Patterns of use of benzodiazepines in psychiatric patients

Background: The benzodiazepine has been one of the most commonly used drugs in psychiatry and general medicine because benzodiazepine have multifaceted actions like pain killing, antiepileptic and others therefore increasing the abuse of these drugs. Objectives (Aims): The aim of the study is to show the indications for benzodiazepine as in psychiatric patients, and to clarify some of the risks and hazards of their use in general.


Introduction
The benzodiazepine has been one of the most commonly used drugs in psychiatry and general medicine as a whole since the introduction of the first item in 1960 which was the Chlordiazepoxide, and because of the euphoria which occurred to physicians after testing its efficacy in treating anxious people, it was increasingly introduced in almost every prescription [1,2] .
The benzodiazepines are minor tranquillizers which recently appeared to have multifaceted actions like pain, killing action, antiepileptic action, sedative action, hypnotic action, accentuation of anaesthetics and muscle relaxant action.
They appear to act through specific receptors in the central nervous system. These receptors appear to have their highest density in the Limbic system, the part of the brain involved in the control of affect and visceral function, they are part of the macromolecular complex that also contains the receptors for gama aminobutyric acid (GABA), the principle inhibitory neurotransmitter in the brain, and the chloride channel through which GABA acts to hyperolarize neuron, i.e. decrease their likelihood of firing. The benzodiazepine are present in the brain they bind to their receptors and facilitate the action of GABA, resulting in increased chloride conductance and therefore greater inhibitory effect on the nervous system. Benzodiazepine have experimentally been shown to suppress neuronal activity in the Limbic system including the hippocampus, amygdala, hypothalamus and the septal region, leading to the hypothesis that these areas are involved in the aetiology of anxiety. [3,4] The first report of dependency liability to benzodiazepine came from Hollister et al [5,6] . only one year after the introduction of chlodiazepoxide, since then there has been steadily increased number of papers concerned with the abuse of these drugs. [4,7]

Methods
The study is a prospective one, and was conducted on psychiatric admissions in the years 2011-2012 in three centres including Ibn-Rushd Teaching Hospital for Mental Illness, Rashad Hospital and Al-Diwaniyah Teaching Hospital-Psychiatric Unit.
The total number of patients collected for whom benzodiazepine were prescribed was 300. Females constituted 34% of the sample (102), and males constituted 66% (198). The age range was distributed throughout three categories, 15-30 years, 31-50 years and 51 and over.
The data were gathered and classified according to the variables and factors listed in the appendix page.

Results
Data for benzodiazepine prescription by age and sex are presented in Tables (1) and (2)

Table (2): Number of Patients according to Sex
Taking occupation into consideration, it seems that there is a correlation between young ages, males and certain occupation such as in the case of students, peoples in military services and civil services, as shown in Table ( Chi-square (x 2 )= 46 Degree of Freedom (df)=6 P-value (p.v) = 2 (non specific)

Table (3): Number of Patients According to Occupation
There were certain diagnosis which showed higher frequencies with certain age groups as it is shown down in (Table 4) (4) it has been found that depression, alcoholism, anxiety and conversion reaction constituted the majority of patients for whom benzodiazepines were regularly prescribed during their stay in hospital.
The duration of stay of patients in hospital for each diagnosis encountered in the study is shown down in Table (    As regards to the level of education, it appeared that those patients who were at secondary school level and primary school level were more frequently repeated in the sample, next were those with intermediate school level, and the least represented were those of college level and graduates and the illiterate as shown down in Table (

Table (8): Number of Patients according to the Level of Education.
The benzodiazepine preparations or items, found to be prescribed more commonly for psychiatric inpatients as it is shown down in Table (

Discussion
From the study, it was found that benzodiazepines were used as adjunctive to antidepressants in patients diagnosed as depression with anxiety and those with depression only. For the latter group probably the benzodiazepines were given to treat insomnia. They were prescribed also for alcoholics, those with anxiety and other neurotic disorders (Table (4)). In all the conditions where benzodiazepines were prescribed on regular daily regimen, the doses were tapered gradually. (Table 5) The most common benzodiazepine prescribed was surprisingly chlordiazepoxide, next was diazepam (Table 9). I think there is some bias in this result or they may be a tendency by physician to avoid stereotype of prescribing diazepam.

July
Depending on clinical circumstance, the rate of onset of action may be an important variable in choosing benzodiazepine item, for example, rapid onset is important for patients who have trouble falling asleep, but a more slowly acting drug might be useful when insomnia comes later in the night.
Alprazolam was found to be used as a hypnotic more than other items, next was diazepam and loranzepam.
Taking occupation into consideration, it appeared that a high correlation between young ages, males and certain occupation such as in the case of students (20%), people in military service (20.7%), and civil services (19.7%). These sectors of the society were probably under higher stress.
People in single status were more represented in the sample (49%), next were the married (42%) and about a quarter of the latter group were originally with psychiatric illness before marriage.
The level of education of patients as listed down in (Table  8), it was shown that people of higher social and educational status were less presented in the sample because probably such people are still avoiding the stigma of mental hospital, and because younger and lower educated people could not deal well their social problems, besides they could not consult privately.
When duration of benzodiazepine use was considered the pattern emerged was related to the duration of stay in hospital and type of diagnosis labeled to the inpatients. The duration of stay in hospital in days ranged from 28 days for alcoholics to 7 days for patients with conversion reaction (Table 5).
In Table 7, it is shown that some patients with more than one admission, and benzodiazepines were prescribed for them in each admission, a majority of such patients i.e., with more than one admission were alcoholics, however it was not possible to know whether such patients continued to use benzodiazepines throughout the period between admissions or not, because such information was not supported in the case notes.
Concerning the age, among the 24 patients in the study who fell in the age group (over 51 years), only two of them were above 60 years of age and for both chlordiazepoxide was used in a dose of 15mg per day, all others were treated with the same dose regime as the younger age group, which ranged between 30-60mg of chlordiazepoxide per day.

Conclusion
The prescribing of drugs in general and benzodiazepines in particular, is a complex social process, much more than one might readily imagine. The following points may be considered useful in minimizing the hazards of such drugs as the benzodiazepines: 1. There is a considerable evidence that psychotropic drugs in general, and benzodiazepines in particular are overprescribed, especially by general practitioners. Their unwanted effects contribute to a serious public health hazards, such drug abuse, increased social hostility in situations where people are grouped together, and a frustrating stimulus is introduced. [8,5] . In addition, the problem of cost, as overprescribing throws heavy demands upon an already restricted national budget, so one should adopt more thoughtful prescribing policies. [9,7] 2. The effect of a drug a benzodiazepine, upon an individual is a complex interaction that depends on the drug, the patient's pathophysiological state, psychological and social factors. There are so many variables involved such as their pharmacological actions, unwanted effects and interactions with other drugs, the patients' medical and psychiatric history and those factors that will influence the outcome of treatment. [10,11] 3. We should learn more about normality and social problems, and resist offering chemical solutions to non-medical problem. [12,13] 4. Unless there are definite indications for immediate symptomatic relief, a planned withholding of drugs will often be rewarded by a significant favourable response to the initial interview, or even a spontaneous recovery. [14,11] 5. In administering a drug, we should tailor the dose to the patients clinical needs. And we should not prescribe drugs in