From the Editor
In a recent conversation with a resident, we discussed benzodiazepines. “I’ve never prescribed one,” he explained.
This class of medications is very much out of fashion. But, after decades of overuse, have we swung to the other extreme, and forgotten an important tool in our pharmacologic toolkit? In the first selection, we consider a British Journal of Psychiatry editorial. Dr. Edward Silberman (of Tufts University School of Medicine) and his co-authors argue that benzodiazepines are underappreciated. The selection ties well into a commentary that recently appeared in The American Journal of Psychiatry. Dr. Jerrold F. Rosenbaum (of Harvard Medical School) writes: “My own son, a first-year resident in psychiatry, looks at me as if I served on the wrong side in the Spanish Civil War when I speak of benzodiazepines.” Is there a clinical takeaway here?
In the second selection, writer and comedian Andrew Lizotte discusses the challenges of being a patient in our mental health system. He shares some jokes – but, ultimately, notes ongoing stigma and power imbalances. “We see how mental illness is portrayed in the media. We are scared of being shot by police during a ‘routine health check.’ We see the lack of empathy. Then people wonder why we don’t ask for help.”
Finally, with an eye on COVID-19, we look at a short paper in The Lancet about those doctors who have lost their lives in the pandemic. “These lives are also a reminder of the ongoing dedication and service of those who continue to care for patients at a time when COVID-19 cases and deaths are increasing in many countries.”
Selection 1: “Benzodiazepines: it’s time to return to the evidence”
Edward Silberman, Richard Balon, Vladan Starcevic, et al.
The British Journal of Psychiatry, 12 October 2020 Online First
When benzodiazepine anxiolytics were first introduced in the 1960s they were viewed as a liability-free alternative to barbiturates and meprobamate and were prescribed widely to patients with complaints of anxiety. After a decade of experience, it had become clear that benzodiazepines could be abused, and the pendulum began to swing towards suspicion of them. It is now commonly believed that they are dangerous drugs, prone to abuse and addiction. Treatment guidelines caution against their use as first-line or long-term therapy. It has become almost standard for clinical publications about benzodiazepines to issue warnings about dependence, abuse, addiction, tolerance or dangerousness, even when their central topic is an unrelated matter. Clinicians who advocate use of benzodiazepines may risk opprobrium from peers and institutions.
So opens an editorial by Silberman et al.
“Although demonstrating a range of potential liabilities, including cognitive and psychomotor impairment, possible risk in pregnancy and severe and/or prolonged withdrawal syndromes, it does not confirm that these medications are primary drugs of abuse or gateway drugs leading to other substance abuse.”
Drawing from the literature:
- “The database was scrutinised in the 1980s and 1990s in a series of extensive reviews, including a volume commissioned and published by the American Psychiatric Association. In aggregate, they comprise over 2000 literature citations, dealing with both animal and human studies bearing on abuse, misuse and dangerousness of benzodiazepines. Their authors conclude that benzodiazepines ‘do not strongly reinforce their own use and are not widely abused drugs. When abuse does occur, it is almost always among persons who are also abusing alcohol, opiates or other sedative hypnotics…’”
- “Although co-abuse of benzodiazepines has risen in the context of the opioid epidemic, there has been no newer evidence suggesting that either benzodiazepine abuse or any other substance abuse has its genesis in prescribed treatment for general (i.e. non-substance-abusing) patients.”
- “In his 2005 review of benzodiazepine abuse and dependence, O’Brien states, ‘benzodiazepines are usually a secondary drug of abuse – used mainly to augment the high received from another drug or to offset the adverse effects of other drugs. Few cases of addiction arise from the legitimate use of benzodiazepines.’”
Why is there a bias against benzodiazepines? The authors argue that there are several unfounded beliefs about these medications.
Two are highlighted here:
Benzodiazepines prescribed for anxiety disorders are likely to be abused.
The authors disagree. “Benzodiazepines have a short latency of onset to calming or sedating effects, which may make them attractive to people who abuse substances. However, they are not prone to being abused by those with no such history. Conflating risk in these two populations stigmatises people with anxiety disorders and deprives them of treatment that might restore them to more functional lives.”
Benzodiazepines are dangerous in overdose.
The authors disagree. “Benzodiazepines alone are among the safest of psychotropic medications, with lethal dose LD50 estimates for most in the range of thousands of mg/kg. Even alprazolam, which may be more toxic, has an estimated LD50 range of 300–2000 mg/kg. Taken in conjunction with alcohol or opioids, they markedly raise the lethality of these already dangerous substances. That benzodiazepines are safe for the vast majority of people with anxiety disorders for whom they are prescribed is obscured by commonly used phrases such as ‘benzodiazepine-related death’ to describe a lethal combination of opioids and benzodiazepines ingested by a polysubstance-abusing person.”
“Benzodiazepines are highly effective for treatment of anxiety disorders, but are not for everyone, have potential liabilities and are best used in conjunction with targeted psychotherapies.”
A few thoughts:
- This is a good editorial.
- Has the pendulum swung too far?
- I’m reminded of a comment that Dr. Richard Goldbloom makes in his autobiography (which, for the record, is highly readable): today’s dogma is tomorrow’s malpractice.
- The American Journal of Psychiatry has recently published an editorial by Dr. Rosenbaum, a former Psychiatrist-in-Chief of Massachusetts General Hospital. He opens with some examples from his practice: “In the early 1980s, there was a woman with agoraphobia in Beacon Hill who, after being given alprazolam and the support of a visiting research assistant, declared she had walked on grass for the first time in many years (having missed her son’s wedding, among other events over that time.) There was the physician with a history of panic attacks, ongoing social anxiety, and irritable bowel syndrome who achieved remission for decades on clonazepam and as-needed alprazolam for emergencies, eventually tapering to a low dose of clonazepam at bedtime. At his 60th college reunion, he encountered a classmate he had once admired and, knowing she had also held affection for him, he later mused to me that ‘if I had met you back then, I wonder how my life might have unfolded differently.’”
“The efficacy of benzodiazepines in anxiety is well established, but based on the current practice of many more recently trained physicians, these medications reduce anxiety for the physicians themselves by their refusing to prescribe them.” It’s a good line, and then he draws on the literature, including his own studies.
- When to prescribe? Dr. Rosenbaum offers good advice: “Some benzodiazepine prescribing is straightforward, for example, as a brief intervention for acute distress or as-needed use for a phobic anxiety (e.g., airplanes) or transient insomnia. Some prescribing situations are, however, to be avoided if possible, like prescribing to manage persisting distress resulting from a personality disorder or for patients with known current or past substance use disorders.” He also offers a warning: “An important guideline is to avoid chronic administration for acute problems and to set a goal for those on maintenance therapy of gradually working to find the lowest effective dose, which over time might become less or none, especially in older patients, in whom increasing sensitivity to the medication, the likely presence of more drugs interacting, memory concerns, and fall risk are important clinical issues to be assessed.”
- After decades of overprescribing, our general approach to benzodiazepines has been to avoid them. These two papers are iconoclastic, but they raise good points. A quick and obvious reminder though: there are alternatives to this class of medications.
The AJP commentary can be found here:
The BJP editorial can be found here:
Selection 2: “Mental-health support can be like a game of snakes and ladders”
The Globe and Mail, 16 October 2020
In a time when we’re openly debating the ways in which our societal systems are broken, I’d like to put forth the following joke:
‘I’ve started seeing a therapist, so I can stop being bullied by my psychiatrist.’
If you don’t get the joke, congratulations. You don’t want to get it, and I sincerely hope you never do. If you have a suspicion that you might get the joke, let me say that medication made my life better. It is not your fault you need medication. You did not fail. Take the medication. There are great doctors, who genuinely care. Please reach out. That said, it is going to take a long time to get there.
So begins an essay by Lizotte.
He talks about the power imbalance in psychiatry with a bit of humour.
- Basic freedoms. “Patients must look like they need enough help, the doctors need to believe you, but not believe you need so much help that they take away your belt and shoelaces.”
- Dealings with doctors. “Doctors will say things to you like, ‘I don’t find that your delusions are grand enough.’ First of all … ouch! I’m already in a psych ward, my self-esteem didn’t really need to be taken down a peg.”
- Medications. “As long as someone controls my access to medication, I find I must measure my performance in milligrams. I take a deep breath, look into my doctor’s eyes and think, ‘How much pain do they need me to be in today?’ Everything said has a weight to it. Literally. It is measured out in milligrams added or taken away. It is the difference between being put into withdrawal, being able to hold down a job or just function.”
Though there are jokes in the essay, it ends with a call to action:
“If you suffer from mental illness and are functioning well, please become a doctor and change the language, become a teacher and change the perception, become a politician and make access to help easier. Often real change is about bringing a new perspective to an old conversation. If you have a mental illness, it does not relegate your opinion to the shadows. You have the opportunity to contribute in a way that is desperately needed. Be your own advocate. You are bridging the language barrier. Your perspective can literally redefine the human experience for someone.”
A few thoughts:
- This is a good essay.
- At points, this article was tough to read – not because of the prose or jokes, but because of the underlying message.
- The call to action is thoughtful.
The full Globe essay can be found here:
Selection 3: “A tribute to some of the doctors who died from COVID-19”
The Lancet, 28 November 2020
The global COVID-19 death toll stands at more than 1.3 million. Among the lives lost have been those of health-care workers, who have had crucial roles throughout the response and continue to serve at the front lines. At the outset of the pandemic, doctors warned of the potential implications of the virus. As the virus spread, many doctors provided treatment for a disease they little understood, while others contributed to accelerated research on potential treatments and vaccines. And as the COVID-19 pandemic worsened worldwide, health professionals worked tirelessly to provide care for patients – some even emerged from retirement to provide assistance.
It is not possible to honour all of the health workers who have died from COVID-19, but in telling the stories of a few of the health professionals from different specialties and various countries who lost their lives to the disease, these short obituaries serve as a tribute to the many other health workers who have died in the pandemic. These lives are also a reminder of the ongoing dedication and service of those who continue to care for patients at a time when COVID-19 cases and deaths are increasing in many countries.
So begins an obituary in The Lancet.
An internist who lived and died in Ecuador. A surgeon from Pakistan. A Spanish primary care doctor.
I’ll highlight the story of Dr. Sara Bravo Lopez, the Spanish doctor:
“There is a tradition at the Faculty of Medicine at the University of Valladolid in Spain that when medical students reach the end of their studies they celebrate a last dinner with their professors. Although she had a leg injury as her class’s event approached… Sara Bravo Lopez was determined to take part in the celebration. ‘She kept dancing all night, happy, because we were finally doctors,’ said her classmate Luis Cabezudo Molleda, an internal medicine resident at the Complejo Asistencial Universitario de Palencia.”
The obituary goes on to note her bedside manner:
“Cheerful and indefatigable, she had a gift for soothing patients. Cabezudo said Bravo possessed that ability even in her medical school days, where she had a knack for calming her classmates before important exams. ‘She had the exact words that help people relax,’ he said.
She contracted the virus when at work: “Bravo had taken a colleague’s shift and was caring for patients who came into the health centre and were later diagnosed with COVID-19, Cabezudo said. ‘She died because she loved her work, she did it bravely and she did it always thinking of others,’ he said.”
Dr. Lopez was just 28.
The paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.