The Use of Antidepressants in Patients With Benzodiazepine Dependence
Janhsen and colleagues describe the disturbing proportions of benzodiazepine use and speak of 230 million defined daily doses (DDD) prescribed per year to patients covered by statutory health insurance (1). With 1341 million DDDs in 2013, antidepressants are prescribed even more frequently (2).
With regard to the common practice of prescribing both substance groups concomitantly, there is only the brief statement: “The use of antidepressants is recommended only in patients with comorbid depressive symptoms.“ Here, reference is wrongly made to a study (3) evaluating the use of an antidepressant on benzodiazepine withdrawal in explicitly non-depressive patients. This recommendation of Janhsen et al. is not helpful since almost all patients with addiction show depressive symptoms as part of their illness.
The Drug Commission of the German Medical Association (AkdÄ) has recently issued a detailed statement on the problem of identifying a depressive disorder in patients with alcohol dependence and treating it with pharmacotherapy (4). These recommendations can essentially be applied to patients with benzodiazepine dependence as well. Key messages include: Symptoms such as lack of energy, social withdrawal, insomnia, and a sense of guilt are in most cases associated with addiction and not related to an independent mood disorder. A depressive disorder can only be reliably diagnosed after at least two to four weeks of abstinence. Stringent treatment of addiction is crucial, also to improve depressive symptoms. Along with strict abstinence, depressive symptoms frequently improve.
Prescribing antidepressants will inevitably reinforce ideas typically associated with addiction, such as the assumption that the oral intake of substances is the only way to control the mental state. Physicians should be self-critical and ask themselves whether they take this approach only to avoid the unpleasant discussion about addiction. It remains unclear whether and how antidepressants are acting when concomitantly addictive substance are continuously consumed.
The same recommendations are made in the S3 guideline/National Disease Management guideline Unipolar Depression.
Prof. Dr. med. Tom Bschor
Abteilung für Psychiatrie, Schlosspark-Klinik, Berlin
Klinik und Poliklinik für Psychiatrie und Psychotherapie,
Universitätsklinikum Carl Gustav Carus Dresden
Conflict of interest statement
Prof. Bschor has received conference fees and reimbursement of travel expenses by Lundbeck and Astra Zeneca. He has received lecture fees from Lilly, BMS, esparma (Aristo), Servier, Astra Zeneca, Sanofi, and Lundbeck.
|1.||Janhsen K, Roser P, Hoffmann K: The problems of long-term treatment with benzodiazepines and related substances—prescribing practice, epidemiology and the treatment of withdrawal. Dtsch Arztebl Int 2015; 112: 1–7 VOLLTEXT|
|2.||Schwabe und Paffrath (eds.): Arzneiverordnungs-Report 2014: Aktuelle Daten, Kosten, Trends und Kommentare. Berlin: Springer 2014; 923.|
|3.||Tyrer P, Ferguason B, Hallström C, et al.: A controlled trial of dothiepin and placebo in treating benzodiazepine withdrawal symptoms. Br J Psychiatry 1996; 168: 457–61 CrossRef MEDLINE|
|4.||AG Psychiatrie der AkdÄ: Empfehlungen zum Einsatz von Antidepressiva bei alkoholabhängigen Patienten. Arzneiverordnung in der Praxis (AVP) 38: 27–29. www.akdae.de/Arzneimitteltherapie/AVP/Ausgaben/2003–2014/20112.pdf#page=3&view=fitB (last accessed on 7 February 2015).|