Indian Write-Ups

Psychiatric manifestations secondary to medical disorders are common. Studies show that up to 64% of the patients visiting primary care physicians have psychiatric disorders or symptoms, most common being anxiety and depression. One of the medical conditions which is frequently associated with anxiety and depression is chronic pain, which is similar to pain due to malignancy, musculoskeletal disorders like rheumatoid arthritis etc.

In coexisting medical and psychiatric disorders the immediate management of physical illness is important because undiagnosed and untreated psychiatric disorders are associated with high morbidity or potential fatal diseases.

The management of the medical illness and psychiatric symptoms requires prescription of drug for a prolonged duration (chronic therapy).

One of the agents currently used is benzodiazepines like alprazolam, diazepam, chlordiazepoxide.

The main reasons for the popularity of use of benzodiazepines is the apparent effectiveness in relieving anxiety and safety (vis-a-vis) barbiturates in terms of over dosage and dependence potential.

Benzodiazepines are used by the doctors in the treatment of anxiety, insomnia and other conditions like chronic pain and for vague non descript symptoms associated with symptoms of anxiety.

Though benzodiazepines enjoys popularity in the treatment of anxiety the adverse effects associated with their use particularly when required in long term (for chronic pains) should not be over-looked.

The adverse effects include :

CNS depressant effect

Lead to daytime drowsiness when used in excessive doses and still higher doses result in mental confusion and ataxia. The elderly who generally suffer from chronic pains are particularly susceptible to ataxia and unexpected falls.

Performance deficits

Sedation may produce performance deficits. Impaired psychomotor and psychological performance reported after acute and chronic ingestion of benzodiazepines.

Anteregrade amnesia

May lead to effect on long term memory.

Behavioural disturbances

Para-doxical effects in form of sleep-walking, verbal abuse, self- mutilation, suicidal ideation and violence. This must be brone in mind in cases of patients with history of impulse control problems.

Long term benzodiazepine use is associated with a general dulling and blunting of emotional response.

Benzodiazepines act on endocrine function through hypothalamus and anterior pituitary - leading to menstrual irregularities, premenstrual tension, breast enlargement, gynecomastia and galactorrhea.

Dependence & Post taper symptoms.

The discontinuation of long term use of benzodiazepines which generally is the case in chronic pains leads to:

• Re-emergence of anxiety symptoms i.e. the original symptoms of anxiety re-appear because an effective treatment has been removed. The symptoms are similar in quality and severity to the original anxiety symptoms being treated with benzodiazepine drug therapy.
• Rebound symptoms i.e. symptoms of anxiety and insomnia return, but are more intense than those that were originally treated with benzodiazepine drug therapy.

New symptoms, never previously experienced by the patient, develop during or shortly after discontinuation of benzodiazepine drug therapy. Many withdrawal symptoms mimic the initial presenting symptoms for which the drug was prescribed the first time. Thus perpetuating benzodiazepine prescription.

• und and withdrawal symptoms occur after discontinuing short life benzodiazepine and are delayed (days to weeks) with long life benzodiazepine. Though most symptoms resolve within 3-4 weeks, some suggest that they may last for months.
• mergence symptoms appear gradually and over a long period of time. Rebound symptoms develop within hours to days after benzodiazepine discontinuation. True withdrawal symptoms may develop rapidly or several days after discontinuation of benzodiazepines. These symptoms include visual and auditory hallucinations, seizure, lacrimation, nasal congestion, photo phobia, psychosis, sweating, cramps etc.

The contemporary view is thus unanimous about short term efficacy of benzodiazepines, but long term use in chronic pain is questionable especially since safe and effective alternatives are available.

In chronic pains which usually require long term administration of drugs that take care of anxiety and depression, a drug that is well tolerated by the patients and can be used for long term therapy; ought to be preferred.

The management of anxiety and depression associated with chronic pains includes:

PHARMACOTHERAPY

• Treatment of medical conditions with specific therapy
• Treatment of anxiety and depression with a non benzodiazepine

Antidepressants such as

• propanolol 100 mg
• dothiepin 75-150 mg once daily
• doxepin 75-100 mg twice or three times
• fluroxetine 20mg once daily
• hydroxyzine 50 mg

These drugs are well tolerated and can be used for long term therapy.

Long term use of these agents is not associated with abuse or dependence potential. These drugs are effective in treating anxiety and depression (fluoxetine has no anxiolytic properties). However these drugs need to be continued even after symptoms of anxiety and depression are relieved and continued treatment between six weeks to four months is recommended.

Besides drugs non drug therapies effective in management of anxiety and depression associated with chronic pain are:

• Cognitive therapy techniques which comprise various methods by which individuals learn to distract or distance themselves form their pain.
• Relaxation training (meditation, yoga) which has been widely used in the treatment of chronic pain.

CONCLUSION

• Chronic pain of varying etiology is frequently associated with anxiety and depression. Benzodiazepines are often used indiscriminately for such condition.
• Benzodiazepines have a number of side-effect like CNS dependence, cognitive deficits, performance deficits, behavioural abnormalities, emotional blunting, endocrine changes and dependence and withdrawal symptoms.
• Anxiety and depression associated with chronic pain requires long term treatment. Drugs which are well tolerated ought to be prescribed. Benzodiazepines which have adverse effect should be avoided.
• Pharmacotherapy like use of antidepressants (dothiepin, doxepin) play an important role in the treatment of anxiety and depression in chronic pain.
• Non drug therapies like psychotherapy, meditation, relaxation techniques and cognitive therapies also play an important role in the treatment of anxiety and depression.