Biomedical subjects
Publications and source records attributed to P Tyrer.
A benzodiazepine-dependent patient may evoked a feeling of guilt in his or her GP. Most doctors now feel that withdrawal, however difficult, should be attempted. In an unmotivated patient this can be a particularly time-consuming and sometimes frustrating, exercise.
The impact of introducing a divisional psychiatric service based in the community in Nottingham in 1981 on adult psychiatric admissions (patients aged 15-65) was examined with data from the Nottingham case register. During 1980-5 the number of psychiatric admissions fell significantly (4.5% a year) compared with the national figures (0.46% a year). Admissions were reduced most for the diagnoses of affective psychosis and neurotic and personality disorders. The average duration of admission fell by 3.6% a year, and use of inpatient beds fell by 37.5%. Integrating hospital and community psychiatric services by creating sectors is a viable and economically feasible way of improving psychiatric services.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Fifty-one out-patients presenting with generalised anxiety disorder were included in a double-blind trial, and treated with either buspirone (a new non-benzodiazepine antianxiety drug) or diazepam over 6 or 12 weeks, after which they were abruptly withdrawn and continued on placebo to 14 weeks. Ratings of anxiety and other symptoms were administered fortnightly and additional withdrawal symptoms noted. Forty patients completed the study; 8 of the 11 drop-outs were taking buspirone. Both drugs reduced anxiety, diazepam more rapidly, but with greater withdrawal symptoms, particularly after 6 weeks. Regular treatment with diazepam for 6 weeks leads to a significant risk of pharmacological dependence that is not present with buspirone.
Explore the source record for details and available documents.
210 psychiatric outpatients with generalised anxiety disorder (71), or panic disorder (74), or dysthymic disorder (65) diagnosed by an interview schedule for DSM-III were allocated by constrained randomisation to one of five treatments: diazepam (28), dothiepin (28), placebo (28), cognitive and behaviour therapy (84), and a self-help treatment programme (42). All treatments were given for 6 weeks and then withdrawn by 10 weeks. Ratings of psychopathology were made by psychiatric assessors blind to both treatment and diagnosis before treatment and at 2, 4, 6, and 10 weeks after randomisation. 18 patients had insufficient data for analysis because of early drop-out. There were no important differences in treatment response between the diagnostic groups, but diazepam was less effective than dothiepin, cognitive and behaviour therapy, or self-help, these three treatments being of similar efficacy. Significantly more patients in the placebo group took additional psychotropic drugs in the 10 week period, and those allocated to dothiepin and cognitive and behaviour therapy took the least.
Explore the source record for details and available documents.
Monoamine oxidase inhibitors (MAOI's) have been shown to be significantly superior to placebo in the treatment of some anxiety disorders, particularly agoraphobia and mixed anxiety--depressive states. There is no convincing evidence that MAOI's are effective treatment in pure anxiety states, whether or not panic is present as a major symptom, although they are effective in so-called endogenous anxiety. Many past published studies of MAOI's have yielded poor results because the drugs have been prescribed for insufficient time (less than four weeks) or at too low dosage. There are no important therapeutic differences between the MAOI's apart from the faster speed of response with the nonhydrazine compound, tranylcypromine. Treatment often has to be long-term, and some degree of pharmacological dependence may develop. A few clinical studies have compared the efficacy of MAOI's and tricyclic antidepressants in anxious disorders. There is growing evidence that MAOI's are somewhat more effective than tricyclic antidepressants in the treatment of anxiety disorders and when phobic anxiety is an important component of a depressive disorder.
The recognition that all minor tranquillizers carry the risk of dependence has had a significant impact in their prescription over the years. But it has only recently had the same impact on the prescribing of benzodiazepines because their dependence risks were not recognized until late. Approximately one third of all patients prescribed a benzodiazepine regularly for six weeks or longer will experience withdrawal symptoms if the drug is withdrawn suddenly after this time. Even if the drug is withdrawn gradually withdrawal symptoms may still lead to demands for further prescription. The major change in prescribing has been towards shorter and intermittent treatment so that tolerance is reduced and withdrawal symptoms avoided. This is appropriate for acute anxiety reactions but more difficult for longer term anxious and depressive neurotic disorders, which have a much longer natural history. Continuing evidence that other drugs not specifically marketed for the relief of anxiety, particularly the antidepressants, are effective in relieving this anxiety has led to increased prescription of antidepressants. Some patients may also be helped by treatment with beta-blocking drugs and new agents such as buspirone which have no significant dependence potential. There has also been a move away from drug treatment to psychological treatments for anxiety as a consequence of concern over dependence. For some conditions, particularly medical ones such as spasticity and epilepsy, benzodiazepines may be considered for long-term treatment. They may also be regarded as necessary for more severe psychiatric disorders, usually as an adjunct to other therapy. In such instances the dependence risk is acknowledged but the benefits of treatment are considered to outweigh them. There may also be patients who are dependent on benzodiazepines but the alternative of withdrawing the drug may lead to dependence on a more dangerous drug such as alcohol. In such cases it is reasonable to regard continued prescription of the benzodiazepine as the least dangerous course of action. It is important to maintain a perspective of dependence on minor tranquillizers, particularly as attitudes are in danger of being distorted by excessive media attention. To date there is no evidence that dependence on benzodiazepines leads to any dangerous long term sequelae although there is concern over their effects on higher cognitive function. Nevertheless, the dangers of barbiturates, alcohol and nicotine are so much greater that it would be unfortunate if public concern led to excessive restrictions on the use of benzodiazepines.(ABSTRACT TRUNCATED AT 400 WORDS)
Therapists are only now just beginning to clear a way through the jungle of personality disorder and any recommendations about drug treatment have to be tentative and, to some extent, speculative. Nevertheless, it is reasonable to conclude that drug treatment, mainly in the form of antipsychotic agents, should be considered in borderline and antisocial personality disorders and also possibly in the schizotypal group. There is also growing evidence that two drugs used in the treatment of manic-depressive psychosis, lithium and carbamazepine, may have independent effects in controlling aggression and impulsiveness and be of value of borderline and antisocial personality disorders. In histrionic and dependent personality disorders, drug treatment is in general contraindicated and for the remaining group our ignorance of the possible benefit of the drugs is almost total. However, the negative effect of these personality disorders on response to treatment in the presence of depression, anxiety, and other abnormal mental state disorders suggests that drug treatment probably has little part to play in management of these particular personality disorders. A major deficiency in our knowledge, which can only be remedied by long-term studies that are extremely difficult to mount, is the recommended duration of treatment with drugs in personality disorder. No guidelines exist at present but now that some measure of efficacy has been established duration of treatment needs to be addressed.
Explore the source record for details and available documents.
beta-Adrenoceptor blocking drugs have been used for the treatment of acute stress reactions, adjustment disorders, generalised anxiety, panic disorder and agoraphobia. In general they are effective in these disorders if somatic or autonomic symptoms are prominent but not extreme in degree. Thus, they are of more value for the relatively mild tremor of the anxious violinist in public performance than in the severe shaking noticed during a panic attack. It is most likely that beta-blockers act primarily by blocking peripheral adrenergic beta-receptors; symptoms that are mediated through beta-stimulation, such as tremor and palpitations, are helped most. Improvement is noted within 1 to 2 hours and with relatively low doses (e.g. propranolol 40 mg/day). Some recent studies, however, have suggested that when longer treatment using higher doses (e.g. propranolol 160 mg/day) is given, improvement in other forms of anxiety is noted after several weeks of treatment. beta-blocking drugs are useful adjuncts to existing treatments for anxiety and are likely to enjoy wider use now that benzodiazepines are being avoided due to their dependence risks.
Three hundred and fifty seven patients with conspicuous psychiatric morbidity in two general practices in Nottinghamshire, one urban and one rural, were followed up for three years after original assessment. All patients were initially assessed for current mental state, personality status and alcohol problems using standard instruments. Of these patients 131 were diagnosed as suffering from anxiety states and other neurotic disorders. In the three year period 87% had received treatment from the general practitioner and 24% had been referred to a psychiatrist. The most common treatment was a prescription for tricyclic antidepressants (59%) but benzodiazepines were prescribed for the longest period. Only 8% of patients received psychotherapy or behaviour therapy. It is argued that this pattern of treatment represents the best use of current knowledge.
Explore the source record for details and available documents.
New psychiatric out-patients with depressive, phobic, and anxiety neurosis were randomly allocated to out-patient care or to one of two types of day hospital treatment, one specialising in psychotherapy and the other offering all forms of day care. Of 106 patients who entered the study, 78 had assessments of psychiatric symptomatology and social adjustment both before treatment and after 4, 8 and 24 months. There was no significant difference in outcome between depressive, phobic, and anxiety neurosis, and no overall difference in response to treatment between the three types of care. Suicidal symptoms were significantly less common in out-patients. In many respects, neurotic disorder can be regarded as a single syndrome.