Misplaced Pages

Revision as of 16:24, 27 June 2009

	Benzodiazepine has been listed as one of the Natural sciences good articles under the good article criteria. If you can improve it further, please do so. If it no longer meets these criteria, you can reassess it.
Article milestones Date Process Result February 13, 2009 Good article nominee Not listed May 19, 2009 Good article nominee Listed June 24, 2009 Featured article candidate Not promoted
Current status: Good article

This article has not yet been rated on Misplaced Pages's content assessment scale. It is of interest to the following WikiProjects:

Please add the quality rating to the {{WikiProject banner shell}} template instead of this project banner. See WP:PIQA for details. Chemicals Low‑importance This article is within the scope of WikiProject Chemicals, a daughter project of WikiProject Chemistry, which aims to improve Misplaced Pages's coverage of chemicals. To participate, help improve this article or visit the project page for details on the project.ChemicalsWikipedia:WikiProject ChemicalsTemplate:WikiProject Chemicalschemicals Low This article has been rated as Low-importance on the project's importance scale. Please add the quality rating to the {{WikiProject banner shell}} template instead of this project banner. See WP:PIQA for details. Pharmacology Top‑importance This article is within the scope of WikiProject Pharmacology, a collaborative effort to improve the coverage of Pharmacology on Misplaced Pages. If you would like to participate, please visit the project page, where you can join the discussion and see a list of open tasks.PharmacologyWikipedia:WikiProject PharmacologyTemplate:WikiProject Pharmacologypharmacology Top This article has been rated as Top-importance on the project's importance scale. Please add the quality rating to the {{WikiProject banner shell}} template instead of this project banner. See WP:PIQA for details. Medicine High‑importance This article is within the scope of WikiProject Medicine, which recommends that medicine-related articles follow the Manual of Style for medicine-related articles and that biomedical information in any article use high-quality medical sources. Please visit the project page for details or ask questions at Misplaced Pages talk:WikiProject Medicine.MedicineWikipedia:WikiProject MedicineTemplate:WikiProject Medicinemedicine High This article has been rated as High-importance on the project's importance scale.

/Archive 1 /Archive 2, /Archive 3, /Archive 4

What is wrong with this paragraph

WhatIamdoing insisted that I accept abuse from LG as given and get on with the program. So, what is wrong with this paragraph? LG reverted it three times, after each sentence as I was writing it. (Note for LG: Mind WP:TLDR and AGF. I will stop reading your argument beyond ten sentences and at the first word of abuse. Note for Eubulides and everyone: "Please ignore for a second style problems with the last view and some other grammar and style problems and concentrate on the content.")

SUGGESTED: "The data on the The effects of long-term use is contradictory. One interpretation of this data, exemplified by Ashton maintain that benzodiazepines have all the characteristic of drugs of dependence and result "in the insidious development of increasing psychological and physical symptoms." On the prolonged exposure they may worsen anxiety and cause depression, and deficits of learning, memory and attention. Another view counters that "despite considerable scientific evidence that the risk of drug abuse with benzodiazepines is low, there is tremendous prejudice against their use in many individuals, in certain treatment settings, and even countries (e.g., United Kingdom)." This view argues that the short-term treatment for generalized anxiety disorder and panic disorder makes no sense as these disorders continue long-term. Its proponents assert that the current practice is to "continue treatment for 6 to 18 months before tapering and attempting discontinuation." An intermediate, empirical, position advocates careful and limited use of benzodiazepines. In this view, if the prolonged treatment is necessary, the patient reports sustained benefits from a benzodiazepine and no signs of misuse are visible, there is no harm from this practice."

On the other hand, the current version (below) exaggerates side effects, and does not represent other points of view. IMHO, the majority view is the balanced third view in the suggested version. The Sceptical Chymist (talk) 19:12, 25 June 2009 (UTC)

CURRENT:"The long-term adverse effects of benzodiazepines include a general deterioration in physical and mental health and tend to increase with time. Not everyone however, experiences problems with long-term use. The adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs. Additionally an altered perception of self, environment and relationships may occur.

Refs

1. Ashton H (2005). "The diagnosis and management of benzodiazepine dependence" (PDF). Curr Opin Psychiatry. 18 (3): 249–55. doi:10.1097/01.yco.0000165594.60434.84. PMID 16639148.
2. Sadock, Virginia A.; Sadock, Benjamin J.; Kaplan, Harold I. (2000). Kaplan & Sadock's comprehensive textbook of psychiatry. Hagerstown, MD: Lippincott Williams & Wilkins. ISBN 06833012840. {{cite book}}: Check |isbn= value: length (help)CS1 maint: multiple names: authors list (link)
3. Norman TR, Ellen SR, Burrows GD (1997). "Benzodiazepines in anxiety disorders: managing therapeutics and dependence" (PDF). Med J Aust. 167 (9): 490–5. PMID 9397065.{{cite journal}}: CS1 maint: multiple names: authors list (link)
4. Hammersley D, Beeley L (1996). "The effects of medication on counselling". In Palmer S, Dainow S, Milner P (eds.) (ed.). Counselling: The BACP Counselling Reader. Vol. 1. Sage. pp. 211–4. ISBN 978-0803974777. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: editors list (link)
5. Ashton H (2004). "Benzodiazepine dependence". In Haddad P, Dursun S, Deakin B (eds.) (ed.). Adverse Syndromes and Psychiatric Drugs: A Clinical Guide. Oxford University Press. pp. 239–60. ISBN 978-0198527480. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: editors list (link)
6. Stewart SA (2005). "The effects of benzodiazepines on cognition" (PDF). J Clin Psychiatry. 66 (Suppl 2): 9–13. PMID 15762814.

Discussion

I've fixed the refs. Please place any comments below. WhatamIdoing (talk) 18:15, 25 June 2009 (UTC)

Discussion on text in above section

Ref is not discussing long-term effects so ref is being misused to say things that aren't in citation. The statement "data is conflicting" is opinion by Sceptical Chymist and is therefore original research. I cannot agree with this original research and misuse of refs. They are only discussing long-term use. It is fine to discuss the fact other doctors believe in long-term use. This is represented in the article already and I don't oppose this. As far as the UK being "extreme" I think that it is only fair to then state how some countries eg hong kong have benzos listed as dangerous drugs and countries like Holland and several other european countries have stronger stances against benzos and then cite how America's health body publishes research connecting benzos to cancer and there is a team of doctors in America who campaign against benzos whereas this is not the case in the UK, gotta keep things in perspective. To be honest though, I think pitting America against the UK is going to lead issues unless we put it in balance by listing other countries which have stronger stances than the UK. I also think that it would worsen the article.--Literaturegeek | T@1k? 19:41, 25 June 2009 (UTC)

You are welcome to provide citations saying that the long term effects are exagerated. I intentionally added the statement that "not everyone is effected by adverse long-term effects" one because it puts it into context, does not exagerate it and 2 because it is true. One tip as well, all of the studies into benzos which follow people up for 6 - 12 months show improvements in some measure, physical, mental health. The drug companies and regulatory bodies don't challenge this data, they just ignor it so I think it is unlikely that you will find a source that challenges it but if you find one I am not opposed to you using it. just opposed to using irrelevant refs to do a synthesis and original research is all. There are lots of good psychiatry and addiction books which discuss these long-term effects. I can provide more citations if you like.--Literaturegeek | T@1k? 19:47, 25 June 2009 (UTC)

The problem as I see it is that Sceptical feels that NPOV policy means that refs can be misused and original research is allowed in these cases to achieve neutrality. I cannot agree to this editing practice.--Literaturegeek | T@1k? 19:50, 25 June 2009 (UTC)

The "intermediate" position is original research and implies that clinical guidelines and systematic reviews are "extremist" thus I feel it is not me who is breaking NPOV but you. We must stick to refs and no original research. Hope this helps clarify my position.--Literaturegeek | T@1k? 19:53, 25 June 2009 (UTC)

P.S. thanks to those who are trying to resolve this. I believe it is impossible to resolve this without outside eyes so your help is much appreciated.--Literaturegeek | T@1k? 19:55, 25 June 2009 (UTC)

The evidence based truth is the abuse potential of benzos is "moderate" or intermediate. The abuse potential is not high and it is not low. I dunno where authors got the low stat from, never seen a review of animal and human studies which came to that conclusion. They are still commonly abused by drug misusers.--Literaturegeek | T@1k? 21:01, 25 June 2009 (UTC)

Here we ago again with TLDR. Is that too hard to get to the point in the first paragraph? I read the first 10 sentences as promised. Which "Ref is not discussing long-term effects"? -- please specify, and I will answer. "Not everyone is effected by adverse long-term effects" is true but vague, and may create an impression that 90% of the people get addicted, for example. "Data is conflicting" is not OR, see for example ref 6 :" The literature is divided, however, on the persistence of cognitive effects in patients taking benzodiazepines long-term." What are you other arguments against the suggested paragraph? Try to be concise. Bulletize the points. Start with the most important point and with the most important idea in each point. The Sceptical Chymist (talk) 21:25, 25 June 2009 (UTC)

Oh you mean conflicting with cognition, the review author in ref 6 concluded that impaired cognition did occur, so you are using primary sources within a review to come up with your own conclusions,,, but,,, this is already discussed in the cognitive section Benzodiazepine#Cognitive_effects, which I still don't fully agree with. What I am looking for is a long term follow-up study say 6 - 12 months post withdrawal which finds no improvements in physical or mental health. Do you have any refs which says data is conflicting in this regard? Reference two does not say that the data is conflicting and does not discuss long-term effects so thus I feel is original research and a misuse of a ref. I find your approach to discussing references remains combative.--Literaturegeek | T@1k? 22:08, 25 June 2009 (UTC)

• This is a simple question and requires only a "Yes" or "No" answer: Do we have a high-quality reliable source that directly says that there are disagreements about the long-term effects of this drug? If yes, please give me the PMID or ISBN. If no, please just say no. Note that "Here are six sources, all of which say different things," is not what I'm after. I'm after a source that directly says, with little or no beating about the bush, "There are disagreements about the long-term effects of this drug." WhatamIdoing (talk) 00:10, 26 June 2009 (UTC)

"While the recent NICE guidelines suggest that long term use is contraindicated (NICE, 2004), others suggest that fears about abuse are exaggerated and may limit use of these medications to the disadvantage of patients who would otherwise benefit (APA, 1998)."Cambridge textbook of effective treatments in psychiatry" ISBN-10: 052184228X, p. 546. The Sceptical Chymist (talk) 00:33, 26 June 2009 (UTC)

"The major controversy surrounding the use of benzodiazepines has concerned the risks of long-term treatment, specifically tolerance, abuse, dependence and withdrawal effects." Anxiety and Anxiolytic Drugs, p.474, ISBN-10 3-540-22568-4 The Sceptical Chymist (talk) 00:45, 26 June 2009 (UTC)

From the same book, "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532

Your second comment, not sure what you are implying. If you are implying that that statement means that the existance of tolerance and withdrawal doesn't occur or is debated and controversial then I think you are taking that quote out of context.

I am not opposed to the inclusion that there are doctors who believe in long term use but I don't feel that it should be given undue weight. It is a notable enough viewpoint to include but should not be used in the article text to minimise or even ridicule the NICE clinical guidelines or systematic reviews as "extremist".

I don't believe the quotes are related to long-term effects.

Here is a good ref to use. It discussed some of the long-term effects as well as evidence of long-term effectiveness.--Literaturegeek | T@1k? 01:19, 26 June 2009 (UTC)

1. LG, are you saying that a sentence that includes the words "risks of long-term treatment" does not say anything about "long-term effects"? As I understand it, SC is writing about adverse effects in people that take these drugs for years. This is not the same subject as adverse effects that last for years after you've taken the drug.
2. ISBN 103540225684 (the second source) clearly and directly seems to agree with the first sentence in SC's proposal ("The data on the The effects of long-term use is contradictory"). It mentions a "major controversy" over "risks of long-term treatment". I think that fully addresses LG's concern above about whether this sentence represents impermissible original research. It's not original research if a reliable source plainly states the fact. LG, are you prepared to withdraw your objection in the face of this evidence? WhatamIdoing (talk) 01:34, 26 June 2009 (UTC)

I can't access that page of the book on google books but no I am not saying that. I am saying that it means the use of the drugs is controversial because of their adverse effect profile with differing opinions on the risk-benefit ratio but equally I found a page where the author clarified his views on the controversy where he said those advocating long term use for anxiety are a minority view in the literature (he cited some authors promoting the view so he was referring to literature). Also the quote is not directly relevant to dispute long-term adverse effects of benzodiazepines on physical and mental health and whether improvements occur after withdrawal from long term use. If you disagree, I am open to how it could be used in the benzo article. I am not opposed to compromising. Let me know your thoughts. Perhaps we could add a sentence before the long-term effects saying "their is major controversy surrounding the risk benefit ratio and the incidence of long-term adverse effects of benzodiazepines." Whilst it is not discussing the long-term effects on physical mental health and whether people improve after withdrawal,,, I think it might be a borderline case of using common sense and bending the rules a little but if that is what is needed, I happy to come up with a compromise.--Literaturegeek | T@1k? 01:54, 26 June 2009 (UTC)

It does not back up the view the "data is contradictory" but does back up the viewpoint that there is controversy over opinions of the risk benefit ratio.--Literaturegeek | T@1k? 02:01, 26 June 2009 (UTC)

Zero adverse effects

• W! This is a simple question and requires only a "Yes" or "No" answer: Do we have a high-quality reliable source that directly says that "Not everyone however, experiences problems with long-term use". Do not insult my intelligence by saying that the source that states "The abuse in the therapeutic users of BDz is rare" supports LG's statement. If yes, please give me the PMID or ISBN. If no, please just say no. Note that I'm after a source that directly says, with little or no beating about the bush, "Not everyone however, experiences problems with long-term use".The Sceptical Chymist (talk) 00:20, 26 June 2009 (UTC)
  • I interpret the statement as requiring a source that states that at least one long-term user has experienced zero adverse effects, whether perceived or unperceived by the user, and regardless of whether the user considers the adverse effect to be important (since the word "problems" is not qualified by words like "significant"). I'm not aware of any such source, and thus I'm skeptical of this being an appropriate claim for a Misplaced Pages article to make. My lack of awareness of such a source should not be taken as proof that no such source exists. WhatamIdoing (talk) 01:29, 26 June 2009 (UTC)

I don't really want to get involved here as both sides seem quite worked up about this, but there are certainly references that show long-term use of benzodiazepines without causing harm if you would accept older reviews or primary studies. The problem with only relying on these big meta-review papers is that they tend to presume that things which are statistically true for the majority of patients will therefore be true for every single patient, even though this is clearly not the case. Sure perhaps 80% of patients prescribed benzodiazepines long term will suffer declining efficacy and side effects which eventually outweigh the benefits of treatment, but that still leaves a substantial minority of patients who do not suffer these side effects and still find the treatment effective even after many years. I tend to agree with Sceptical Chymist in this respect, there is not a universal consensus on this even though the politically correct view seems to be that benzos are bad and should never be prescribed long term. However I deplore the name-calling and negative attitude on both sides, lets please just work on improving the article! Meodipt (talk) 01:43, 26 June 2009 (UTC)

We need up-to-date evidence, but as far as I'm concerned, this claim only requires proof that one person used this drug for a long time and experienced no adverse effects. If we can't find a single report of any individual that experienced no adverse effects, then either we're not trying very hard, or we shouldn't be making the claim. WhatamIdoing (talk) 01:53, 26 June 2009 (UTC)

That was not a single-word answer from W. It was weaseling. No, we just need a respectable author who would say with a straight face "Not everyone however, experiences problems with long-term use" of benzodiazepines. The Sceptical Chymist (talk) 02:30, 26 June 2009 (UTC)

I absolutely deplore name-calling. Is there a single instance where I did it to LG? The Sceptical Chymist (talk) 02:19, 26 June 2009 (UTC)

I think a compromise can be reached, see above. All I want is the sources to be accurate represented, undue weight is not used etc.--Literaturegeek | T@1k? 02:04, 26 June 2009 (UTC)

Yeah I think there is clearly scope for compromise here. Just say the majority view is that long-term benzo presciption is not appropriate but it may still be suitable in a minority of patients, should be easy enough finding refs for both those statements. Meodipt (talk) 02:09, 26 June 2009 (UTC)

I know people who use benzos and are not suffering mental or physical adverse effects from it so I admit and know for a fact that people do exist who do not suffer adverse effects due to long-term use. They may be "functionally" dependent on the drug but it does them no psychological or physical harm. The main thing though is to focus on reliable sources. I am not opposed to older sources if newer sources don't exist but not a fan of debunking new research with old research. Thanks for your views Meodipt. I do appolgise for losing my cool.--Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)

Good idea on long-term use, how about this citation. Quote, "Long term prescription is occasionally required for certain patients."--Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)

I do not know how we can say which view is majority or which minority without doing original research. Guidelines appear to disagree -- that is NICE vs. APA. Textbook authors pipe in with their disparate comments. That is why I tried to present the spectrum of the views without being judgmental AND without saying which view is more prevalent. In that I followed WP:NPOV to the letter. The Sceptical Chymist (talk) 02:23, 26 June 2009 (UTC)

I think that we go by what the best quality sources say. A non-systematic review of a few uncontrolled clinical trials would not be superior to a systematic review of the literature. I don't see a big conflict between NICE and the APA when the author says this. "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532--Literaturegeek | T@1k? 02:31, 26 June 2009 (UTC)

I think that we're confusing "do adverse effects happen" with "should this be prescribed". 100% of patients receiving cisplatin-containing chemotherapy regimens experience undesirable adverse effects. That is an entirely different question from whether or not the drug is justifiable. This section, as I understand it, attempts to identify the adverse effects that appear in long-term users of this drug -- not whether or not the drug is helpful to long-term users. WhatamIdoing (talk) 02:48, 26 June 2009 (UTC)

Side effects of the long-term use of benzodiazepines

How representative of the consensus view of the professionals is this sample of the long-term side effects from the current version of the article?

The adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs.

Below I will try to present a random sampling of psychiatric textbooks from my shelf, warts and all. The Sceptical Chymist (talk) 02:39, 26 June 2009 (UTC)

• Side effects include sedation, fatigue, and memory impairment. Although these medications carry a potential risk of abuse, the risk is felt to be overestimated in patients with anxiety disorders (Uhlenhuth, et al., 1989). Avoidance of these medications out of fear of abuse may be more problematic than the risk of abuse. If benzodiazepines are employed over an extended period of time, patients are at risk for recurrence of symptoms when they are tapered. (ISBN 0-471-43478-7, p 356) The Sceptical Chymist (talk) 02:48, 26 June 2009 (UTC)

Those side effects are acute side effects. Tolerance to the hypnotic effect occurs in days or weeks so it is definitely not referring to long-term effects. It is not discussing adverse effects which may result from long-term use. I am not trying to be antagonistic but this is why editing beside you led to dispute because I felt you were misrepresenting refs to delete or challenge facts you didn't like.--Literaturegeek | T@1k? 02:54, 26 June 2009 (UTC)

No, you got it right. Those are the short-term effects. I was just trying to show that I am not concealing anything. So the only long-term effect is recurrence of symptoms, according to that textbook. The Sceptical Chymist (talk) 02:59, 26 June 2009 (UTC)

No, it is just saying when people stop their medication their symptoms may return either I assume beccause the drug was alleivating the symptoms or as a rebound withdrawal effect. You are adding to what they say. I could find a book which discusses George Bush but never mentions his wife, then could I claim he was never married? It is still claiming a citation says something when it doesn't in my opinion.--Literaturegeek | T@1k? 03:09, 26 June 2009 (UTC)

I said "warts and all". This was the only place in the book where long term side effects of BDs were mentioned. Do not blame me, blame the authors. I just quote them. The Sceptical Chymist (talk) 03:22, 26 June 2009 (UTC)

Okie dokie, understood, we shall blame the authors then. :)--Literaturegeek | T@1k? 03:25, 26 June 2009 (UTC)

• Like the barbiturates, long-term use of benzodiazepines can lead to physical dependence, and abrupt discontinuation can produce an unpleasant, or even dangerous, withdrawal syndrome. (ISBN-10: 0-471-25401-0, p 132) The Sceptical Chymist (talk) 02:59, 26 June 2009 (UTC)

• Probably more important are the observations that long-term benzodiazepine therapy interferes with concentration and memory of new material. However, it does appear that the ability to remember and recall information learned prior to benzodiazepine therapy is not compromised. Although this can be a particular problem in elderly patients and may even lead to confusional, delirious, and even pseudodementia-type pictures, these effects on memory are generally subtle. These adverse effects, in particular, must be monitored with each individual patient to balance these relatively minor memory disturbances (if they occur) with clinical efficacy.(Chapter 31.10, Kaplan & Sadock’s) The Sceptical Chymist (talk) 03:06, 26 June 2009 (UTC)

• The role of benzodiazepines in brain damage has been reviewed (SEDA-14, 36). Cognitive impairment in longterm users can be detected in up to half of the subjects, compared with 16% of controls, but the issue of reversibility with prolonged abstinence is unresolved. Cognitive toxicity is more common with benzodiazepines than other anticonvulsants, with the possible exception of phenobarbital (84)....These findings suggest that long-term use of benzodiazepines is a risk factor for increased cognitive decline in elderly people...Withdrawal symptoms occur in at least one-third of long-term users (over 1 year), even if the dose is gradually tapered (111). (Meyler's side effects of drugs) The Sceptical Chymist (talk) 03:17, 26 June 2009 (UTC)

• After long-term administration (weeks to months) tolerance develops. While most patients rapidly become tolerant to the sedative side effects of these drugs, some patients, particularly the elderly, experience excessive sedation, poor memory and concentration, motor incoordination and muscle weakness. In extreme cases in the elderly, an acute confusional state may arise which simulates dementia... In addition to the tolerance that occurs following the long-term treatment of a patient with a benzodiazepine, dependence also arises... It has been estimated that 15–30% of patients on benzodiazepines for longer than a year may encounter problems in trying to discontinue their medication. (ISBN 0 471 52178 7, p 236)

• However, benzodiazepines are associated with risk of dependence after long-term usage (Tyrer et al., 1983; Rickels et al., 1988) and, although there may sometimes be withdrawal problems (‘discontinuation symptoms’) with antidepressants (Haddad, 1997), they are less likely to lead to persistent consumption than benzodiazepines. Because of this, the general guidance is to give benzodiazepines only for short-term treatment up to 4 weeks (Priest & Montgomery, 1988; Ballenger et al., 2001; NICE, 2004; Baldwin et al., 2005). Although this statement is frequently repeated, it is often ignored by many who prescribe in general practice. It is also worth adding that, as both generalised anxiety disorder and somatoform disorders are chronic conditions, it is highly unlikely that less than 4 weeks treatment would be of value. In practice, because both patients and practitioners find benzodiazepines to be of some value, they continue to be prescribed, either regularly or intermittently, over long periods and this applies even when the risks of dependence are known and explained. Short-term regular prescriptions of benzodiazepines are often of limited benefit and if followed by immediate withdrawal this benefit disappears (Tyrer et al., 1988) and so intermittent irregular but long-term use becomes the norm, even when patients are fully aware of the risk of dependence (Holton & Tyrer, 1990). (p 531,ISBN-13 978-0-521-84228-0,)

The above quote really sums it up I think. While it is important to note the clinical prescribing guidelines in the page, it is even more important to say why despite these guidelines warning against long-term use, benzodiazepines nevertheless still are often prescribed for long periods of time. If both sides aren't noted the page doesn't really explain why such long-term prescription would happen, if the adverse effects are inevitably so bad. Meodipt (talk) 06:15, 27 June 2009 (UTC)

• Around 80% of all such prescriptions in England are for those aged 65 years or over (Curran et al., 2003), and many patients remain on the drugs for months or years (Taylor et al., 1998). This prescribing is likely to lead to development of dependence and many other adverse effects on health (Ashton 1995). All currently marketed hypnotics have been associated with at least some features of dependence and have demonstrated a potential for misuse and dose escalation in at least a minority of patients (Ashton, 1995; Hajak et al., 2003; Lader, 1999). (p 402, ISBN-13 978-0-521-84228-0,) The Sceptical Chymist (talk) 03:36, 26 June 2009 (UTC)

• Unfortunately, although needed, effective and reasonably safe long-term BZD therapy for anxiety disorders has had various problems associated with it, especially in the elderly, including: Excessive daytime drowsiness; Cognitive impairment and confusion sychomotor impairment and a risk of falls; Paradoxical reactions and depression; Intoxication, even on therapeutic dosages; Amnestic syndromes; Respiratory problems; Abuse and dependence; Breakthrough withdrawal reactions (Principles & Practice of Psychopharmacotherapy, 4th Edition Copyright ©2006 Lippincott Williams & Wilkins > Table of Contents > Chapter 12) The Sceptical Chymist (talk) 03:43, 26 June 2009 (UTC)

Hi meodipt, the article already mentions that large amounts of people are still prescribed these drugs long-term (unless it got deleted and I didn't realise). Sceptical Chymist has used that paragraph out of context and misused the ref to make this change which he intends inserting into the main article I presume. If you read the tyrer book, he clarifies his opinion of what the evidence based literature says by saying this From the same book and on the next page ""it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532 I feel that this type of editing is harmful to[REDACTED] and this article and is original research and misuse of references and I cannot compromise and accept misrepresented references. Presumably Tyrer believes that long-term use for anxiety is ineffective from reviewing the evidence and the risks outweigh the benefits.--Literaturegeek | T@1k? 12:46, 27 June 2009 (UTC)

We should stick to the conclusions of the authors and minority viewpoints should not be given undue weight and should not be used to delete or minmise majority evidence based viewpoints.--Literaturegeek | T@1k? 12:55, 27 June 2009 (UTC)

First, these excerpts are about long-term effects not prescribing. Second, the above sampling of textbooks shows that the current description of the long-term side effects in the article written by LG does represent only minority view. Third, it is LG who takes quotes out of context. I shall address this below. The Sceptical Chymist (talk) 15:32, 27 June 2009 (UTC)

Of course short-term therapy would be ineffective for a long-term disorder but the authors views are that it is a minority view that long-term use of benzos is effective. You need to quote him in context. Your suggested edits are misleading as they imply long-term effectiveness and imply that the author believes long-term use is effective. Are you happy enough to quote the source in its correct context? Will you add to the quote that it is a minority view that long-term use is effective?--Literaturegeek | T@1k? 16:05, 27 June 2009 (UTC)

I addressed the alleged "reference misuse" below The Sceptical Chymist (talk) 16:09, 27 June 2009 (UTC)

Questions about U Sheffield paper

I have a few questions about this U Sheffield paper, which is used several times in the article: <ref name=cgftmamoa2004>{{cite web|author=McIntosh A, Cohen A, Turnbull N ''et al.''|title=Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder|url=http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf|publisher=National Collaborating Centre for Primary Care|format=PDF|year=2004|accessdate=2009-06-16}}</ref>.

1. The paper proclaims itself to be a "guideline"; however, it contains the following caveat on p 2: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." I wonder if using a real NICE guideline would be better.

2. This paper is 165 pages long. I believe that for each citation a page number should be provided. At the very least, a shorter range of pages could be given, if all citations are from the same part or chapter. For example, it would be nice to have numbers/range for the pages that confirm the bold parts in this sentence: "Their use beyond two to four weeks is not recommended in clinical guidelines, as tolerance and a physical dependence develops rapidly, with withdrawal symptoms including rebound anxiety occurring after six weeks or more of use.<ref name=cgftmamoa2004>" (bold mine, TSC).

3. This paper is used to support the following statement: "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy; benzodiazepine use has been found to interfere with therapeutic gains from these therapies."(emphasis mine, TSC). LG reverted my failed verification tag with the following edit summary: "Page six Sceptical. I don't fake refs.". I look at page 6 and still cannot find support for the bold part of this statement. The Sceptical Chymist (talk) 00:46, 27 June 2009 (UTC)

I don't see anything in that reference to support the bolded statement in (3), although I just used a keyword search rather than reading all 165 pages! My understanding was that a combination of psychotherapy and pharmacotherapy is usually more effective than either treatment alone, although this has been better established with SSRIs than with benzos The most recent review I could find specifically about benzos vs CBT vs both failed to find a statistically significant trend in either direction and concludes there is inadequate evidence at this point to say for sure which is better. (PMID 19160253) Meodipt (talk) 04:40, 27 June 2009 (UTC)

Meodipt, the keyword search may not work because the concept could have different wording in the source. So, to be fair, I skimmed through all 165 pages (!) before inserting the failed verification tag. And LG had the gut to revert the tag and claim that he "don't fake refs." Thank you for finding the Cochrane review that directly disproves the questionable sentence in the text; I was not aware of it. The Sceptical Chymist (talk) 11:25, 27 June 2009 (UTC)

Hi, hope these replies address your points.

Point 1.

That is just a routine legal disclaimer which you will often see in publications. It is still a systematic review of the peer reviewed literature so I think it is irrelevant. NICE would have peer reviewed it before publishing it on their website.--Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)

Point 2.

I can do this, but will need time.

Point 3.

I thought you were talking about the cited sentence before that which is on page 6. See page 76 for this statement.--Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)

RE: Point 1. That little "routine legal disclaimer" means that this is not a NICE guideline and that it has not been officially reviewed and approved by NICE. Is there an official NICE guideline? - that is the question. The Sceptical Chymist (talk) 15:33, 27 June 2009 (UTC)

It is an official guidance, it is listed under their guidance sub domain, so they must have reviewed it and accepted it before they placed it on there as that is used for national prescribing guidelines. There is no way they would publish a systematic review on their national guidance subdomain if they didn't approve it or even review it.--Literaturegeek | T@1k? 15:39, 27 June 2009 (UTC)

That section of their website is used by all National Heealth Trusts when forming policy so it is not possible they would publish something there without NICE reviewing it first.--Literaturegeek | T@1k? 15:50, 27 June 2009 (UTC)

I marvel at the LG's denial the facts. The paper says: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." Please answer this question, are there NICE guidelines which say that they are NICE guidelines? The Sceptical Chymist (talk) 16:13, 27 June 2009 (UTC)

RE: Point 2. Accepted.

RE: Point 3. What statement on p 76? The Sceptical Chymist (talk) 16:19, 27 June 2009 (UTC)

Benzodiazepines and worsening of sleep quality

I have questions about this sentence: "Drawbacks of benzodiazepines including worsening of sleep quality such as increased light sleep, decreased deep sleep as well as tolerance, dependence and rebound effects"

1. The abstract of reference PMID 18824834 only states: "The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives.". Perhaps, there is something in the full text that supports the worsening of sleep quality. Would it be possible to quote it?

2. Reference PMID 7525193 (Ashton, 1994) has three problems.

a) It does not support the purported "worsening of sleep quality". To the contrary, it states "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep."

b) It is 15 years old, and was written before the introduction of many non-benzodiazepines. It states, for example, that "Benzodiazepines and related drugs are probably the best (as well as the most widely used) hypnotics at present available."

c) Ashton does not, generally, represent the mainstream medical views. In various publications, she advocated the views that BDz have "all the characteristics of drugs of dependence", result "in the insidious development of increasing psychological and physical symptoms" and cause "neurological damage" when taken long-term in therapeutic doses.

If possible, we should find a better reference. The Sceptical Chymist (talk) 01:45, 27 June 2009 (UTC)

You are quoting sources out of context by only quoting one or two sentences. Benzos do promote a "sense" of a deep sleep, i.e. patients think they are getting a good sleep when they are actually getting a light sleep. There is really no dispute in the literature that benzodiazepines cause a worse sleep profile and even the drug companies highlight this themselves to promote the likes of zaleplon and zolpidem. The 1994 ref says this, "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep. However, they alter the normal sleep pattern: Stage 2 (light sleep) is prolonged and mainly accounts for the increased sleeping time, while the duration of slow wave sleep (SWS) and rapid eye movement sleep (REMS) may be considerably reduced."

Point B is irrelevant because that sentence is not cited in the article, however, it was correct at the time. Other hypnotic agents eg antihistamines, antipsychotics, alcohol, opiates have too many side effects or are even worse in promoting sleep than benzos. There is eveidence that zolpidem and zaleplon are more effective than benzos in promoting a more natural sleep.

C. Ashton does not say they cause neurological damage, she says it is possible and one of your psychiatric text books quoted a review saying pretty much the same that data is conflicting on whether benzos cause brain damage so her views are in keeping with the evidence base. The world health organisation. Again one of your psychiatric text books which you want to quote, I looked it up and it reviewed the evidence that benzos cause increasing psychological and physical symptoms and concluded that they did and recommended that most long-term users of benzos be withdrawn from long-term use. Benzos would have to have the characteristics of drugs of dependence otherwise the world health organisation would not have listed them as Schedule IV controlled drugs.

I wouldn't mind using the psychiatric text books that you suggested to cite about brain damage, increasing mental and physical health problems if you want newer and better refs.--Literaturegeek | T@1k? 14:44, 27 June 2009 (UTC)

2A. In the psychiatric context "quality" as in "quality of life" and, similarly, "quality of sleep" means subjectively rated quality. That is what patient feels about the effects of the drug. For example, sometimes antidepressants may "objectively" improve depression but not improve "quality of life". Similarly, however "unnatural" the objective structure of BD-induced sleep is, BDs do improve "quality of sleep" even according to Ashton The sentence you inserted contradicts the source. Psychiatrists here, please correct me if I am wrong. The Sceptical Chymist (talk) 15:07, 27 June 2009 (UTC)

2B and C. Your arguments do not obviate the need of a better and newer source. And Ashton is not mainstream. Quoting Ashton about side effects of BDs is like quoting David Healy on the antidepressant suicidality. Both Ashton and Healy have been correct in many things but they also sometimes exaggerated their case. They are not mainstream. The Sceptical Chymist (talk) 15:07, 27 June 2009 (UTC)

I did say we could use your psychiatric text books which say that long-term use being effective is a minority view and use them for the discussion about brain damage and long-term effects. David Healy is into the media campaigning side of things. Ashton is an academic who has published more on benzos than most others and is one of the most quoted peer reviewed researchers. She is not controversial so it is an unfair comparison.--Literaturegeek | T@1k? 15:16, 27 June 2009 (UTC)

Ok, I have been answering loads and loads of your questions now where you attack any source that you don't like. I would like to know your motives for investing an immense amount of time and effort resorting to quoting sources out of context to make them say the opposite which today you have been continuing to do. Why are you doing it? Why are you determined to make according to one of your own sources which you misused on the talk page says is a minority view and you want to make it a majority view and downplay or eliminate the majority view of peer reviewed researchers?--Literaturegeek | T@1k? 15:19, 27 June 2009 (UTC)

Because you are trying to present what is, arguably, a minority view as the only truth. The Sceptical Chymist (talk) 16:15, 27 June 2009 (UTC)

But your source says it is a minority view and the majority view is in keeping with evidence based clinical guidelines. I know it is "arguable" in the sense that you can fill the talk page up with misrepresented facts and all sorts of original research claims and weak sources. That is why we are in a dispute. Anything can be argued, what we need to stick with is what the best quality sources say giving the due weight and minority views lower weight.--Literaturegeek | T@1k? 16:22, 27 June 2009 (UTC)

Miscellaneous style comment(s)

• This sentence is confusing: "However, even in those without impaired liver functioning, the shorter acting drugs may be less effective in reducing the symptoms of alcohol withdrawal and may lead to break through seizures, and thus are not recommended for outpatient detoxification." There are four negatives, which makes it hard to follow: without (1) impaired (2) less (3) in reducing (4). The Sceptical Chymist (talk) 02:32, 27 June 2009 (UTC)

Re-write of Anxiety, panic and agitation

I extensively re-wrote the Benzodiazepine#Anxiety, panic and agitation chapter. This re-write (below) separates anxiety disorders from other indications, removes multiple redundancies and acknowledges the existence of a controversy about their long-term efficacy. Is there anyone who opposes to this version? The Sceptical Chymist (talk) 03:09, 27 June 2009 (UTC)

Anxiety, panic and agitation

Because of their effectiveness, tolerability and rapid onset of anxiolytic action, benzodiazepines are frequently used for the short-term treatment of anxiety. Their use beyond two to four weeks is not licensed and is not recommended in evidence based clinical guidelines, as tolerance and physical dependence may develop rapidly. The guidelines recommend antidepressants, the anticonvulsant drug pregabalin and cognitive behavioural therapy as the first line treatment options. In addition, benzodiazepine use has been found to interfere with therapeutic gains from psychotherapy.<ref name=cgftmamoa2004 /better reference needed> Deleted per comment . These clinical guidelines are often ignored in general practice because GAD and PD are chronic conditions, and it is "highly unlikely that less than 4 weeks treatment would be of value". In practice, if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained. added per comment

There has been a controversy as to whether the benzodiazepines maintain their anti-anxiety action long-term, and the issue still remains undecided. A majority of the follow-up studies do not suggest a significant loss of therapeutic effect over time. Furthermore, they do not provide evidence that the increase of dose is necessary to maintain the anxiolytic action. A recent review on clonazepam notes that some longitudinal data "suggest an ability to maintain improvement without tolerance for up to three years"; however, long-term controlled studies in panic disorder are lacking. Another review of longitudinal studies notes that the improvement is maintained in 30–60% of patients with panic disorder on the same or lowered dose and suggests that there is not "significant development of therapeutic tolerance" to benzodiazepines.

Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. They are also used to treat the acute panic caused by hallucinogen intoxication. Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania.

The Sceptical Chymist (talk) 03:09, 27 June 2009 (UTC)

I oppose it because you misrepresented the author by quoting him out of context to make him say the opposite of what he said. See this section above for my problems with this.Talk:Benzodiazepine#Side_effects_of_the_long-term_use_of_benzodiazepines--Literaturegeek | T@1k? 14:47, 27 June 2009 (UTC)

LG also alleges the same above . As a proof that I misinterpreted the reference isbn0-521-84228-X he quotes the following short excerpt from p 532: "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view.". In reality, it is LG who misinterprets the authors conclusions. The full paragraph from which he quotes is concerned with a relative efficacy of BDz and antidepressants. And the snippet he gave is about poor efficacy of benzodiazepines in comorbid anxiety and depression. Below is the full paragraph with the LG's selective quotation italicized. The important part he omitted is in bold. Let the reader judge for himself. The Sceptical Chymist (talk) 16:02, 27 June 2009 (UTC)

Psychological symptoms of anxiety may respond better to antidepressant drugs than to benzodiazepines, but there have been few comparator-controlled studies, and most reveal no significant differences in efficacy between active compounds (Mitte et al., 2005). Benzodiazepines have only limited efficacy against depressive symptoms, and given the comorbidity of GAD with depression and potential hazards associated with prolonged use of benzodiazepines, antidepressant treatment is preferable to prescription of benzodiazepine anxiolytics in ‘cothymia’ and other mixed conditions (Ballenger et al., 2001; Baldwin et al., 2005; Mitte et al., 2005). There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988); it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable (Taylor, 1989; Romach et al., 1995), but this remains a minority view.

The Sceptical Chymist (talk) 16:02, 27 June 2009 (UTC)

Nice try but the section of that book is about generalised anxiety disorder. It can be read online. Proof that he was not talking about people with depression when he made that statement is to look up his cited sources that he used as examples and you will see that they were talking about the 4 week guidelines in general or for anxiety, NOT in regard to anxiety and depression.--Literaturegeek | T@1k? 16:13, 27 June 2009 (UTC)

I don't expect you to type out the whole section but you know that section is about generalised anxiety disorder so quoting the one paragraph is misleading but like I say won't hold that against you as typing the whole section could be quite time consuming. He just mentioned within a paragraph about anxiety and depression. Also he says general advice, so obviously he is talking about benzos for all indications including anxiety, "There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988)" How else can general advice be taken? Why would he cite a source about anxiety and a source about benzos for all indications if he was only talking about those with "depression"? It is obvious what he means.--Literaturegeek | T@1k? 16:19, 27 June 2009 (UTC)

Here we go again denying evident facts and obscuring them by TLDR. LG, please let readers judge. Please be merciful to the reader and use colons to ident your replies. The Sceptical Chymist (talk) 16:24, 27 June 2009 (UTC)

1. ^ Stevens JC, Pollack MH (2005). "Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents". Journal of Clinical Psychiatry. 66 (Suppl 2): 21–27. PMID 15762816.
2. ^ McIntosh A, Cohen A, Turnbull N; et al. (2004). "Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder" (PDF). National Collaborating Centre for Primary Care. Retrieved 2009-06-16. {{cite web}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
3. Barbui C, Cipriani A (2009). "Proposal for the inclusion in the WHO Model List of Essential Medicines of a selective serotonin-reuptake inhibitor for Generalised Anxiety Disorder" (PDF). WHO Collaborating Centre for Research and Training in Mental Health. Retrieved 2009-06-23.
4. Cloos JM, Ferreira V (2009). "Current use of benzodiazepines in anxiety disorders". Current Opinion in Psychiatry. 22 (1): 90–95. doi:10.1097/YCO.0b013e32831a473d. PMID 19122540.
5. Silk, Kenneth R.; Tyrer, Peter J. (2008). Cambridge textbook of effective treatments in psychiatry. Cambridge, UK: Cambridge University Press. p. 531. ISBN 0-521-84228-X.{{cite book}}: CS1 maint: multiple names: authors list (link)
6. Nardi AE, Perna G (2006). "Clonazepam in the treatment of psychiatric disorders: an update". Int Clin Psychopharmacol. 21 (3): 131–42. doi:10.1097/01.yic.0000194379.65460.a6. PMID 16528135.
7. Doyle A, Pollack MH (2004). "Long-term management of panic disorder" (PDF). J Clin Psychiatry. 65 (Suppl 5): 24–8. PMID 15078115.
8. Cite error: The named reference bnf2009 was invoked but never defined (see the help page).
9. Wyatt JP, Illingworth RN, Robertson CE, Clancy MJ, Munro PT (2005). "Poisoning". Oxford Handbook of Accident and Emergency Medicine (2nd ed.). Oxford University Press. pp. 173–208. ISBN 978-0198526230.{{cite book}}: CS1 maint: multiple names: authors list (link)
10. Zimbroff DL (2008). "Pharmacological control of acute agitation: focus on intramuscular preparations". CNS Drugs. 22 (3): 199–212. doi:10.2165/00023210-200822030-00002. PMID 18278976.
11. Curtin F, Schulz P (2004). "Clonazepam and lorazepam in acute mania: a Bayesian meta-analysis". J Affect Disord. 78 (3): 201–8. doi:10.1016/S0165-0327(02)00317-8. PMID 15013244.
12. Gillies D, Beck A, McCloud A, Rathbone J, Gillies D (2005). "Benzodiazepines alone or in combination with antipsychotic drugs for acute psychosis". Cochrane Database Syst Rev (4): CD003079. doi:10.1002/14651858.CD003079.pub2. PMID 16235313.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• Misplaced Pages good articles
• Natural sciences good articles
• All unassessed articles
• GA-Class chemicals articles
• Low-importance chemicals articles
• GA-Class pharmacology articles
• Top-importance pharmacology articles
• WikiProject Pharmacology articles
• GA-Class medicine articles
• High-importance medicine articles
• All WikiProject Medicine pages