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Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials

  • Rebecca L. Gould (a1), Mark C. Coulson (a2), Natasha Patel (a3), Elizabeth Highton-Williamson (a3) and Robert J. Howard (a3)...
Abstract
Background

The use of benzodiazepines has been advised against in older people, but prevalence rates remain high.

Aims

To review the evidence for interventions aimed at reducing benzodiazepine use in older people.

Method

We conducted a systematic review, assessment of risk of bias and meta-analyses of randomised controlled trials of benzodiazepine withdrawal and prescribing interventions.

Results

Ten withdrawal and eight prescribing studies met the inclusion criteria. At post-intervention, significantly higher odds of not using benzodiazepines were found with supervised withdrawal with psychotherapy (odds ratio (OR) = 5.06, 95% CI 2.68–9.57, P<0.00001) and withdrawal with prescribing interventions (OR = 1.43, 95% CI 1.02–2.02, P=0.04) in comparison with the control interventions treatment as usual (TAU), education placebo, withdrawal with or without drug placebo, or psychotherapy alone. Significantly higher odds of not using benzodiazepines were also found for multifaceted prescribing interventions (OR = 1.37, 95% CI 1.10–1.72, P = 0.006) in comparison with control interventions (TAU and prescribing placebo).

Conclusions

Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

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Copyright
Corresponding author
Dr Rebecca Gould, Department of Old Age Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email: rebecca.gould@kcl.ac.uk.
Footnotes
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This research was supported by the Mental Health of Older Adults and Dementia Clinical Academic Group within King's Health Partners Academic Health Sciences Centre at the Institute of Psychiatry, King's College London and the South London and Maudsley National Health Service Foundation Trust.

Declaration of interest

None.

Footnotes
References
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Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials

  • Rebecca L. Gould (a1), Mark C. Coulson (a2), Natasha Patel (a3), Elizabeth Highton-Williamson (a3) and Robert J. Howard (a3)...
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eLetters

Study of Petrovic et al. erroneously classified as 'withdrawal with psychotherapy'

Hilde Habraken, researcher, Farmaka
06 October 2015

I believe there is still an error in the new version of the article.

The study of Petrovic et al. "Fast withdrawal from benzodiazepines in geriatric inpatients: a randomised double-blind, placebo-controlled trial (Eur J Clin Pharmacol. 2002 Jan;57(11):759-64), is included in the subset of studies about 'Withdrawal with psychotherapy'.

Instead it should have been included in the subset of studies about 'Withdrawal with pharmacotherapy'.

This is clear from the study abstract:

OBJECTIVE:

We have previously demonstrated that temporary substitution with a low-dose hypnosedative drug may lead to successful withdrawal from chronic benzodiazepine (BZD) use in the majority of patients admitted to a geriatric ward. In the present study, a withdrawal programme was evaluated in which the habitual treatment with BZDs was replaced by either 1 mg lormetazepam or placebo, defining withdrawal success rate, sleep quality and withdrawal symptoms as main outcomes.

METHODS:

The target population was geriatric inpatients who had been taking BZDs for at least 3 months. Subjects suffering from mental disorders were excluded. Lormetazepam or placebo were randomly assigned and given in a double-blind fashion. After 1 week, the replacement therapy was discontinued. Subjective estimations of sleep quality and withdrawal symptoms were registered at predefined intervals, four times in a period of 30 days, using standard questionnaires (the Pittsburgh Sleep Quality Index and the Benzodiazepine Withdrawal Symptom Questionnaire, respectively).

RESULTS:

The success rate was significantly higher in the lormetazepam substitution group (80% vs 50% in the placebo group, P < 0.05). Both the subjective quality of sleep and withdrawal symptoms were significantly better in the lormetazepam substitution group. Important withdrawal effects were observed in the control group in two patients with a history of chronic alcohol abuse.

CONCLUSIONS:

Initial replacement therapy with a low-dose BZD is preferred over placebo, since the latter alternative is associated with worse sleep quality and a lower success rate. Placebo must only be used under medical scrutiny, given the potential for unmasking delirious symptoms, especially in patients with concomitant alcoholism.

It is also clear from the methods section in the full text (p 760): 'The differential effects of lormetazepam versus placebo on withdrawal success rate and symptom scores were the main outcomes of the present study'.

The methods section also states that patients (from both groups) received psychological support if they wished during the study (p. 760, first column):

'Psychological consulting was offered to patients who experienced problems during the withdrawal procedure.'

So I think it is not correct to classify this withdrawal study in the category 'Withdrawal with psychotherapy'. As a consequence the results of the pooled analyses for both the categories 'Withdrawal with pharmacotherapy" and "Withdrawal with psychotherapy" are not correct.

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Conflict of interest: None Declared

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