I recently read an article by Fredric Neuman, MD, Director of the Anxiety and Phobia Center at White Plains Hospital, NY. The article is titled The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium, and was published in June 2012 by Psychology Today. Thanks to Medicalskeptic for the link.

Dr. Neuman opens by telling us that benzodiazepines are “. . . very commonly prescribed for any sort of discomfort.”

“They are called anxiolytics, and they are prescribed for any level of anxiety and more or less to anyone who asks for them.”

Dr. Neuman has been working at the Anxiety and Phobia Center for 41 years, first as Associate Director and then as Director. So when he says that benzos are routinely given to “anyone who asks for them,” it’s probably safe to say that he’s being accurate.

He tells us that the benzos have a “modest tranquilizing effect” in the doses at which they are “usually prescribed.” But –

“…I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills.”

and

“…I think these individuals suffer a loss of self-confidence. Their ability to rely on themselves has been undermined by their reliance on these drugs.”

Dr. Neuman asserts that benzos

“…are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.”

He provides a list of those adverse effects that concern him most.

They are addicting. They effect coordination, particularly in the elderly. They compound the effect of other drugs and alcohol. They interfere to some extent with memory.

And to this list he adds the dangers of abrupt discontinuation and

“…the fact that I think something is lost, as I indicated above, when someone relies on something make-believe to get through the day.”

Dr. Neuman concludes:

“…these drugs are sometimes helpful a little, and in some ways hurtful a little. But I don’t wish to give the impression that they are really bad. If a patient demands them, I will usually acquiesce, assuming the dose is small. I always encourage patients to take less as time goes on. If they won’t, I don’t usually argue with them.”

and

“I know most doctors give these drugs much more readily than I do.”

Discussion

In the article Dr. Neuman comes across as a reasonable and helpful person. He prescribes benzos, but he recognizes and articulates the disempowering aspect of relying on drugs, and I think it is reasonable to assume that in his practice he encourages people to pursue genuine resolution of fears and anxieties rather than chemical masking. But what struck me most forcibly in the article was the sentence:

“If a patient demands them, I will usually acquiesce, assuming the dose is small.”

Dr. Neuman is to be commended for his honesty, but it is a truly amazing admission – particularly his use of the word “demand.” It has long been my contention that there is very little essential difference between psychiatric “prescribing” of psychoactive drugs and the illegal selling of drugs on the street. Dr. Neuman’s use of the word “demand,” his admission that he usually acquiesces, and his credible assertion that most doctors prescribe these drugs more readily than he does, lends support to this contention, at least as far as benzos are concerned. It is difficult to reconcile his statements with the notion that these drugs, when used in a psychiatric context, are medications being prescribed to treat illnesses.

Mortality Hazard

The same day that I read Dr. Neuman’s piece, I also read an article in the BMJ: Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study, by Weich et al. Here are the conclusions:

“In this large cohort of patients [34,727 participants and 69,418 matched controls] attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality [hazard ratio: 3.3] over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.”

The increased risk for those participants who had taken only benzodiazepines was slightly higher at 3.68. Risk ratios were adjusted for age, gender, and the following health problems: “arthritis, asthma, cancer, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, gastrointestinal disorders, hypertension, musculoskeletal disorders, anxiety disorders, sleep disorders, other (non-anxiety), psychiatric disorders, and prescriptions for non-study drugs.” The association followed a dose-response pattern. Participants who had taken benzos at the highest doses had a hazard ratio of 5.1.

Even allowing for the standard disclaimer, the study raises serious doubts as to the oft-claimed safety of these products, especially as other studies have produced similar findings. It should also prompt us to question Dr. Neuman’s somewhat cavalier approach to these products – an approach which in my experience is widespread in psychiatry. A three-fold increase in mortality rate over seven years is not a trivial matter.