Question

Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let's discuss their use in our health care systems and the impact on our patients.
Things to consider might include:

Safety: How could the side effect profile affect your patients?
Efficacy: Are benzodiazepines efficacious for anxiety and sleep?
Use: Are they under or over prescribed? How can we ensure safe use of these medications?

Consider the following case:

A 46 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises.

What non-pharmacological and pharmacological therapies would you recommend for her?

Answer 1

Benzodiazepines have qualities that can help to reduce anxiety and seizures, relax the muscles, and induce sleep.

Short-term use of these medications is generally safe and effective. However, long-term use is controversial because of the potential for tolerance, dependence, and other adverse effects. It is possible to overdose on benzodiazepines, and mixing them with alcohol or other substances can be fatal.

• Benzodiazepines are used for a range of health issues, including anxiety, sleep disorders, and alcohol withdrawal.
• They work by triggering a tranquillizing chemical in the brain.
• Side effects can include dizziness, drowsiness, poor co-ordination, and feelings of depression.
• Mixing alcohol with benzodiazepines can be fatal.
• Hospital admissions for benzodiazepine misuse have tripled since 1998.

Benzodiazepines work by enhancing the effect of the neurotransmitter GABA. The drugs contain chemicals that add to the calming effect already produced by the human body and keep the brain in a more tranquilized state.

Side effects

The side effects of benzodiazepine usage may include:

• drowsiness
• confusion
• dizziness
• trembling
• impaired coordination
• vision problems
• grogginess
• feelings of depression
• headache

The long-term use of benzodiazepines can also result in physical dependence. Dependency can begin after using the drugs for as little as one month, even on the prescribed dosage. The withdrawal symptoms of benzodiazepines include trouble sleeping, feelings of depression, and sweating.

How can we ensure safe use Benzodiazepines?

The key to effective and safe long-term use of benzodiazepines is: the careful selection of patients who might benefit from them; administration in clinical situations in which they are more likely to be beneficial; use of lower doses and in conjunction with an antidepressant, if possible; monitoring and managing their side-effects; and minimising the risk of withdrawal symptoms and relapse, mainly through tapering the dose and/or combining with effective psychological interventions.

What non-pharmacological and pharmacological therapies would you recommend for her?

Pharmacological therapies: Pharmacotherapy is currently the most common treatment modality for insomnia, but long-term use of hypnotics in chronic insomnia can become complicated by drug tolerance, dependence or rebound insomnia. Since insomnia is a chronic condition, long-term and safe treatments are warranted. Non-pharmacological options provide longer lasting benefits.

If a cause of insomnia is identified, initial treatment should be directed at the specific factor. If insomnia persists, non-pharmacologic and/or pharmacologic interventions should be instituted. Hypnotic agents are the treatment of choice for the management of acute or transient insomnia. The expected goal is to normalize the sleep pattern within a few days to weeks. Behavioural interventions are important aspect of the treatment of chronic primary insomnia.

Non-pharmacological therapies:

1. Stimulus control therapy

Effective and recommended therapy in treatment of chronic insomnia (Standard)

Objective is to train the insomnia patient by a set of instructions designed to re-associate the bed and bedroom with sleep and to re-establish a consistent sleep-wake schedule:

• Go to bed only when sleepy;
• Get out of bed when unable to sleep;
• Use the bed/bedroom for sleep only (no reading, watching TV etc.);
• Arise at the same time every morning;
• No napping.

2. Relaxation training

Effective and recommended therapy in treatment of chronic insomnia (Standard)

Aimed at reducing somatic tension (e.g. progressive muscle relaxation, autogenic training) or intrusive thoughts at bed time (e.g. imagery training, meditation) that interfere with sleep.

3. Cognitive Behavioural Therapy (CBT) with or without relaxation therapy

Effective and recommended therapy in treatment of chronic insomnia (Standard)

CBT includes various combinations of both cognitive as well as behavioural interventions. The cognitive component is aimed at changing patient's beliefs and attitudes about insomnia. The behavioural component may include therapies such as stimulus control therapy, sleep restriction or relaxation training. Sleep hygiene education is often also included.

4. Sleep Restriction

Effective and recommended therapy in chronic insomnia (Guideline)

It involves curtailing the amount of time in bed to actual amount of time spent asleep. For example, if a patient reports sleeping an average of 6 hours per night, out of 8 hours spend in bed, the initial recommended sleep window (from lights out to final arising time) would restrict to 6 hours. Periodic adjustments to this sleep window are made contingent upon sleep efficiency, until optimal sleep duration is reached. Therapy creating mild sleep deprivation, and then lengthening sleep time as sleep efficiency improves.

5. Multi-component therapy (without Cognitive therapy)

Effective and recommended therapy in treatment of chronic insomnia (Guideline)

• Combining stimulus control therapy, relaxation training, sleep hygiene education
• Combining stimulus control therapy, sleep restriction therapy, sleep hygiene education
• Combining sleep restriction therapy, stimulus control therapy

6. Paradoxical intention

Effective and recommended therapy in treatment of chronic insomnia (Guideline)

It involves instructing the patient to remain passively awake and avoid any effort (i.e. intention) to fall asleep. The goal is to eliminate performance anxiety, as it may inhibit sleep onset. This parameter is limited to sleep initiation insomnia.

7. Biofeedback

Effective and recommended therapy in treatment of chronic insomnia (Guideline)

It provides visual or auditory feedback to patients to help them control some physiological parameters (e.g. muscle tension) in order to seek reduction in somatic arousal.

EEG Neurofeedback training: It is a self-regulation method that makes use of learning theory, more specifically, the paradigm of operant conditioning.⁸ While the EEG is measured; the patient receives instant feedback (visual and/or auditory) on the cortical activity of the brain. The goal of this treatment modality is to normalize the functioning of the brain by inhibiting and/or reinforcing specific frequency bands.