Sedative-hypnotic drugs consist of several classes of compounds, which have anxiety-- alleviating properties and sleep-promoting properties. These include benzodiazepines and related compounds. They are reported to have a higher therapeutic index and lower abuse potential than older drugs like barbiturates. This has resulted in widespread prescription of benzodiazepines and related drugs for a variety of indications - to such an extent that over 1 million of the UK population use benzodiazepines for more than one year (Puri and Hall, 1998). Physical and psychological dependence as well as paradoxical agitation, ataxia and amnesia have been described as adverse reactions to benzodiazepine use. There has also been a recent increase in the prescription of newer drugs related to benzodiazepines like zolpidem and zopiclone.

The Royal College of Psychiatrists produced a report re-evaluating the risks and benefits of benzodiazepine prescription (Royal College of Psychiatrists, 1997). It suggests that these drugs could be appropriately used for anxiety states, ideally intermittently or on an "as required" basis, but not usually for more than four weeks continuously. The report also suggests that benzodiazepine use should be limited to two to four weeks for insomnia.

Dependence often results from "prolonged medical use" but may also result from availability of benzodiazepines as "street drugs" (Gelder et al., 1989). In fact, iatrogenic dependence is extremely widespread with an estimated 2 million adults taking benzodiazepines each day in the UK (Ritson et al., 1993).

Recent national information from the Regional Drug Misuse databases shows that the population rates for known drug problems in the north-west is far higher than that for any other regional office, and is almost twice the UK average (Ashton, 1995). A substantial proportion of those presenting with drug problems to services used benzodiazepines (24 per cent), most commonly temazepam.

In view of the significant potential iatrogenic contribution to benzodiazepine abuse, the high use of these drugs in the psychiatric specialty and high reported prevalence in the north-west, we hypothesized that benzodiazepine and related drug prescription would be high in this region.

We aimed to study benzodiazepine and related drug prescription in the mental health out-patient services of Queen's Park Hospital, Blackburn, Lancashire.

Methodology

A representative sample consisting of all patients who attended the mental health out-patient clinics in the first week of October 2000 were included for the study. Case records of all subjects were perused to identify subjects who had been prescribed benzodiazepines/related drugs during that week. These case records were studied in greater detail to collect information regarding diagnosis and benzodiazepine/ related drug prescription. Data were systematically collected and were analyzed descriptively.

Results

A total of 177 patients attended mental health out-patient clinics of Queen's Park Hospital, Blackburn during the representative first week of October 2000. Of these, 11 (6.2 per cent) had been prescribed benzodiazepines or related drugs.

Diagnosis

Seven (64 per cent) of the subjects on benzodiazepines/related medications were diagnosed as suffering from "anxiety and depressive illness", and one each (9 per cent) had alcoholic hallucinosis, paraphrenia, organic brain syndrome and obsessive compulsive disorder respectively. One patient had co-morbid hypertension. Three subjects (27 per cent) had been ill for less than one year, three (27 per cent) had been ill for periods ranging from one to ten years, and three (27 per cent) were ill for more than 10 years. Duration of illness was not clear in two subjects.

Prescription related information

Four (36 per cent) of the 11 subjects had been prescribed diazepam, two (18 per cent) were prescribed temazepam, and one each was prescribed lormetazepam and oxazepam respectively. A further three subjects (27 per cent) were prescribed benzodiazepine-related drugs like zolpidem and zopiclone. The duration of the sedative-hypnotic use is summarized in Table I.

The indications for prescription of the drug was anxiety in four patients (36 per cent), sleep disturbance, panic attacks and stress in one patient each, while it was not recorded in the remaining four. The course of sedativehypnotic was not recorded as planned in ten (91 per cent) of the 11 patients' case records. Previous drug history was not recorded as having been reviewed in ten (91 per cent) of the cases. Factors contributing to the above indication for prescription of sedativehypnotic drugs (i.e. anxiety, insomnia, etc.) were assessed and addressed in four (36 per cent) of the 11 cases.

All subjects had been on the sedativehypnotic medication for more than four weeks, but the reason for continuation of the drug beyond four weeks was documented in only four of the 11 records. In these cases, reasons for continuation were as below:

(1) "persistence of anxiety when benzodiazepine was attempted to be tapered";

(2) "difficult social circumstances";

(3) "persisting sleep disturbances";

(4) "patient was coping well with diazepam".

It was not clear in any of the case records whether the patients had been cautioned about the possible effects of sedative-- hypnotics on ability to drive, or operate machinery, or about their potential for dependence/abuse.

An attempt was made to find out whether the sedative-hypnotic drug was initiated by the mental health team or by the patient's own general practitioner in the community. However, these data were not clear in most of the case records, as the drug "appeared" in the prescription on a previous review (often without any record of the circumstances) and had continued ever since.

Discussion

This is a retrospective case record-based study looking at sedative-hypnotic drug prescriptions in a mental health out-patient service in the north-west. The sample was drawn in a fashion so as to represent the general out-patient population attending mental health clinics in this part of the UK.

Results show that 6.2 per cent of the sample had been prescribed sedative-- hypnotics during the week studied. This was a lower rate than we had anticipated on the basis of previous information regarding the high occurrence of iatrogenic benzodiazepine use-related problems in the north-west. In that sense, our initial hypothesis of high rates of benzodiazepine prescriptions among mental health out-patients is not supported. The rate of 6.2 per cent appears quite appropriate considering that psychiatric symptoms are major indications for use of these drugs. However, we were unable to identify any previous study of a similar nature with which to compare our findings. A majority of patients had been diagnosed as suffering from "anxiety with depression" (which probably translates to a mixed anxiety depressive disorder according to current classificatory systems).

Diazepam, temazepam and related drugs like zopiclone and zolpidem were the commonest drugs among the present study sample. This finding is a little different from what was previously known about temazepam being the most commonly abused benzodiazepine among patients with known drug problems and could be explained from the fact that subjects in this study were not actually "abusing" sedatives - rather were using prescribed medications for a number of indications. None of the subjects who were prescribed benzodiazepines had been using them for less than four weeks. All subjects had been on these medications for more than four weeks, with a majority using them for one to 12 months. This finding seems contrary to guidelines suggesting discontinuation of the sedative-hypnotic drugs in two to four weeks, as mentioned in the BNF and by the Royal College report. Documented reasons for continuing the medication beyond four weeks (like "persistence of anxiety .. .") suggest that the drugs themselves could be propagating the indication for the drug. There has, however, been some debate on the value of long-term use of benzodiazepines in psychiatry in the recent past, especially among patients with schizophrenia. A possible role of longer-term prescription of these drugs for anxiety states (beyond the recommended four weeks) has been acknowledged in some circumstances, wherein "the alternatives to benzodiazepine are considered worse than the use of the benzodiazepines" (Royal College of Psychiatrists, 1997).

The major indication for the sedativehypnotic drugs in this study was anxiety symptoms (in 45 per cent of the cases). However, a review of previous drug history assessing and addressing other factors contributing to the anxiety (by way of psychological interventions, etc.) were not documented as having been attempted. Als the course of treatment was not recorded a having been planned in the case records. These aspects also are contrary to guideline which suggest that, before starting the patie on sedative-hypnotic medications, the previous drug history should have been reviewed, other contributory factors for the anxiety/insomnia should be addressed, and the course of benzodiazepines should be planned in advance.

An important aspect of the results of this study is the lack of adequate documentation regarding the sedative-hypnotic prescription, which makes it difficult to gauge the exact extent of benzodiazepines prescription among psychiatric out-patients. This could be a potential problem in terms of planning clinical care for the patient (especially if the patient consults a different trainee/consultant in consecutive appointments). The retrospective study design as well as lack of complete information in the patients' case records thus limit the results of this study.

Furthermore, psychiatric case records may not be an entirely accurate estimate of the use of benzodiazepines by patients. These drugs may be prescribed from a variety of sources including general practitioners and physicians, which are not always apparent in psychiatric case notes. This could partly account for the lower prevalence of benzodiazepine prescription in this study than was initially anticipated.

In summary, this study found that 6 per cent of psychiatric out-patients were on sedative-hypnotic medications for their anxiety symptoms for periods lasting a few months or more. Future studies need to be conducted more rigorously so as to ascertain various aspects of benzodiazepine and related drug prescriptions.

This Article has been submitted by the Jeremy's Prophecy Dot Com team for informational and educational purposes. Jeremy's Prophecy Dot Com is a website dedicated to telling the story of Jeremy Jacobs, a character in the novel, Jeremy's Prophecy Dot Com.