They can also be psychologically addictive in some individuals.
Studies have shown that people who take benzodiazepines over a long period of time may develop tolerance that reduces the therapeutic benefits. If tolerance occurs, larger doses of benzodiazepines may be needed to bring about desired results.
Long-term use of benzodiazepines may result in physical dependence and withdrawal symptoms if the medication is stopped or decreased suddenly. Withdrawal symptoms may include:
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Neurobiology Of Panic Disorder
It is currently hypothesized that patients with panic disorder inherit an especially sensitive fear mechanism involving several brain structures . Both heritable factors and stressful life events, particularly in early childhood, appear to be associated with the onset of panic disorder. Under normal conditions, the central nucleus of the amygdala serves as a relay for sensory information between the higher cortical centers and the brain stem nuclei. In patients with panic disorder and other anxiety disorders, the central nucleus of the amygdala also receives additional information from the higher cortical centers, which represent cortical processing of the initial sensory information. Abnormalities in this cognitive processing could lead to the misinterpretation of sensory information known to be a hallmark of panic disorder. It is thus speculated that there is a deficit in the relay and coordination of sensory information originating from the cortex and brain stem, which results in heightened amygdalar activity, with resulting behavioral, autonomic, and neuroendocrine activation typical of the panic attack.
Do I Need This Treatment
A certain amount of anxiety or insomnia is a normal reaction to what is happening in your life. You may worry or feel stressed, and sometimes these feelings can keep you up at night. Most often, these feelings pass and are not a problem. However, these feelings can become a problem when they continue over a longer term, cause severe distress, make you feel physically ill and affect your behaviour. This kind of anxiety may be triggered by a challenging life event. It can also be a symptom of a mental health problem.
The ability to fall asleep and to sleep through the night can be affected by many types of health problems. These include physical conditions that cause pain or trouble breathing, as well as mental health problems. When sleep is disrupted, health can be further affected.
While each situation is unique and different treatment approaches may be called for, benzodiazepines can help to provide relief.
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What Is The Role Of Benzodiazepines In The Treatment Of Anxiety Disorders
Intravenous or oral acute sedation with benzodiazepines may be used. Alprazolam has been widely used for panic disorder, but it is currently discouraged because of its higher dependence potential alprazolam has a short half-life, which makes it particularly prone to rebound anxiety and psychological dependence. Clonazepam has become a favored replacement because it has a longer half-life and empirically elicits fewer withdrawal reactions upon discontinuation.
Prompt use of benzodiazepines can ease the uncomfortable anxiety associated with the attack and can provide the patient with definitive confidence that treatment can control the symptoms. This is particularly helpful for preventing subsequent visits to emergency services while longer-term therapy is helping the patient gain control.
Selective Serotonin Reuptake Inhibitors
Paroxetine and sertraline are approved by the U.S. Food and Drug Administration for the treatment of panic disorder, with abundant evidence supporting their short-and long-term efficacy. However, even with a small initial dosage and slow titration some patients are unable to tolerate the initial anxiogenesis associated with initiation of SSRI therapy and delayed onset of efficacy.
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